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2021_MA-POS_PA-List_20210101 V30_non_EXL_filexlsx [PDF]

2021_MA-POS_PA-List_20210101 V3.0_non_EXL_file.xlsx

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December 29, 2020
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2021 MA POS Priorization CPT Code List version 1.7 Publication date: January 1, 2021 Note: Select services performed offline require authorization. If network opportunities can be identified, an administrative denial will be issued. For services listed as not requiring prior authorization, please contact Provider Services to ensure that the service is covered by the Bright Health member benefit. SAD means self-administered medicine. General CPT Information Requirements System Logic UM Performance PA for Code in Group Applies to All Codes CPT Code Short Description Long Description Authorization Required? Group PA within specific group UM Exam Type USA CPT Code Indicator 00100 ANESTH SALIVARY GLAND ANESTHESIA SALIVARY GLAND ANESTHESIA NO Authorization Needed BIOPSY 00102 ANESTH REPAIR CLIT LIP ANESTHESIA LIP SAMPLING WITH 00ASTIC USE RED FACED 00ASTIC REVED3. THESIA EYE LOCK RECONSTRUCTIVE No Authorization Required PROCEDURE 00104 ANESTH ELECTROSHOCK ANESTHESIA ELECTROCOVULSIVE No Authorization Required TREATMENT 00120 ANESTH EAR SURGERY ANESTHESIA EXTERNAL MIDDLE & No Authorization Required INNER EAR W/BX NOSE 00124 ANESTH EAR EXAM EXAM ANESTH EXAM EXAM EXAM Auth/IN REQUIRED AUT. 00126 ANESTH TYMPANOTOMY ANES XTRNL MIDDLE & INNER EAR W/BX No Authorization Required TYMPANOTOMY 00140 ANESTHETIC PROCEDURES ON THE EYE ANESTHESIA EYE NO OTHER No Authorization Required SPECIFIED 00142 ANESTHESIA LENS SURGERY ANESTHESIA EYE ANESTHESIA NO OTHER PURPOSE AUT. NEAL TRANSPLANT No authorization required 00145 ANESTH VITREORETINAL SURG EYE ANESTHESIA VITREORETINAL No authorization required SURGERY 00147 ANESTH IRIDECTOMY ANESTHESIA IRIDECTOMY EYE No authorization required 00148 ANESTH EYE EXAMINATION ANESTHESIA OPHTHALMOSC OPY No authorization required 00160 ANESTH NOSE/SINUS EXAMINATION WITHOUT ANESTHESIA ZIJE NO EXAMINATION OF ANESTHESIA ES NOS 00162 ANESTH SURGERY NOSE/SINUS ANESTHESIA NOSE AND ACCESSORIES BINUS No approval required RADICAL SURGERY 00164 ANESTH BIOPSY NOSE NOSE ANESTHESIA AND ACCESSORIES BINUS No approval required SOFT TISSUE BIOPSY 00170 ANESTHETIC PROCEDURE FOR ANESTHESIA MOULD IN TRAORAL WITH ANESTHETIC BIOPSY NOSE IN R01AIR2 Auth TRAORAL M/ BIOPSY REP ARATION No Authorization Required Cleft Palate 00174 ANESTHESIA PHARYNGEAL SURGICAL ANESTHESIA INTRAORAL W/BX EXC No Authorization Required RETROPHARYNGEAL TUMOR 00176 ANESTHESIA PHARYNGEAL SURGICAL ANESTHESIA INTRAORAL W/BIOPSY No Authorization Required RADICAL SURGICAL ANESTHESIA 0019 0 ANESTHESIA COURSE. SKULL No approval required NOS 00192 ANEST. FACIAL BONES SURGICAL ANEST. FACIAL BONES/SCRANIAL SURGERY No approval required W/PROGNATISM 00210 ANESTH. SURGICAL SKULL NOSE ANESTHESIA INTRACRANIAL No authorization required PROCEDURE NO. NESTH SKULL DRAINAGE ANESTHESIA INTRACRANIAL No approval required PROCEDURE SUBDURAL TAPS 00214 ANESTH SKULL DRAINAGE ANES INTRACRANIAL HOLES No approval required W/VENTRICULOGRAPHY 00215 ANESTH SKULL REPAIR/FRAKTANES INTRACRANIAL/EVELATION No approval required DEPRSD S KULL FX XDRL INTERNAL 00216 CULAR No approval required fox PRO CEDURE 00218 ANESTH SPECIAL MAJOR SURGERY ANESTH INTRACRANIAL PROCEDURE I No authorization required SEAT 00220 ANESTH INTERNAL NERVE ANESTH INTRACRANIAL CEREBROSPINAL No. Authorization required FLUID ASSEMBLY 00222 ANESTH MAJOR NERVE SURGERY ANES INTRACRANIAL No authorization required ELE CTROCONESCAD ELECTROCOAGNER ANESTH /PTRUNK ANES INTEG MUSC & NRV HEAD No authorization required NECK&POSTERIOR TRUMP 00320 ANESTH NECK ORGAN 1YR/> ANES ESOPH THIRD LARYNX STRAND & No authorization required LYMPH NECK 1YR 00322 ANESTH THYROID BIOPSY ANES ESOPH THIRD LARKS TRACKET & No AuthHRD NKR B0XTHNES CH < 1 YR ANESTHIA IA LARYNX & TRACHEA No authorization required CHILDREN

00474 ANESTHETIC SURGERY OF RIBS ANESTHESIA PARTIAL RESECTION OF RIB No authorization required RADICAL 00500 ANESTHETIC SURGERY OF ESOphagus ANESTHESIA OF ESOphagus No authorization required 00520 ANESTHETIC PROCEDURE ON CHEST MEASURE AuthOSPHAGEAL OPERATION ANESTHESIA OF ESOPHAGUS Br. Required 00520 ANESTHETIC CHEST PROCEDURE AuthOSCHOSHESPY No. 2 ANESTH CHEST COATING BIOPSY ANESTHESIA CLOSED CHEST NEEDLE No approval required PLEUR BIOPSY 00524 ANESTH CHEST DRAINAGE ANESTHESIA CLOSED CHEST BONE No approval required PNEUMOCENTEZY 00528 ANES MEDIASCOPY & DX TORSKI ANES No approval required MEDIASTINOSCOPY & THORASCOPY WITHOUT 1 LUNG VN TJ OR ALUNG 005 IASTINOSCOPY & THORAXCOPY W/1 LUNG VNT 00530 ANESTH PACE INSERTION ANESTH PERMANENT TRANSVENOUS No approval required PACE INSERTION 00532 ANESTH VASCULAR ACCESS ANESTHESIA ACCESS CENTRAL VENOUS No approval required CIRCULATION 00534 ANESTH CARDIOVERTER/DEFIB ANESTH TRANSVENOUS US No approval required INSJ/ALTERNATIVE USE A0 PHC 7 CARDIOVERTER/DEFIB ANESTH 3 CARDIAC ELECTROPHYSIOL STDY No authorization required W /RF ABLATION 00539 ANESTH TRAC - BRONCHIAL RECONSTRUCTION TRACHEOBRONCHIAL ANESTHESIA No authorization required RECONSTRUCTION 00540 ANESTH CHEST SURGERY ANESTHORACOTOMY & No authorization required THORACOSCOPY NOSE 00541 ANESTH SINGLE-LUNG VENTILATION ANESTH THORACOTOMY ANESTHORACOTOMY W1 00542 AÆSTHESI FJ ERNELSE PLEURA ANESTHES THORACOTOMY & no authorization required THORACOSCOPY DECORTICATION 00546 ANESTH LUNG CHEST WALL SURGERY THORACOTOMY & No authorization required THORACOSCOPY LUMONAL RESC 00548 ANESTH TRACHE BRONCHI SIRRG ANESTHORACOTOMY & THORAXCOPY No authorization required TRACHESTA & BRONHI 05 AL No authorization required DEBRIDEMENT 005 60 ANESTH CARDIAC SURGEON WITHOUT ANESTH PUMP HRT PERICARDIAL SACK AND GRT no. approval required VELS U/O PMP OXT 00561 ANESTHETICS HEART SURG

00802 ANESTH FED LAYER REMOVAL ANES LOWER ANT PORT WALL No approval required PANICULECTOMY 00811 ANES LWR INTST NDSC NOS ANESTHESIA LOWER INTST ENDOSCOPIC No approval required PX NOS 00812 ANESTH INTST ANESST ANESST SINTOS IC No approval required PX SCR COLSC 00813 ANES UPR LWR GI NDSC PX ANESTHESIA Combined Upper and Lower Approval Not Required GI Endoscopic PX 00820 Anesth's Abdominal Wall Surgeon Anesthesia Lower Back No Approval Abdominal Wall Approval Required 00830 Anesth's Anesthesia Repair Anesthesia Anesthesia Anesthesia Anesthesia Lower Back. 0832 ANESTHETIC HERNIA REPAIR ANES LWR ABD VENTRAL & INCISIONAL No. Authorization required HERNIA REPAIR 00834 ANESTH HERNIA REPAIR < 1 YEAR ANES HERNIA REPAIR LOWER ABDOMEN No authorization required NOS & 1 YEAR AGE 00836 ANESTH HERNIA REPAIR PREEMIE ANES HRNA RPR LWR ABD NOS No authorization required

01112 ANESTH BONE ASPIRATE/BX ANES BONE MARROW ASPIR&/BX No approval required ANT/PST ILIAC CREST 01120 ANESTH SURGICAL PELVIC PELVIC ANESTHESIA No approval required 01130 ANESTH APPREDUOD BODY Aquic red OR REVISION 01140 ANESTH AMPUTATION AT PELVIC ANESTHESIA INTERPELVI ABDOMINAL No approval required AMPUTATION 01150 ANESTH PELVIC TUMOR SURGERY ANES RADICAL PELVIC TUMOR XCP No approval required HINDQUARTERS AMP. ANESTH PELVIC SURGERY ANES OPEN SYMPHYSIS No approval required PUBIS/SACROILIAC JOINT 01173 ANESTH FX PELVIC REPAIR ANES OPN RPR DISRPJ PELVIC/COLUMN No approval required FX ACETABULUM 01200 ANESTH HOTELID PROCEDURE ANESTHESIA CLOSED HIP JOINT No approval required PROCEDURE 01200 ANEST OF ARTHRIP ACONESTHO FOS HO PY ARTHRIC . IP-LED No approval required PROCEDURE 01210 ANESTHETIC HOTEL OPERATION ANESTHESIA OPEN HIP JOINT No approval required PROCEDURE NO. 01212 ANESTH HIP DISARTICULATION ANESTHESIA OPEN HIP JOINT No authorization required DISARTICULATION 01214 ANESTH HIP ARTHROPLASTY ANESTHESIA OPEN TOTAL HIP No authorization required ARTHROVISTHE REP15NESSI ARTHRO2 PLASTIC OPEN REVISION TOTAL HIP No authorization required ARTHROPLASTY 01220 Thigh ANESTHESIA PROCEDURE ANESTHESIA CLOSED PROCEDURE No approval required TOP 2/ 3 FEMUR 01230 ANESTH femur operation Anesthesia OPEN SURGERY OF THE UPPER No authorization required 2/3 FEMUR NOSE 01232 ANESTH AMPUTATION OF FEMUR ANESTHEMAS Auth. 234 ANESTH RADICAL THIGH ANES UPPER 2/3 FEMURA RADICAL No approval required LIFT 01250 ANESTH SURGERY OF LEG ANESTH NERVE MUSCLE TENDON FASCIA & No approval required BURSAE UPPER LEG 01260 ANESTH SURGERY OF LOWER VENNER INCLUDES ING ANES OR AUT. 0 ANESTH FEMORAL ARTERY SURRG UPPER LEG ARTERY ANESTHESIA INCLUDING No authorization required BYPASS GRAFT 01272 ANESTH FEMORAL ARTERY SURRG ANES ART UPPER LEG W/BYPASS GRAFT No authorization required FEM ART LIG 01274 ANESTH FEMORAL EMBOLECTOMY ANES UPPER LEG W/BYPASS NO Auth NESTH KNEE SURGERY ANESTH NERVE MUSCLE TENDON No approval required FASCIA&BURSA KONE&/POPLT 01340 ANESTH PROCEDURE KNEE AREA ANESTHESIA CLOSED PROCEDURES No approval required LOWER 1/3 FEMUR 01360 ANESTH SURGERY KNEE AREA/ANESTHESIA CLOSED PROCEDURES No approval required LOW ER 1/3 FEMUR 01360 ANESTH SURGERY KOL YEN/ ANESTHESIA NECESSARY PROCEDURES CLOSED AREA AUT. 01380 ANESTHESIA FOR KNEE JOINT PROCEDURE ANESTHESIA CLOSED PROCEDURE No. Auth Required KNEE 01382 ANESTH DX KNEE ARTHROSCOPY ANESTH DIAGNOSTIC ARTHROSCOPIC None Auth Required PROC KNEE 01390 ANESTH KNEE AREA PROCEDURE ANES CLOSED PROC. UPPER END CAR. AREA ANES OPEN PROC UPPER END OF TIBI No Authorization Required FIBULA& /PATELLA 01400 ANESTH KNEE SURGERY ANES OPEN/SURRG ARTHROSCOPIC PROC No Authorization Required KNEE NO. EE NO. TH OPEN/SURGICAL ARTHRS KNEE No Authorization Required DISARTICULATION 01420 KNEE ANESTHESIA APPLICATION OF ANESTHETIC CAST Use No Authorization Required KNEE REMOVAL/REPAIR 01430 ANESTHESIA KNEE SURGERY ANESTHESIA KNEE VEINS & POPLITEAL No Authorization Required AREA NO. 01432 KNEE ANESTHESIA KN EE & POPLITEAL no. Approval Required FISTULA NOS 01440 ANESTH KNEE ARTERY SURG KNEE AND POPLITEAL ARTERY No Approval Required AREA 01442 ANESTH KONE ARTERY SURG ANES ART KONE POPLITEAL TEAEC No Approval Required W/WO PATCH GRAFT 01444 ANESTH KNEE ARTERY ANESTH ANESTH ANEE ARTERY REPC. RPR OCCLS/ARYS 01462 ANESTHETIC PROCEDURE OF LOWER LEG ANESTHESIA CLOSED PROC. LEG LEG No authorization required ANKLE AND FOOT 01464 ANESTH ANKLE/FOOT ARTHROSCOPY ANESTHESIA ARTHROSCOPIC No authorization required PROCEDURE ANKLE AND FOOT 014YSFOOT 014YMUGER ANESTH/ANKLES No authorization required LEG/ANKLE/FOOT NO. 01472 ANESTH ACHILLES SURGERY ANES RPR LETTERS ACHIL No approval required W/WO GRAFT 01474 ANESTH LOWER LEG SURGERY ANESTHESIA GASTROCNEMIUS No approval required RECESSION ANESTHONE LEG 0148C RECESSION ANESTHONE 0148C WER No approval required LEG /ANKLE/FOOT NO. 01482 ANESTH RADICAL LEG SURGERY ANES RADICAL RESECJ INCL BELOW No authorization required KNEE AMPUTATION 01484 ANESTH REVISION OF LOWER LEG ANES OPEN OSTEOTOMY/OSTEOPLASTICS No authorization required REVISION OF TIBIA AND/FITALBULA ANESTH ANESH ANESTH A86 REVISION ANESH 014 Authorization required REPLACEMENT 01490 ANESTH LOWER L E.g. . GASTING ANES GASTING LOWER LEG No approval required REMOVAL/REPAIR 01500 LEG ARTERY ANESTH SURGICAL ANESTHESIA LOWER LEG ARTERY ANESTHSIA No approval required W/BYPASS GRAFT NOS 01502 ANESTH LWR LEG EMBOLECTOMY ANESTH LOWER LEG ARTERY ANESTHESIA No approval required W/BYPASS GRAFT NOS 01502 ANESTH LWR LEG EM BOLECTOMY ANESTHESIA W BOTTOM Required 01520 ANESTH LOWER VENNESURG AESTHESIA FRIENDS ON LOWER LOWER No approval required

01522 ANESTH LOWER LEG VENOUS SURGICAL ANES FRIENDS LOWER LEG VENUS No authorization required THRMBC DIR/W/CATH 01610 ANESTH SHOULDER SURGERY ANES NRV MUSC TNDN FSCIA BURSA No authorization required SULCE SHOULDER ANESTH 01610 ANESTH CL OSED HUMRL H/N STRNCLAV No authorization required LED & SHO LED 01 622 ANES DX SHOULDER ARTHROSCOPY ANES DIAG ARTHROSCOPIC SHOULDER No Approval Required LED PROC NO. 01630 ANESTHESIA SHOULDER SURGERY ANES ARTHRS HUMERAL H/N SHOULDER Auth STRN3 DER JOINT AMPUTATION ANESTHESIA ARTHROSCOPIC SHOULDER No authorization required DISARTICULATION 01636 ANESTHESIA FOR AMPUTATION ANES ARTHRS No authorization required INTERTHORACOSCAPULAR AMPUTATION 0 1638 ANESTH SHOULDER REPLACEMENT ANESTHESIA ARTHROSCOPIC TOTAL SHOULDER No authorization required fox REPLACEMENT 01650 ANEST SHOULDER ARTERIES ARTERIES ARTERIES AUT. NOS 01652 ANESTHESIA DISTANT SURGICAL ANESTHESIA OF THE SHOULDER AXILAR-BRACHIAL No approval required ANEURISM 01654 ANESTHESIA OF THE SHOULDER VASCULAR SURGERY OF THE ARTERY OF THE SHOULDER AND AXILLA No approval required BYPASS GRAFT 01656 ANESTH SURGICAL VEIN OF THE ARM-LEG ESTHESIA AXILLARY-FEMORAL No approval required BYPASS GRAFT 016 70 ANESTH HAND-LEG MERRY SURG AXILLA No approval required 01680 ANESTH SHOULDER GASTING ANES SHOULDER GAST APPL No approval required REMOVAL/REPAIR NO. S HOLDER 01716 ANESTH BICEPS TENDON REPAIR ANESTHESIA BICEPS TENODESIS No. approval required RUPTURE OF LANG SENE 01730 ANESTHESIA UPPER ARM PROCEDURE ANESTHESIA CLOSED PROCEDURES No approval required HUMERUS 3WHREL HUMERUS 3W 3W 3W 3W 2W 3W COPY ANESTHESIA JOINT EASY DIAGNOSIS No approval required ARTHROSCOPIC 01740 ANEST H UPPER ARM SURGERY ANES OPEN/ SURGICAL ARTHROSCOPIC None required approval LAKAT PROC NOS 01742 ANESTH HUMERUS SURGERY ANESTHESIA OPEN /SURRG ARTHRS No authorization required Osteotomy HUMERUS 01744 ANESTH HUMERUS REPAIR NO. Humerus 01756 Anesth Radical Humerus Surg Anesthesia Open/Surg Arthrs No Approval Required Radical Proc Elbow 01758 Anesth Humeral Lesion Surg Anesteth Open/Surg Arthrs Exc No Approval Required Cyst/Tumor Humerus 01760 Anesth Elbow Substitute for Anesth Open/0 Required 770 ARTERY SURG ARTERIES FOR ANESTHESIA UPPER ARM & no authorization required ELBOW NOSE 01772 ANESTH UPPER ARM EMBOLECTOMY ANESTHESIA ARTERY UPPER No authorization required ARM&ELBUE EMBOLECTOM 01780 ANESTH UPPER ARM VENUS SURGICAL ANESTHESIA VENNER AUSTHESIA VENNER 01 UPPER ARM VEIN RE PAR ANESTHESIA VENNER UPPER ARM & No Auth Pk fox ALBU PHLE BORRHAPHY 01810 ANESTH FOREARM SURGERY ANESTH NERVE MUSCLE TDN No approval required FASCIA&BURSA FOREARM HAND 01820 ANESTH LOWER HAND PROCEDURE ANESTH RADIUS ULNA ANESTH RECORD/1HAND Required D9 ANESTH RECORD/1HAND X RECORD ARTHROSCOPY AESTHESIA DIAGNOSIS No approval required ARTROSC OPIC PROC HAND 01830 ANESTH FOREARM SURGERY ANES ARTHRS/ ENDSCPY DSTL RADIUS No Approval Required ULNA/WRIST/HAND 01832 ANESTH WRIST REPLACEMENT ANESTHESIA ARTHRS/ENDOSCPIC No Approval Required TOTAL RECORD REPLCMT 01840 ANESARTH ANESARTH FORWRISTIA Approval Required & HAND NO. 01842 ANESTH LWR EMBOLECTOMY OF THE HAND ANESTH ARTERY FOREARM WRIST & No authorization required EMBOLECTOMY OF THE HAND 01844 ANESTH VASCULAR SHUNT SURG ANESTHESIA VASCULAR SHUNT/SHUNT No. Authorization required REVISION 01850 ANESTH LOWER ARM VEEAR NO. . ANESTH LOWER ARM VEEAR NOS 01852 ANESTH LWR HAND VEIN REPAIR ANES VENNER FOREARM HAND No Approval Required PHLEBORRHAPHY 01860 ANESTH LOWER ARM CAST ANES FOREARM VEIN/HAND STRUT No Approval Required APPL RMVL/REPAIR 01916 ANESTH D X ARTERIOGRAPHIC ANESTHESIA AUT. NESTH HEART CATHETERIZING ANES C-CATHJ W/C ANGIOGRAPHY & No Authorization Required VENTRICULOGRAPHY 01922 ANESTH CAT OR MRI SCAN ANESTH NON-INVASIVE No Authorization Required IMAGING/RADIATION THERAPY 01924 ANES THER INTERVENTION WORK ARTRL ANESTHESIA THER IVNTL RADIOLOGY APPLICATION NR25 Auth. THESIA CAROTID/CORONAR THER No authorization required IVNTL RAD 01926 ANES TX INTERV RAD HRT/CRAN ANES ICRA ICAR/AORTA THER IVNTL No authorization required RAD ARTL 01930 ANES THER INTERVEN RAD VENA ANES VENOUS/LYMPATIC NOS THER No authorization required IVNTLAD ANTLADNES RAD 1930 N INTRAHEPATIC/PORTAL Approval not required THER IVNTL RAD 01932 ANES TX INTERV RAD TH VENOUS ANESTHESIA INTRATHORACIC/JUGULAR Approval not required THER IVNTL RAD 01933 ANES TX INTERV RAD CRAN VEIN ANES INTRACRANIAL THER AuthLYNTL RAD No.

01935 ANESTH PERC IMG DX SP PROC ANESTHESIA PERQ IMAGE GUIDED No authorization required SPINE DIAGNOSTICS 01936 ANESTH PERC IMG TX SP PROC ANESTHESIA PERQ IMAGE GUIDED No authorization required THERAPEUTIC ANESTHESIA SPINE 01951 DIAGNOSTICS 01936 EXC/DB RDMT No authorization required W/WO GRFT 4% TBSA 019 52 ANESTH BURN 4-9 PERCENT ANES 2/3 DGR BRN EXC/DBRDMT No Approval Required W/WO GRFT 4-9% TBSA 01953 ANESTH BURN EACH 9 PERCENT ANES 2/3 DGR BRD No Approval Required W/WO GRF EA 9 % TBS 01958 ANESTH ANTEPARTUM MANIPULATED ANESTHESIA EXTERNAL CEPHALIC No Authorization Required VERSION 01960 ANESTH VAGINAL INSERT ANESTHESIA ONLY ANESTHESIA VAGINA LOADING Auth1CS REQUIRED Auth1CS DELIVERY AREA DELIVERY ONLY No Authorization Required 01962 ANESTH EMERGENCY HYSTERECTOMY ANESTH EMERGENCY HYSTERECTOMY IJA No authorization required FØ DELIVERY LANDING 01963 ANESTH CS HYSTERECTOMY ANESTHESIA C HYST NO USE No authorization required ANALG/ANES CARE 01965 ANESTH INC/MISSET AB PROC ANESTHESIA COMPLETE 6 INCOMPLETE ANESTHESIA 6 INCOMPLETE 6 AB PROCEDURE ANESTHESIA INDUCED ABORTION No authorization required 01967 ANESTH/ANALG VAG DELIVERY NEURA XIAL LABOR ANALG/ANES PLND No approval required VAGINAL DELIVERY 01968 A NES/ANALG CS APPENDIX LIVER ANES CESARN DLVR FLWG NEURAXIAL No approval required ANALGANNES ALG9 ANALGANNES ALG9 LABORATORY. -ON ANES CESARN HYST FLWG NEURAXIAL No approval required LABOR ANALG/ANES 01990 SUPPORT ORGAN DONOR PHYSIOL SUPPORT HARVEST ORGAN No approval required FROM BRAIN DEATH PT 01991 ANESTH NERVE BLOCK/INJ ANESJXVPOS/AquiNTHER. 01992 ANESTH N BLOCKER/INJ ADD ANES DX/DERNE NERVE No Approval Required BLOCKER/INJECTION APPARENT POS 01996 HOSP MANAGE CONT Drug ADMIN DAILY HOSP MGMT EDRL/SARACH CONT No Approval Required Drug ADMN 01999 ADMINISTRATE ADMN. general medicine required - Other full services and clinical examination procedures 10004 FNA BX U/U IMG GDN EA ADDL FINNEEDLE ASPIRATION BX U/O IMG No approval required GDN EA ADDL 10005 FNA BX W/US GDN 1. READ FINNEEDLE ASPIRATION BX W/US GDN No Auth 1. LESION 10006 FNA BX W/US GDN EA ADDL FINNEEDLE ASPIRATION BX W/US GDN Auth Required EA ADDL 10040 ACNE SURGERY ACNE SURGERY Authorization Required Complete Clinical Examination Surgery of the Integumentary System 10080 PDRAINALOFCY 10080 CYST No Authorization Required SIMPLE 10081 PILONIDAL CYST DRAINAGE INCISION AND PILONIDAL CYST DRAINAGE Approval required Full clinical examination operation COMPLICATED cover system 10120 FOREIGN BODY REMOVAL INCISION AND FOREIGN BODY REMOVAL NO. Y Incision and removal of foreign body Clinical examination surgery TOMA BULLA/CYST covering system 10180 COMPLEX WOUND DRAINAGE INCISION & DRAINAGE COMPLEX PO Authorization required Full clinical examination surgery WOUND INFECTION covering system 11000 DEBRIDE INFECTED SKIN DBRDMT EXTENSV ECCEM/INFECTION SK N Authorization required 1 BDUP 1 BDUP SYSTEM 1 BDUP 1 BDUP 1 01 DEBRIDE INFECTED BONE ADDIN- na DBRDMT EXTNSVE EXEM/INFECT SKN AUTOMISATION Surgery required full clinical exam EA 10% BDY Surf Integumentar System 11004 Debride Genitalia and Perineum DBRDmt SKN T/m/m/m/m/ m/m authorization authorization surgical review required DEBRID100M ARCH WALL DBRDMT SKN SUBQ T/M/F NECRO approval required Full clinical review Surgery INFCTJ ABDL WALL cover system surgery 11006 DEBRIDE GENIT/PER/ABDOM WALL DBRDMT SKN SUBQ T/M/F NECRO approval required full integumentary review surgery INFCT system 11008 FERN MESH WITH ABD WALL REMOVAL OF PROSTHETIC MAT ABDL Full clinical review surgery required WALL TO INFECTION integumentary system 11010 DEBRIDE SKIN AT FX SITE DBRDMT W/RMVL FM FX&/DISLC authorization Full CSUBQ0 authorization SK1S 1 11 DEBRIDE SKIN MUSC AT FX SITE DBRDMT W/RMVL FM FX&/DISLC SKN Authorization Required Surgery Full Clinical Exam SUBQ T/M/F MUSC Cover System 11012 DEB SKIN BONE AT FX SITE DBRDMT FX&/DISLC SUBONE T/M/F B Surgery Complete clinical examination of the integumentary system 11042 DEB SUBQ TISSUE 20 SQ CM/< SUBCUTANEOUS TISSUE DEBRIDEMENT Authorization required Full clinical examination operation 20 SQ CM/< integumentary system 11043 DEB MUSC/FASCIA CM 20 DEB MUSC/FASCIA CM & FASCIA 20 Full surgical procedure required clinical examination CM/ < integumentary system 11044 DEB BONE 20 SQ CM/< DEBRIDEMENT SKONE MUSCLE I/FASCIA approval Required Surgery complete clinical examination 20 SQ CM/< integumentary system 11045 DEB EDITION EDITION EDIT. Authorization Required Surgery Full Clinical Examination ADDL 20 SQ CM Covering System 11046 DEB MUSC/FASCIA ADD-ON DEBRIDEMENT MUSCLE &/FASCIA EA Authorization Required Surgery Full Clinical Examination ADDL 20 SQ CM Covering System 11047 DE BRONE ADDIMENT ADION ADION Authorization Required Surgery Full Clinical Examination 20 SQ cm Integumentary System 11055 Trim Skin Lesion Paring/Cutting Benign Authorization Required Operation of Complete Clinical Review Authorization Required Operation of Complete Clinical Review Authorization Required Operation of Complete Clinical Review Authorization Required Hyperkeratotic Lesions> 4 Integumentary System 11102 Tangntl Bx Hud PUNCH BIOPSY SKIN SINGLE LESION No approval required 11105 PUNCH BX SKIN EA SEP/ADDL SKIN USE BIOPAL/ADDL PUNCH BIOPAL.

nr 0 REMOVAL OF NAIL PLATES AVULSION NAIL PLATES No approval required Surgery of PARTIAL/COMPLETE SIMPLE 1 integumentary system 11732 REMOVAL OF NAIL PLATES ADDING AVULSION NAIL PLATES PARIAL/COMP No approval required Surgery of SIMPLE EA ADDL INTEGUMENTAL SYSTEM 1732 REMOVAL OF NAIL PLA TES 0 DRUNK 17BLOOD GUAL HEMATOMA Approval not required know 11750 NAIL BED REMOVAL CUTTING NAIL MATRIX PERMANENT No authorization required REMOVAL 11755 NAIL BIOPSY UNIT NAIL BIOPSY UNIT SEPARATE No authorization required Work Cover System PROCEDURE 11760 REPAIR B2NA R6. NAIL BED RECONSTRUCTION NAIL BED RECONSTRUCTION W/ GRAFT No authorization required Cover System Surgery 11765 NØMFOLD TÅWEGLE EXCISION NAIL FOLD SKIN EXCISION Cover System Surgery 11770 REMOVE PILONIDAL CYST SIMPLE EXCISION PIL/7P1 EXCISION Mandatory REMOVE PILONIDAL CYST EXPAND FROM PILONIDAL CYST/SINUS EXCISION Approval not required COMPLICATED Integumentary System Surgery 11772 REMOVE PILONIDAL CYST COMPL EXCISION PILONIDAL CYST/SINUS No approval required COMPLICATED Integumentary System Surgery 11970 REPLACE TISSUE EXPANDER EXPANDER EquiPANDER EquiPANDER EquiPANDER EquiPANDER REPLACE SUPER MAN STHESIS Integumentary System 11971 REMOVE TISSUE EXPANDER(S) ) ) REMOVE ANJE TISS EXPANDER U/O Approval Full Clinical Review Required Surgery INSERTION OF PROSTHESIS Cover System 11976 REMOVAL OF CONTRACEPTIVE CAPS REMOVAL OF IMPLANTS No approval required CONCEPT COVERS 11983 REMOVAL/IMPLANT/INSERT NO. uth Need SECOND DLVR IMPLT 12001 RPR S/N/AX/GEN/TRNK 2.5CM/< SINGLE REPAIR No approval required HEAD/NECK/AX/GENIT/TRP 2.5CM/< 12002 RPR S/N/AX/GEN/ TRNK2. 6-7.5CM SMPL REPAIR No. Approval required HARD BOTTOM/NECK/AXE/GENIT/BUMPER 2.6- 7.5CM 12011 RPR F/E/E/N/L/M 2.5 CM/< SINGLE REPAIR F/E/E/N/L/M 2.5CM/< No Approval Required 12013 RPR F/E/E/N/L/M 2.6-5.0 CM SINGLE FIX F/E/E/N/L/M 2.6CM-5.0 No Approval Required CM 12015 RPR F/E/E/N / L/M 7.6-12.5 CM SIMPLE REPAIR F/E/E/N/L/M 7.6CM- No Approval Required 12.5 CM 12016 RPR FE/E/EN/L/M 12.6-20.0 CM SIMPLE REPAIR F/E/ E /N/L/M 12.6CM- No Approval Required 20.0 CM 12017 RPR FE/E/EN/L /M 20.1-30.0 CM SIMPLE REPAIR F/E/E/N/L/M 20.1CM- No Approval Required 30.0 CM 12018 RPR F/E/E/N/L/M >30.0 CM SINGLE REPAIR F/E/E/N/L/M >30.0 CM No Approval Required 15769 GRFG AUTOL SOFT TISS DIR EXC ENGRAVING AUTOLOG SOFT TISS No approval required DIRECT EXC 15771 GRFG AUTOL FAT LIPO 50 CC/< GRAVING AUTOLOGOUS GREASE NO APPROVAL REQUIRED LIPO 50 CC OR LESS 15772 GRFG AUTOL FAT LIPO EA ADDL OVERPAY AUTOLOGOUS GREASE 7 NO. RFG AUTOL FAT LIPO 25 CC/< AUTHORIZED AUTOLOG FAT ENGRAVING LIPO 25 CC OR LESS 15774 GFRG AUTOL FAT LIPO EA ADDL AUTOLOG FAT ENGRAVING NO AUTHORIZED LIPO EA ADDL 25 CC 15774 15774 TRNS 15774 15774 TRNS. ANSLANTAT 1 -15 Authorization required Full clinical examination surgery PUNCH GRAFTS Cover system 15776 HAIR TRNSPL >15 PUNCH GRAFTS PUNCH GRAFT Hair transplant >15 Authorization required Full clinical examination surgery PUNCH GRAFTS Cover system 15780 FACET GRAFT DERMA Surgical approval for full clinical examination Integument system 15781 SEGMENTAL FACIAL DERMABRASION SEGMENTAL FACIAL DERMABRASION Approval required Full clinical examination cover system surgery 15782 DERMABRASION EXCEPT FACIAL DERMABRASION REGIONAL OTHER Approval required Full clinical examination surgery NOT Cover system 15782 DERMABRASION EXCEPT FACIAL DERMABRASION REGIONAL OTHER Approval required Full CPRACEBRION Surgery Full CPRACEBRION 378 2 FL DERMABRASION ON EACH SIDE SURFACE OF EACH SIDE. Permissions Required Full Clinical Integumentary Review Surgery 15786 ABRASION LESION SINGLE ABRASION 1 LESION Permissions Required Full Clinical Integumentary Review Surgery 15787 ABRASIONS LESION ADD-ON ABRASION EACH ADD-ON 4 LE SIONS authorization required OR CHlinESS Integumentary System 15787 ABRASION LESIONS ADD-ON ABRASION. PEL EPIDERM OF THE FACE CHEMICAL PEEL OF THE EPIDERMAL FACIAL Permit required Surgery of the complete clinical examination of the integument system 15789 CHEMICAL FACIAL PEEL OF THE SKIN OF THE FACIAL CHEMICAL PEEL OF THE DERMA OF THE FACE Permit required Surgery of the complete clinical examination of the integument system 15792 CHEMICAL PEEL OF THE FACIAL SKIN NON FACIAL Review of PEEL FACIAL NONFACIJAL Authorization PEEL FACIAL NONFACIJAL integument mentally system 15793 CHEMICAL PEELING WITHOUT FACE CHEMICAL PEELING WITHOUT FACE DRMAL Permissions required Surgery of full clinical examination of the covering system 15820 REVISION OF LOWER EYEBROWS BLEPHAROPLASTIC LOWER EYEBROWS Permissions required Surgery of full clinical examination of the covering system 15821 LOWEREYOFBL REVISION OF LOWEREY PLASTIC Surgery required full clinical examination HERNIA FAT PILLOW cover system 15822 UPPER EYEBROW REVISION UPPER EYEBROW BLEPHAROPLASTY Permissions required Operation Full clinical examination cover system 15823 UPPER EYEBROW REVISION UPPER EYEBROW BLEPHAROPLASTY Permissions required Surgery of the entire C4C5MO system SK12C2M0000 0000000 FOREHEAD WRINKLE RYTHIDECTOMY FOREHEAD Full approval required Surgery clinical examination of the integumentary system

15825 WRINKLE REMOVAL RHYTIDECTOMY NECK W/PLATYSMAL Permissions Required Full Clinical Exam Surgery Integumentary System TIGHTENING 15826 WRINKLE REMOVAL RHYTIDECTOMY GLABELLAR FROWN Surgical Review LINE Required Full 82 FACIAL WRINKLE SELECTION RHYTIDECT OMY CHIN AND NECK Approval Required Full Clinical Exam Surgery Integumentary System 15829 SKIN WRINKLE REMOVAL RHYTIDECTOMY SMAS FLAP Permissions required Surgery Full Clinical Examination Integumentary System 15830 EXC SKIN ABD SKIN EXCISION ABD INFRAUMBLIC PERSONAL authorization Full Clinical Examination Integumentary PA1 832 EXCISE EXCISION EXCISION EXCISION Skin & SUBQ Authorization Required Full Clinical Surgery TISSUE Examination Integumentary System Thigh 15833 EXCISE EXCESSIVE SKIN OF THE LEG TOO HEAVY SKIN & SUBQ Approval Required Full Clinical Examination Surgery TISSUE OF THE APPLIED SYSTEM 15834 EXCISE SCUBA & SUBQ Q Approval Required Full Clinical Examination Surgery OF THE HIP TISSUE 15835 EXCISE EXCESSIVE SKIN EXCISION OF THE BUTT EXPRESSED SKIN & SUBQ Approval Required Full Clinical Surgery Surgery review TISSUE GUARD cover system 15836 EXCISION HAND SKIN EXAMINATION SUBCIS authorization Review HAND TISSUE cover system 15837 EXCITING ARM/HAND EXCESS SKIN EXC RECONSIDERATION OF SKIN & SUBQ TISSUE Approval required Operation of full clinical Review FOREARM/HAND cover system 15838 EXCISION OF EXCESSIVE SKIN FAT PAD EXC EXCSV SKIN AND SUBQ TISSUE Permissions Required Surgery System SUB C15SE 19 SKIN & TISSUE EXCISION EXCISION EXCISION EXCESSIVE SKIN & SUBQ Permissions Required Full Clinical Review Surgery TISSUE OTHER AREA Blanket ary System 15847 EXC SKIN ABD APPENDIX EXCISION FORECAST SKIN EXCISION & SUBQ Approval Required Full Clinical Review Surgery SSUAMEGEN integumentary SSUAMEEN INTEgumentary 5 5 5 8 ON SUTURE REMOVAL UNDER No. Approval required ANESTHESIA SAME SURGEON 15851 SUTURE REMOVAL DIFFERENT SURGEON SUTURE REMOVAL UNDER Approval not required AN ESTHESIA DIFFERENT SURGEON 15852 CHANGE NOT ON FIRE PLACEMENT DRESSING CHANGE UNDER ANESTHESIA UNDER ANESTHESIA 15 SEARCH REQUIRED AND 15 HEAD LIPECTOMY ASSIST & authorization required Full Clinical Review Surgery ram system DOORS 15877 SUCTION LIPECTOMY CARDAP SUCTION CARDAP LIPECTOMY Authorization Required Operation Full Integumentary System Clinical Review 15878 SUCTION LIPECTOMY UPR EXTREME SUCTION LIPECTOMY UPPER Authorization Required Full Clinical Review Surgery 8 Luctre Integumentary System 8 Ectomy LWR Extreme SUG ASSISTER LIPECTOMY Lower Authorization Required complete clinical examination of the Extremity of the integumentary system 15999 REQUEST FOR DESTRUCTION OF PREMALIGNANT REQUEST TOO MALIGNANT REQUEST TOO SMALL GN0 READ 2-14 DESTRUCTION OF PREMALIGNANT LESIONS Br approval required 2 -14 EA 17004 DESTRUCTION OF PREMALIGNANT LESIONS 15/> DESTRUCTION OF PREMALIGNANT LESIONS No approval required 15/> 17106 DESTRUCTION OF SKIN LESIONS DESTROYED ANJE KOZNIH VASC approval required torn Surgery of the entire clinical system 1 0CM 1 PROLIFERATE 1 S0 CM 1. DESTRUCTION B9 LESION 1-14 DESTRUCTIVE BNIGN LESIONS TO No approval required 14 17111 DESTRUCTIVE LESION 15 OR MORE DESTRUCTIVE BNIGN LESIONS 15/> No approval required 17311 MOHS STAGE 1 H/ N/HF /G MOHS MICROGRAPHIC H/N/H/F/G required 1. Moh. Auth. Code in group STAGE 5 BLOCKS Applies to all codes within the specified group 17312 MOHS ADDL STAGE MOHS MICROGRAPHIC H/N/H/F/G No Mohs PA approval required for code in the group EACH ADDL STAGE Applies to all codes within the specified group 17313 MOHS DEGREE 1 T/A/L MOHS BODY/HAND/LEG 1. DEGREE 5 No Mohs PA approval required for a code in the BLOCKS group Applies to all codes within the specified group 17314 MOHS ADDL DEGREE T/A/L MOHS BODY/HAND/ LEG EA STAGE Approval required Mohs PA for code in group AFTER 1ST STAGE Applies to all codes within specified group 17315 MOHS SURG ADDL BLOCK MOHS TRUMPET/HAND/LEG EA ADDL No Mohs PA approval required for code in group BLOCK ANY STAGE Applies applies to all codes within a certain group 17340 SKIN CRYOTHERAPY CRYOTHERAPY CO2 SLUSH LIQUID N2 authorization required Reconstructive Full clinical examination ACNE 17360 SKIN PEELING TREATMENT CHEMICAL PEELING ACNE authorization required Reconstructive Full clinical examination 17380 HAIR REMOVAL 0 ELECTROVALIZATION OF HAIR REMOVAL 0 Reconstructive required Complete clinical examination MINUTE 1 7999 SKIN TISSUE PROCEDURE UNEXAMINED PX SKIN MUC MEMBRANE and Authorization Required Full Clinical Review Surgery SUBQ TISSUE Covering System 19294 PREP TUM CAV IORT PRTL MAST PREP TUMOR CAVITY IORT W/PARTIAL approval required Radiotherapy Full Clinical Review MASTECTOMY 19300 BREKOMMAST. gery of Full Clinical Review Integumentary System 19303 MAST SIMPLE COMPLETE MASTECTOMY SIMPLE COMPLETE Authorization Required Surgery of Full Clinical Review Integumentary System 19307 MAST MOD RAD MAST MODF RAD W/AX LYMPH NODE Authorization Required Surgery of Full Clinical Review W/W 1 SUMIN Integumentary System 19307 MAST AGAINST ROW MAST AGAINST BREAST MASTOPEXIES Approval Required Reconstructive Full Clinical Review 19318 BREAST REDUCTION REDUCTION AMMAPLASTIC Approval Required Full Clinical Review Surgery Cover System 19324 BREAST AUGMENTATION AMMAPLASTIC INCREASE REQUIREMENTS Surgical PLASTIC Authorization Cover Surgical System 19325 B RE-AUGMENTATION WITH PAMAPLASTIC IMPLANT P INCREASE Authorization for the required full operation clinical examination W/PROSTHETIC IMPLANT covering system 19328 REMOVAL OF OTHER IMPLANT REMOVAL OF INTACT BREAST IMPLANT Authorization required Surgical procedure of full clinical examination of covering system 19330 REMOVAL OF OTHER IMPLANT REMOVAL OF REMOVAL OF MAMMARY IMPLANT. Full Clinical Review MATERIAL Cover System 19340 IMMEDIATE BREAST PROSTHESIS IMMT INSJ BRST PROSTH FLWG Approval Full Clinical Review Surgery Required MASTOPEXY MAST/RCNSTJ Cover System 19342 DELAYED BREAST PROSTHESIS DLYD INSJ BRST PROSTH CWling MRC Surgical Approval KRAV STJ Cover System

19355 CORRECT INVERTED NIPPLES INVERTED NIPPLE CORRECTION Approval Required Reconstructive Full Clinical Review 19357 BREST RECONSTRUCTION BRST RCNSTJ IMMT/DLYD W/TISS Approval Required Full Clinical Review Surgery EXPANDERJ1 SCONSTRUBSQ EXPANDERJ1 SCONSTRUBSQ System EXPANDERJ 1S1S6SQ LAT FLAP BRST RCNSTJ W/ LATSMS D/SI FLAP WO- authorization required Full Clinical Review Surgery PRSTHC IMPL Integumentary System 19364 BREAST RECONSTRUCTION BREAST RECONSTRUCTION Required Approval FREE FLAP Authorized Surgical Treatment Full Clinical Review Integumentary System 19366 BREAST RECONSTRUCTION BREAST RECONSTRUCTION Full FLAP Approval Required. linical Review TECHNIQUE cover system 19367 BREAST CONSTRUCTION BREAST CONSTRUCTION TRACK FLAP Approval required Surgery Full Clinical Review 1 PEDICULA Cover System 19368 BREAST CONSTRUCTION BREAST CONSTRUCTION TRAM 1 Approval required Full Clinical Review Operation PEDICULA COVER SYSTEM B19368 BREAST BUILDING BR BREAST BUILDING BREAST BUILDING 1 Authorization required Surgery full clinical examination PEDCL MVASTRE 19369 TRAM FLAP RECONSTRUCTION Authorization required Surgery with full clinical examination DOUBLE PEDICULE cover system 19370 CHEST CAPSULE SURGERY OPEN PERIPROTHETIC CAPSULOTOMY Authorization required Full clinical examination surgery BREAST cover system 19371 CHEST REMOVAL C CAPSULE PERIPROTHETIC CAPS ULA authorization Full required CHEST surgical exam CAPSULES 1 9380 REVISION BREAST RECONSTRUCTION REVISION BREAST RECONSTRUCTION Permissions Required Full Clinical Review Surgery Cover System 19396 DESIGN CUSTOM MULAGE BREAST IMPLANT PREPARATION CUSTOM Permission Required Full Clinical Review Surgery BREAST IMPLANT Covering System 19 499 BREAST SURGICAL PROCEDURE UNLISTED SURGEON SKI BREAST PROCEDURE Authorization required2 FOR REMOVAL OF FOREIGN BODIES FOREIGN BODIES No. Powers Pk Torn Sheath MUSCLE/TENDON SIMPLE 20550 INJ TENDON/LIGAMENT 1 TENDON INJECTION No Aponeurosis Sheath/LIGAMENT Clearance Required 20560 NDL INSJ U/O NJX 1 OR 2 MUSK NEEDED/ 1 MUSK NOT NEEDED AND 2 20561 NDL INSJ W / O NJX 3+ MUSCLE NEEDLE INSERTION WITHOUT INJECTION 3 No Approval Required OR MULTIPLE MUSCLES 20600 DRAIN/INJ JOINT/BURSA U/O US ARTHROCENTESA ASPIR&/INJ SMALL No Approval Required JT/BURSA W/6IN JT /BURSA W/0JINT US /BURSA W/ US ARTHROCNT ASPIR&/INJ SMALL No approval required JT/BURSAW/US REC RPRT 20700 MNL PREP&INSJ DP RX DLVR DEV MANUAL PREP & INSERTION DEEP No approval required DRUG DELIVERY DEV 20700 DELIVERY DEEPR REVL DELIV. DEVICE NO Approval Required 20702 MNL PREP&INSJ IMED RX DEV MANUAL PREP&INSJ INTRAMEDULAR No Approval Required DRUG DLVR DEVICE 20703 RMVL IMED RX DELIVERY DEVICE INTRAMEDURAL DRUG REMOVAL No Approval Required M2-DELIVERY07 RMVL IMED RX DEL IVERY DEVICE V MANUAL PREP&INSJ I-ARTIC DRUG Approval not required LEV ERING UNIT 20705 RMVL I -ARTIC RX DELIVERY DEV REMOVAL INTRA-ARTICULAR DRUG No authorization required DELIVERY DEVICE 20930 SP BONE ALGRFT MORSEL ADD-ON ALLOGRANFT FOR SPINE SURGERY ONLY Authorization required Full clinical review surgery SPculoskeletal system SP 1ct SP culoskeletal system MOR201CT DD-ON ALLOGRANFT FOR SPINE SURGERY ONLY Authorization Required Full Clinical Review Surgery STRUCTURAL Musculoskeletal System 20932 OSTEOART ALGRFT W/SURF & B1 OSTEOARTICULAR ALLOGRAFT Authorization Required Full Clinical Review Surgery W/ARTICULAR SURF & BONE System AL20FTR-- I BONE-MUSCULAR 3RT -MUSCULOSKELET T9 ORTHICAL INTERCALARY Authorization required Full Clinical Review Surgery ALLOGRAFT PARTIAL Musculoskeletal System 20934 INTERCALARY ALGRFT COMPLIC INTERCALARY ALLOGRAFT COMPLETE Authorization Required Full Clinical Musculoskeletal Review Surgery 20936 SP BONE AGRAFT LOCAL ADDITIONAL AUTOGRAFT INCOCAL SURGERY REQUIRED Skeletal System 2093 7 SP BONE AGRFT MORSEL ADD-ON AUTOGRAFT SPINE SURGERY Authorization Required Full Clinical Examination Surgery MORSELIZE D SEP INCISION Musculoskeletal System 20938 SP BONE AGRFT STRUCT ADD-ON AUTOGRAFT SPINE Authorization Required Full Clinical Examination Surgery SECORT MORSEL AGRFT STRUCT IR BONE GRFG Bone Marrow Aspiration Bone Approval Spinal Care Needed Combined with Full Clinical Review ONLY GRFG SPI surgical conditions of the neck and back, including: 20974 ELECTRICAL BONE STIMULATION ELECTRICAL BONE STIMULATION Permit Required Surgery Full Clinical Review HEALING 520974 IMULATION ELECTRICAL BONE STIMULATION Permits Required Full Clinical Review Surgery HEALING INVASIVE Muscular- skeletal system 20979 US BONE STIMULATION LOW INTENSITY US BONE STIMULATION Authorization required Full clinical examination surgery NON-INVASIVE Musculoskeletal TREATMENT 20999 EQUIPED FOR MUSCULO-Skeletal L PRACTICE MUSCULO-Skeletal PRINTED SOLUTION ar full clinical examination SYSTEM GENERAL Treating joint dysfunction 21010 JOINT ICISION THIS ARTHROTOMY TEMPOROMANDIB Approval required ULAR Temporomandibular complete clinical examination Joint dysfunction treatment 21011 EXC FACE LES SC Musculoskeletal system 21050 JOINT REMOVAL CONDYLECTOMY JOINT JOINT JOINT JOINT JOINT JOINT JOINT JOINT JOINT JUD BED KÄLINOMANDI LED dysfunction treatment 21060 JAW JOINT REMOVAL CARTILAGE IČAVICE MENISCECTOMY PRTL/COMPL Authorization required Temporomandibular Complete Clinical Examination TEMPO Complete Clinical Examination of the Mandible PROCEDURE Joint Dysfunction Treatment 21073 REMOTE CORONID PROCESS CORONOIDECTOMY SEPARATE Authorization Required Temporomandibular Complete Clinical Examination PROCEDURE Treatment of Joint Dysfunction 21073 MNPULATION TMJJULATION TIME TIME Oromandibular Complete Clinical Examination REQUIRES ANESTHESIA Treatment of Joint Dysfunction 21085 PRINT PREPARATION I FACIAL PREPARATION/ ORAL DENTURES ORAL Clearance Required Reconstructive Full Clinical Examination SURGICAL SPLINT 21089 FACIAL/ORAL DENTURE PREPARATION MAXILLOFACIAL DENTURE NOT LISTED Approval Required Full Clinical Examination Surgery PROCEDURE muscul21RDEN INTERNATIONAL APPLICATION PROCEDURE muscul21rDen FIXATION DEVICE Approval Required Full Clinical Examination Temporomandibular Joint NON-FX/DISLC D Treatment of dysfunction

21116 JAW INJECTION JOINT X-RAY INJECTION TEMPOROMANDIBULAR Approval required Temporomandibular Full clinical examination JOINT SARTROGRAPHY Treatment of joint dysfunction 21120 CHIN RECONSTRUCTION GENIOPLASTIC AUGMENTATION Authorization Full RECONSTRUCTIVE CHIN 21 REPLIN 1 CRU 21 Reconstructive 1 CRU 21 Reconstructive ive ASTY SLIDER OSTEOTOMY Author required ization Surgical procedure of complete clinical examination ONE STK musculoskeletal system 21122 CHIN RECONSTRUCTION GENIOPLASTY 2/> GLIDE Permissions required Full clinical examination surgery OSTEOTOMIES musculoskeletal system 21123 CHIN RECONSTRUCTION GENIOP GLIDE AGMNTJ Permissions required Full clinical examination surgery WONE/IN GRAFPOST muscular system A251212 MANDIBULA ATION Augmentation AGMNTJ MNDBLR BODY/ANGLE Authorization Required Reconstructive Full Clinical Review Prosthetic Material 21127 Mandibular Bone Resurfacing Agmntj Mndblr Bdy/Angl W/GRF Authorization Required Reconstructive Full Clinical Review OnLay/Interposal 21193 Reconstructive LWR JAW W/O Graft RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L Authorization Required Full Clinical Review Surgery OSTEOT U/O GRF Musculoskeletal System 21194 RECONST LWR JAW W/GRAFT RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L Authorization Required Full Clinical Review Surgery OSTEOT M/GRAFT Musculoskeletal System/2119AW RECONSTO JAW RECONST. RCNSTJ MNDBLR RAMI&/BODY SGTL Approval Required Full Clinical Review Surgery SPLT W/O INT RGD Musculoskeletal 21196 RECONST LWR JAW W/FIXATION RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT Approval Required Surgical Review Musculoskeletal W12 9GD Surgical System W21 RGD1 CGD 19 RECONSTR LWR SEGMENT JAW OSTEOTOMY MANDIBLE SEGMENTAL Authorization Required Full Clinical Review Musculoskeletal Surgery 21199 RECONSTR LWR JAW W/ADVANCE OSTEOTOMY MANDIBLE SGMTL Authorization Required Full Clinical Review Surgery W/GENIOMLOSS 121 musculos 12-2000 musculos 1 GRAFT GRAFT BONE MANDIBEL Required approval Operation Full Clinical Review Musculoskeletal System 21240 ARTHRP RECONSTRUCTION OF TEMPOROMANDIBULAR JOINT Authorization Required Joint Full Clinical Review W/WO AUTOGRAFT 21242 ARTHROPLASTYLDEN RECONSTRUCTION Full Authorization CROMANDI REQUIRED FULL BOARD W2TRAFT 1243 ARTHRP TMPRMAND JOIN RECONSTRUCTION T Authorization Required Joint Full Clinical Review W/ PROSTHETIC PROSTHESIS 21244 MANDIBULAR RECONSTRUCTION RCNSTJ MNDBL XTRORAL Authorization Required Reconstructive Full Clinical Review W/TRANSOSTAL BONE PLATE 21245 JAWDY RECONSTRUCTION RCNSTJ RCNSTJ WRITING Author Full Review RCNSTJ M ACTION PARTIAL 21246 JAW RECONSTRUCTION RCNSTJ MNDBL/MAXL SUBPRIOSTEAL Authorization Required Reconstruct ivna Complete clinical examination IMPLANT COMPLETE 2 1247 LOWER JAW BONE RECONSTRUCTION RCNSTJ MNDBLR CONDYL W/BONE Approval required Reconstructive Full clinical review CARTLG AUTOGRAFTS 21248 MANDBLR RECONSTRUCTION SECOND JAW BONE Author red Temporomandibular Full clinical review IMPLANT PARTIAL treatment of joint dysfunction 21249 JAW RECONSTRUCTION RCNSTJ MANDIBLE/MAXL ENDOSTAL Approval required Temporo mandibular Complete clinical examination IM PLANT KIT Treatment of joint dysfunction 21255 MANDIBULAR BONE RECONSTRUCTION RCNSTJ ZYGMTC ARCH/GLENOID CLG RECONSTRUCTION. 270 AUGMENTATION MALAR AUGMENTATION OF THE LUMBER Bone Required Approval Reconstructive Full Clinical Review MATERIAL 21299 CRANIO/MAXILLOFACIAL SURGERY NOT LISTED CRANIOFACIAL & Approval Required Surgery Full Clinical Review MAXILLOFACIAL MUSCULOSKELETAL PROCEDURE 21499 MAJOR SURGICAL PROCEDURE NOT REQUIRED Surgical Review Full Surgical examination REQUIRED. MAJOR Musculoskeletal System 21601 EXC CHEST WALL TUMOR W/RIBS CHEST WALL TUMOR Full clinical exam required INCLUDING RIBS 21602 EXC CH WAL TUM U/O LYMPHADEC EXCISE CH WAL TUM W/RIB U/O Full clinical exam required MEDSTNL LYMPHADEC 21603 W CH WALHAUMC W CHUMC TUMC W/O /RIB Authorization Required Complete Clinical Exam W/MEDSTNL LYMPHADEC 21685 HYOID MYOTOMY & SUSPENSION HYOID MYOTOMY & SUSPENSION Authorization Required Surgery Complete Clinical Musculoskeletal Examination 21899 NECK/COASTAL SURGEON SURGERY REQUIRED surg. Y from full clinical examination musculoskeletal system 22114 Remove part of lumbar vertebra PTL ECC VRT BDY B1Y LES U/O SPI Authorization Required Full clinical examination surgery cable 1 SGM LMBR musculoskeletal system 22116 Remove segment of SPL BLY VRT B1Y B1Y / 1 SGM EA musculoskeletal system 22206 INCIS SPINE 3 COLUMN THORACIC SPINE POSTERIOR 3 Authorization required Full clinical examination operation THORACIC SPINE Musculoskeletal system 22207 INCIS SPINE 3 COLUMN POSTERIUM LUMBAR COLUMN Full clinical examination required Examination LOWER COLUMN musculoskeletal system 22208 INCIS SPINE 3 COLUMN SHE ADL SEG OSTEOTOMY OF SPINE POSTERIOR 3 Authorization Required Complete Clinical Examination Surgery COLUMN EA ADDL SGM Musculoskeletal System 22210 INCIS 1 VERTEBRAL SEG CERV OSTEOTOMY OF SPINE PST/PSTLAT APPR. 212 INCIS 1 VERTEBRAL SEG THORAK SPINE OSTEOTOMY PST/PSTLAT APPR 1 Approval Required Full Clinical Review Surgery VRT SGM THRC Musculoskeletal System 22214 INCIS 1 VERTEBRAL SEG LUMBAR SPINE OSTEOTOMY PST/PSTLAT APPR 1 Review Approval Required Full SGM SGM2BR Musculoskeletal System 16 INCIS ADDL POSTERIOR SEGMENT OSTEOT SPI PST/PSTLAT APPR 1 VRT Authorization Required Full Clinical Review Surgery SGM EA VRT SGM Musculoskeletal System 22220 INCIS W/DISCECTOMY CERVICAL SPINE OSTEOTOMY W/DSKC ANT APPR Authorization Required Surgery of Whole Musculoskeletal System 2 V CRT 2 V CRT 2 2 INCIS W/DISCECTOMY THORACIC SPINE OSTEOTOMY W/DSKC ANT APPR Authorization Required Full Clinical Review Surgery 1 VRT SGM THRC Musculoskeletal 22224 INCIS W/DISCECTOMY LUMBAR SPINE OSTEOTOMY W/DSKC ANT ANT APPR Authorization VRT ANT APPR APPR. etal system 22226 REVIDE EXTRA SPINE SEGMENT OSTEOT SPI M/DSKC ANT APPR 1 VRT Authorization Required Surgery of Full Clinical Review SGM EA VRT SGM Musculoskeletal System 22510 PERQ CERVICOTHORACIC INJECT PERQ VERTEBROPLASTY Complete CERVICOTHORACIC INJECT PERQ VERTEBROPLA STY Complete study CCO-INJECT. IC Musculoskeletal system 22511 PERQ LUMBOSACRAL INJECTION PERQ VERTEBROPLASTY UNI/BI Authorization required Full clinical examination Surgery INJECTION LUMBOSACRAL Musculoskeletal system 22512 VERTEBROPLASTICS ADDL INJECT VERTEBROPLASTICS EACH ADDL Authorization required Full clinical examination Surgery CERVICO-SACRAL 22512 VERTEBROPLASTICS ADDL BRAL AUGMENTATION PER Q VERT AGMNTJ C AVITY DRAWING UNI/ BI Authorization Required Full Clinical Review Surgery Musculoskeletal CANNULATION 22514 PERQ VERTEBRAL AUGMENTATION PERQ VERT AGMNTJ CAVITY DRAWING UNI/BI Authorization Required Full Clinical Review Surgery CANNULJ LMBR Musculoskeletal System

22515 PERQ VERTEBRAL AUGMENTATION PERQ VERT AGMNTJ CAVITY DRAWING UNI/BI Authorization Required Full Clinical Review Surgery CANNULJ EACH Musculoskeletal System 22526 IT SINGLE LEVEL PERQ INTRDSCL ELECTROTHRM Authorization Required NOW CLOPLASTY Surgical Review of Full CLO PLEV System. 22527 IDET LEVEL 1 OR MORE PERQ INTRDSCL ELECTROTHRM Approval Required Full Clinical Review Surgery ANULOPLASTY ADDL LVL Musculoskeletal System 22532 LAT THORACIC SPINE FUSION ARTHRODESI LATERAL EXTRA CAVITARIA Approval Required Full Clinical Review Surgery THORACIC SPINE FUSION 25MBART 22532325 2000 LATERAL EXTRA CAVITARY authorization required Surgery full clinical examination LUMBAR musculoskeletal system 22534 LAT THOR/LUMB ADDL SEG ARTHRODESIS LAT EXTRACAVITAE EA authorization required Full clinical examination surgery ADDL THRC/LMBR musculoskeletal system 22548 CERVICAL BACK FUSION ARTHRD ANT TRANSORL/XTRORAL C1- authorization Full CDN Muscle OCDN- Surg ical Authorization of WCDN -muscle AREA system 22551 CERVICAL SPINE SECURE&REMOVE BEL C2 ARTHRD ANT INTERTIEAL DECOMPRESSION Authorization required Complete clinical examination surgery CERVICAL BELW C2 musculoskeletal system 22552 ADDL NECK SPINE SPINE ARTHRD ANT INTERDY CERVCL BELW C2 muscle authorization Full CDL muscle surgery numerical system 22554 CERVICAL SPINE FUSION ARTHRD ANT MIN DISCECT INTERBODY Approval Full Clinical Review Required Surgery CERV UNDER C2 Musculoskeletal System 22556 THORAX SPINE FUSION ARTHRD ANT MIN DISCECTOMY Approval Full Clinical Review Required Surgery INTERBODY THORACIC SUPPLIER Musculoskeletal 2MBAR 58 IOR INTERBODY Approval Requir ed Full Clinical review Lumbar Musculoskeletal System Surgery 22585 ADDITIONAL SPINAL FUSION ARTHRODESI ANTERIOR INTERBODY EA Authorization Required Full Clinical Review Surgery ADDL NTRSPC Musculoskeletal System 22586 PRESCRL FUSE W/ INSTR L5-S1 ARTHRODESI PRESACRAL INSTRUCTION FOR COMPLETE L5-S1 ARTHRODESI PRESACRAL SUBMISSION REQUEST 5 S1 Musculoskeletal tal system 22590 SPINE AND SKULL SPINAL FUSION ARTHRODESI POSTERIOR Authorization Required full clinical examination CRANIOCERVICAL musculoskeletal system operation 22595 NECK SPINAL FUSION ARTHRODESI POSTERIOR ATLAS-AXIS Approval Required full clinical examination operation SPART-FUSION 22595 ODESIS PST/PSTLAT CERVICAL Authorization required full clinical examination surgery of examination BELW C2 SGM Musculoskeletal system 22610 SPINE FUSION THORACIC ARTHRODESI Authorization required Full clinical examination surgery POSTERIOR/POSTEROLATERAL Musculoskeletal system THORACIC 22612 LUMBAR SPINE FUSION ARTHRODESI Authorization required POSTERIOR/POSTEROLATERAL Musculoskeletal system LUMBAR Musculoskeletal System 2 2614 SPINE JOINT EXTRA SEGMENT ARTRHOD ESI Approval Required Full Clinical Review Surgery POSTERIOR/POSTEROLATERAL EA ADDL Musculoskeletal 22630 LUMBAR SPINE FUSION ART RHODES POSTERIOR INTERBODY License Required Full Clinical Review LUMBAR Musculoskeletal 22632 EXHR SPINE POSTERY Required Full Clinical Review Surgery EA ADDL Muscular -skeletal system 22633 LUMBAR SPINE FUSION COMBINED ARTHDSIS authorization required Full Clinical Review Surgery POST/POSTEROLATRL/POSTINTERBODY Musculoskeletal System LUMBAR 22634 SPINE FUSION EXTRA SEGMENT ARTHDSIS Authorization Required Full Clinical Review Surgery/POSTERBOLASTICS/muscular/muscular system/muscular system. SEG 22800 POST FUSION VERT SEG ARTHRODESI POSTERIOR SPINAL DFRM Approval Required Approval Surgery Full Clinical Examination 13/> VRT SEG Musculoskeletal System 22808 ANT FUSION 2-3 VERT SEG ARTHRODESI ANTERIOR SPINAL DFRM Approval Surgery Full Clinical Examination 2-3 VRT SEG-System 2-3 FRT SEG 0 Musculoskeletal System 2-7 ANTERIOR SPINAL ARTHRODESIS DFRM Approval Full Clinical Review Required Surgery 4-7 VRT SEG Musculoskeletal System 22812 ANT FUSION 8/> VERT SEG ANTERIOR SPINAL DFRM ARTHRODESIS Approval Full Clinical Review Required Surgery VRT1G8 /> 8/ >8/>VRT SEG 8/> Y 1-2 SEGMENTS KYPHECTOMY ONE OR TWO Authorization required Full clinical examination Surgical SEGMENTS Musculoskeletal system 22819 KYPHECTOMY 3 OR MORE KYPHECTOMY 3 OR MORE SEGMENTS Authorization required Full clinical examination Surgery musculoskeletal 22819 KY 3 OR MORE KYPHECTOMY 3 OR MORE SEGMENTS KYPHECTOMY 3 OR MORE SEGMENTS Approval Required Surgery Full Clinical Examination Musculoskeletal 22819 KYPHECTOMY 3 OR MORE KYPHECTOMY 3 OR MORE SEGMENTS. ION Authorization required Full Clinical Review Surgery Musculoskeletal 22840 INSERT SPINE FIXATION DEVICE POSTERIOR NON-SEGMENTAL Authorization required Full Clinical Review Surgery INSTRUMENTS Musculoskeletal 22841 INSERT SPINE FIXATION DEVICE INTERNAL SPINE FIXATION CABLES License required Full Clinical System Surgery S PIN US PROkeleS2S2C 22 841 POSTERIOR SEGMENTAL FIXATION DEVICE Permission required Full Clinical Review Surgery INSTRUMENTS 3-6 VRT SEG Musculoskeletal 22843 INSERTS POSTERIOR SEGMENTAL SPINE FIXATION DEVICE Permission required Full Clinical Review Surgery INSTRUMENTS 7-12 VRT SEG Musculoskeletal 22844 INSERTS BACK authorization Surgeon y INSERT VEG Full Clinical Review INSTRUMENTS 13/ > VRT SEE Musculoskeletal System 22845 INSERT SPINE FIXATION DEVICE ANTERIOR INSTRUMENT 2-3 Approval Required Full Clinical Examination Surgery SPINE SEGMENTS Musculoskeletal System 22846 INSERT SPINE FIXATION DEVICE ANTERIOR INSTRUMENT FRONT SURGICAL AUTHORIZATION REQUIRED TYPEWRITER. MENTS Musculoskeletal 22847 INSERTS SPINE FIXATION DEVICES ANTERIOR INSTRUMENTS 8/> Approval required Operation Full Clinical Review SPINE SEGMENTS Musculoskeletal 22848 INSERTS BONE FIXATION DEVICES PELVIS FIXATION EXCEPT SACRUM Approval required Operation Full Clinical Review System REINSERT2 8IN9 SPILLERIN9 DEVICE FOR FIXATION Authorization required Full Clinical Examination Musculoskeletal Surgery 22850 REMOTE SPINE FIXATION DEVICES POSTERIOR NON-SEGMENTAL REMOVAL Authorization required Full Clinical Examination Surgery Musculoskeletal INSTRUMENTS 22852 REMOTE BACK FIXATION DEVICES POSTERIOR SEGMENTAL REMOVAL surgical review full segmental surgical system 2 2853 I NSJ BIOMECHANIC UNIT INSJ BIOMCHN DEV INTERVERTEBRAL Authorization required Full Clinical Examination Surgery DSC SPC M/ ARTHRD Musculoskeletal System 22854 INSJ BIOMECHANIC DEVICE INSJ BIOMCHN DEV VRT CORPECTOMY Authorization Required Surgery Full Clinical Examination DEFECT M/ ARTHRD Musculoskeletal System 22855 REVICER REVITER surgeon REVITER REVALYR DEVELOPMENT Full Clinical Review Musculoskeletal INSTRUMENT 22856 CERV ARTIFICIAL DISCECTOMY TOT DISC ARTHRP ART DISC APPRO Approval Required Full Clinical Review Surgery 1 NTRSPC CRV Musculoskeletal

22857 LUMBAR ARTIF DISCECTOMY TOT DISC ARTHRP ART DISC ANT APPRO Approval required Full Clinical Examination Surgery 1 NTRSPC LMBR Musculoskeletal System 22858 SECOND LEVEL CER DISCECTOMY TOT DISC ANT APPRO Approval Required Full Clinical Examination L22858 EL CERVICAL Musculoskeletal System 22859 INSJ BIOMECHANIC UNIT INSJ BIOMCHN DEV NTRVRT DISC SPACE Approval Required Full Clinical Review Surgery No ARTHRD Musculoskeletal 22861 REVISION CERV ARTIFICIAL DISC REVJ RPLCMT DISC ARTHROPLASTY ANT Authorization Required Surgery 1 CR2NT 6 PCL 6 VISE LUMBAR ARTIF DISC REVJ RPLCMT DISC ARTROPLAZA STY ANT Approval Required Full Clinical Review Surgery 1 NTRSPC LMBR Musculoskeletal system 22864 FJERN CERV ARTIF DISC RMVL DISK ARTHROPLASTY ANT 1 Authorization required Operation of full clinical examination INTERSPACE CERVICAL Musculoskeletal system RMVCLUCMIF 22DISKEL 65 ARTHROPLASTY ANT 1 Authorization required Operation of full clinical examination INTER SPACE LUMBAR Musculoskeletal system 22867 INSJ STABLJ DEV W/DCMPRN INSJ STABLJ DEV W/DCMPRN LUMBAR Authorization Required Surgery of Full Clinical Review SINGLE LEVEL Musculoskeletal System 22868 INSJ STABLMP DEV INSJ STABLMP DEV INS WLUMBAR DEV INS Required Surgery of Full Clinical Review SECOND LEVEL Musculoskeletal System 22869 INSJ STABLJ DEV U/ O DC MPRN INSJ STABLJ DEV U/ O DCMPRN LUMBAR Authorization Required Surgery of Full Clinical Review SINGLE LEVEL Musculoskeletal System 22870 INSJ STABLJ DEV W/O INSJ STABLJ DEV INSJ STABLJ DEV INSJ STABLJ DEVINS WLUMBAR ization Required Surgery of Full Clinical Review SECOND LEVEL Musculoskeletal System 22899 SURGICAL SPINE AL PROCEDURE PROCEDURE NOT LISTED BACK CONTROLLED Surgery authorization required for full clinical musculoskeletal examination 22999 SURGICAL PROCEDURE PROCEDURE NOT LISTED PX muscle surgery authorization M Full CLO muscle authorization etal system 23330 SHOULDER REMOVAL FOREIGN BODY REMOVAL FOREIGN SHOULDER BODY Approval not required SUBCUTANEOUS 23470 RECONSTRUCT SHOULDER DER GLENOHUMRL JOINT ARTHROPLASTY JT Authorization required Full Clinical Review Surgery HEMIARTROPLAST Y Musculoskeletal System 23472 RECONSTRUCTION JORDROPLASTY JORDROPLASTY JUDROPLASTY JUDROPLASTY REQUIRED SHOULDER HUPLASTY SHOULDER gery of Full Clinical Review TOTAL SHOULDER Musculoskeletal System 23473 RE VIS RECONST SHOULDER JOINT REVIS SHOULDER ARTHR Approval Required PLSTY Full Clinical Review Surgery HUMERAL/GLENOID COMPNT Musculoskeletal System 23474 REVIS RECONST SHOULDER JOINT REVIS SHOULDER ARTHRPLSTY Approval Required Full Clinical Review Surgery HUMERAL & GLENOID COMPNT Musculoskeletal TREATUREX0 2360 TX HUMERALUS 2360 USE No Approval Required NO MANIPULATION 23615 HUMERAL FRACTURE TREATMENT OPEN TREATMENT PROXIMAL authorization required Full clinical review Surgery HUMERUS FRACTURE Musculoskeletal system 23929 SHOULDER SURGERY PROCEDURE NOT ON SHOULDER LIST Authorization required Full clinical review Musculoskeletal surgery NA 2420 B DEVELOPMENT . No Approval Required ARM/ELBOW SUBCUTAN 24360 RECONSTRUCT ALBUW JOINT ARTHROPLASTY ELBUE W/MEMBRAN Approval Required Joint Full Clinical Review 24361 RECONSTRUCT ELBULE JOINT ARTROPLASTY ELBUE W/DISTAL Approval Required Joint Full Clinical Review HUMRL PROSTC RPLCMT 24362 W PLARTBORPHCA JOFTIM ATA Approval Required Joint Full Clinical Review review LIGAMENT RCNSTJ 24363 ARTHRP ELBOW JOINT REPLACEMENT W/DISTAL HUM&PROX authorization required Usual Full Clinical Review UR PROSTC RPLCM 24365 RADIAL HEAD RADIUS ARTHROPLASTY RECONSTRUCTION requires authorization Usual Full Clinical Review 24366 HEAD RECONSTRUCTION FOR RADIAL HEAD RADIUS ARTHROPLASTY Authorization Required Usual Full Clinical review 24366 RECONSTRUCTION GL FOR RADIUS ARTHROPLASTY Approval Required, Full Clinical Review W/IMPLANT 24370 REVIS RECONST ALBUELED REVIS ALBU ARTHRPLSTY Approval Required, Joint Full Clinical Review HUMERAL/ULNA COMPNT 24371 REVISE RECONST ALBUELED REVIS ALBU ARTHRPLSTY Approval Required, Full Joint Clinical Review HU MERAL&ULNA COMPNT FRUL 5 FX&/DISLC ELBW Authorization Required Joint Full Clinical Review W/ IMPLT ARTHR 24650 TREAT RADIUS BREAD CLOSED TX RADIAL HEAD/NECK FX U/O No Authorization Required MANIPULATION 24999 UPPER ARM/ELBOW SURGERY UNLISTED PROCEDURE Authorization Required Full Clinical/Muscular System Surgery 3W -Muscle-0 5 -2000 FOREARM BURSA CUT AND DRAINAGE. No Authorization Required FOREARM AND/HAND BURSA 25332 HAND JOINT EXAMINATION ARTHRP WRST W/WO INTERPOS W/WO Authorization Required Complete Clinical Joint Examination XTRNL/INT FIXJ 25441 RECONSTRUCT HAND JOINT ARTHROPLASTIC W/WO DISTRA 5 4 42 GENKOSTRUGER HAND JOINT ARTHROPLASTY W/WO PROSTHETIC Authorization Required Common Full Clinical Review RPLCMT DISTAL ULNA 25443 WRIST ARTHROPLASTY RECONSTRUCTION W/PROTEIC Authorization Required Common Full Clinical Review RPLCMT SCAPHOID CARPAL 25444 RECONSTRUCT ARTHROSTY Quintic Review LUNATE REPLACEMENT 25445 HANGER ARTHROPLASTY RECONSTRUCTION W/PROSTHETIC Authorization Required Common Complete clinical examination TRAPEZIUM REPLACEMENT 25446 JOINT REPLACEMENT ARTHRP W/PROSTC RPLCMT DSTL Authorization Required Common Full Clinical Review RDS&PRTL/KARPUS 25447 CARPUS JOINT REPAIR INTERNATIONAL CARPUS ARTHRPAL Authorization Full Clinical Review AL JOINTS 25449 JOINT REMOVAL WRIST REVJ ARTHR P W/REMOVE IMPLANT Authorization Required Joint Full clinical review WRIST 25999 FOREARM OR WRIST SURGERY NOT ON PROCEDURE LIST Authorization required Full Clinical Review Surgery FOREARM/HAND Musculoskeletal 26010 FINGER DRAINAGE Required FINGER 26011 FINGER DRAINAGE 26011 FINGER DRAINAGE FINGER DRAINAGE ER ABSCES FINGER No authorization required COMPLICATED 26020 DRAINAGE OF TENZIJSKO SLEEVE OF HAND ROLLER No approval required DIGIT&/PALM ECH 26025 PALMAR BURSA DRAINAGE PALMAR BURSA DRAINAGE SINGLE B030 RSAS PALMAR BURSA DRAINAGE No approval required MULTIPLE BURSA 26 530 REVISION ARTHROPLASTY OF JOINT JOINT Approval required Complete clinical examination of METACARPOPHALGEAL EACH JOINT 26531 REVISION OF THE PLUMB WITH ARTHRP IMPLANT MTCARPHLNGL JT M/PROSTC Authorization Required Joint Full Clinical 5 JFINGER 26531 HROPLASTY INTERPHALANGEAL Authorization Required Joint Full Clinical Examination EACH JOINT

26536 REVISION/IMPLANT FINGER JOINT ARTHROPLASTY INTERPHALANGEAL JT Approval Required Complete Clinical Joint Examination W/PROSTHETICS EA 26600 TREAT METACARPAL BRUSH CLTX METACARPAL FX U/O No Approval Required IP TXLO 0 FIN MANIPULATION 26 EACH MANIPULATION HAL JT DISLC M/LESS U/O no ANES Authorization Required 26989 HAND/FINGER SURGERY UNSETTLED HAND/FINGER PROCEDURE Authorization Required Full Clinical Musculoskeletal Examination Surgery 27086 HIP FOREIGN BODY REMOVAL RMVL PELVIC/HOOK TUBE FOREIGN BODY 2709 PRO AUTHISS 2709 PRO AUTHORIZED HIP REMOVAL PRO GRADUATE SEPARATOR Authorization on Fox joint Full clinical review PROCEDURE 27091 HIP PROSTHESIS REMOVAL RMVL HIP PROSTH COMP W/TOT Hip Authorization Required Joint Full Clinical Review PROSTH MMA 27096 INJECT SACROILIAC JOINT INJECT SI JOINT Authorization Required Joint Full Clinical/27096 PARTIAL HIP REPLACEMENT HIP HEMIARTHROPLASTY PARTIAL Approval required. Joint Full Clinical Review 27130 TOTAL HIP YDD PLASTIK ARTHRP ACETBLR/PROX FEM PROSTC authorization required Common Full Clinical Review AGRFT/ALGRFT 27132 TOTAL HIP ARTROPLASTY ASSIST ARTHROPLATY TRPTV REQUEST Full HIP JOINT EXAMINATION POSITION REQUEST linear review AGRFT/ALGRFT 27134 REVISER HIP JOINT REPLACEMENT REVJ TOT HIP ARTHRP BTH Required W/WO Authorization Common Full Clinical Review AGRFT/ALGRFT 27137 REVISES HIP JOINT REPORT REVJ TWO HIP ARTHRP ACTBLR W/WOGRFT Full Authorization Clin GRIP REVISION J7137 Full Authorization J7137 MELE REPLACEMENT REVJ ONLY HIP ARTHRP FEMALE W/WO Required authorization Joint Full Clinical Review ALGRFT 27279 ARTHRODESI SACROILIAC JOINT ARTHRODESI SACROILIAC JOINT Approval Required Full Clinical Review Surgery PERCUTANEOUS Musculoskeletal System PERCUTANEOUS Musculoskeletal System F2 ACROILICAJ JOINT Approval Required Full Clinical Review Surgery W/ADMISSION GRAFT Musculoskeletal System 27299 PE JOINT SURGERY LVIC/HIP NOT LISTED PELVIC/HIP PROCEDURE Full approval required Clinical joint examination Joint 27324 TEAM BIOPSY FINE TISSUE REQUIRED TEAM/KNEE FINE TISSUE BIOPSY Full muscle 27324 TISSUE BEND BIOPSY Thigh/KNEE REQUIRED Full muscle 27324 327 EXC Thigh/KNEE LES SC < 3 CM TUMOR EXCISION SOFT TISSUE Authorization Full Clinical Review Required Surgery Thigh /KNEE SUBQ 27340 BURSA REMOVAL KNEE NECK EXCISION OF PREPATELLAR BURSA Approval Required Usual Full Clinical Review 27347 KNEE REMOVAL REQUIRED Full Clinical Joint KNEE 27355 REMOVE FEMURAL LESION EXCISION/CURETAGE OF CYST/TUMOR Approval Required Full Clinical Review Surgery FEMUR Muscu loskeletal System 27356 REMOVE FEMUR LESION/GRAFT EXCISION/CURETAGE CYST/TUMOR License Required Full Clinical System Surgery W/27356 EMUR LESION/GRAFT EXCISION /CYST/TUMOR CURRETAGE Authorization Required Full Clinical Review Surgery FEMUR W/AUTOGRAFT Musculoskeletal System 27358 REMOVE FEMUR LESION/FIXATION EXCISION/C URETHAGE CYST/TUMOR Approval required Full clinical examination Surgery FEMUR FEMUR LESION/FIXATION EN (E) PRTL EXC BONE FEMUR PROX Approval required Full Clinical Examination Surgery TIBIA&/FIBULA Musculoskeletal System 27364 THIGH/KNEE RESECT 5 CM /> WORK TUMOR RESECTION SOFT TIS Authorization required Full clinical review surgery 5 CMKEL/5E system THIGH 5/7KEL /5E THOMAS/KNEE TUMOR RADICAL TUMOR RESECTION SKIN OR Authorization required Full clinical review surgery KNEE Musculoskeletal system 27369 NJX CNTRST KONE ARTHG/CT /MRI NJX PX CNTRST KNE ARTHG CNlinTRST Surgical approval of full KNHRI KR. etal system 27372 FOREIGN BODY REMOVAL DEEP authorization required Full Clinical Review Surgery Thigh/Knee Musculoskeletal System 27403 KNEE CARTILAGE ARTHROTOMY REPAIR W/MENSICUS REPAIR Approval Required Full Clinical Review KNEE PREPR2740FUL 5KNEE 27403 LIGM&/CAPSULE Approval Required Joint Full Clinical Review KNEE SAFETY REPAIR 27407 KNEE LIGAMENT REPAIR PRIMARY RACE REPAIR Required Joint Full Clinical Review LIGM&/CAPSULE KNEERUDS 27409 KNEE LIGAMENT REPAIR REQUIRED RPR 1 REPAIR Full Review RPR 1 KNEE REQUIRED CRLIN RUCIATE 27412 AUTOCHONDROCYTE IMPLANT KONE AUTOLOGU CHON Full Joint Approval Required DROCYTE clinical examination KNEE IMPLANTATION 27415 KNEE OSTEOCHONDRAL ALLOGRANFT OSTEOCHONDRAL KNEE ALLOGRANFT Joint Authorization Required Full Clinical Examination OPEN 27416 OSTEOHONDRAL AUTOGRAFT KNEE OPEN 27416 OSTEOHONDRAL AUTOGRAFT KNEE C7SAQONDRAL AUTOGRAFT KNEE C7SA8Y1 Red Joint Authorization AIR DEGENERATED KNEE CALYSIS ANTERIOR TIBIAL TUBERCLEPLAST IKA Approval required Timing of full clinical examination of the joint 27420 REVISION OF UNSTABLE KNEE CAP RCNSTJ DISLOCATION CUPS Need Approval Joint Full Clinical Review 27422 UNSTABLE KNEE CAP REVISION RCNSTJ DISLC PATELLA W/XTNSR Need Approval Joint Full Clinical Review RELIGNMT&/4MUSCREVISION 27421 Approval Need JOINT CUPS KNEE Full Clinical Review W /PATEL LEXTOMY 27425 LAT RETINACULAR RELEASE OPEN LATERAL RETINACULAR R ELEASE OPEN Required authorization Joint Full clinical review 27427 KNEE RECONSTRUCTION LIGAMENTAL KNEE RECONSTRUCTION Authorization required Common Full clinical review EXTRA-CART

27428 RECONSTRUCTION KNEE LIGAMENTOUS RECONSTRUCTION KNEE Authorization Required Common Full Clinical Review INTRA-ARTICULAR 27429 RECONSTRUCTION KNEE LIGAMENTOUS RCNSTJ AGMNTJ KNEE INTRA Authorization Required Common Full Clinical Review XTR ARTICULAR KN ÆR 27428 LA W/O Authorization Required Common Full Clinical Review PROSTHESIS 27438 REVISE KNEECAP WITH IMPLANT ARTROPLASTIKA PATELLA РевизиJA продукция программы компания клиники преглед W/PROTEZA 27440 REVIZIJA ARTROPLASTIKE ZGLOBNA KONE TIBIAL PLATEAU Odobrenje Potpuni klinični pregled 27441 REVIZIJA ARTROPLASTIKE KOLJENOG ZGLOBNA KOLJENO TIBIAL PLATEAU Odobrenje программе программы программы клиники преглед 27441 RE VIZIJA ARTROPLASTIKE ZGLOBOVA KOLJENA Potpuni klinični pregled DBRDMT &PRTL SYNVCT 27442 Revizija Arroplastike Koljena Five Condyles/Tibial Potrebna Authorizacija Common Full Clinical Review Plateau Kneee 27443 Revizija Wife Joint Arthrp Five Condyles/Tibl Platu Authorization Required Common Full Clinical Review Knie DBRDMT & Prt Intofa Kronehasty 27445 Koljeno Author Zahtijeva Zajednički Potpuni Klinčki Pregled Proteza 274 46 REVIZIJA ARTHRP KOLJENA CONDIL & PLATEAU KOLJENA Nekoda autorizacija Potpuni kliniksi pregled MEDIAL/LAT CMPRT 27447 TOTALNA ARTROPLASTIKA KOLJENA ARTHRP KONE CONDIL & PLATEAU Autorizacija Nekoda klinička revizija MEDIAL&LAT SPACE 54 BLITG 2 REA7 2 MT IMED ROD Nekoda autorizacija Potpuni kliniksi pregled Operacija FEM SHFT mišilno- koštanog sustava 27455 STVARNO ZAPALJENJE KLJENA OSTEOT PROX TIBIA FIB EXC/OSTEOT Požana autorizacija Kirurgija topolog kliniskog pregleda PRIJE EPIPHYSL-a Muskuloskeletni sustava 27457 PONOVNO POSTAVLJANJE KOLJENA OSTEOT OSTEIB PROX TIBIA Equiter Kirurgija topolog kliniskog pregleda. PIPHYSL Mišićno-koštani sustav 27465 HUBALNO SKRAĆENJE OSTEOPLASTIKA VELJAČA SKRAĆENJE Pričné odženje Potpuni kliníkni pregled Kirurgija ISKLUJUJUĆI 64876 Mišićno-koštani sustav 27466 HUBAL DULJENJE OSTEOPLASTIKA VELJAČA DULJENJE Pričné odženje Operacija pune kliničke 27466 6487 6 Mišićno-koštani sustav 27 466 HS OSTPL FEMUR CMBN LNGTH&SHRT required autorizacija Operacija topolog kliniskog pregleda W / FEMORAL SGM TRNSFR mišičlno-koštani sustava 27470 POPRAVAK BEDRA RPR NON/MAL NOGE DSTL H/N U/O Poša autorizacija Operacija topolog kliniskog pregleda GRF mišićno-koštanog sustava 27472 POPRAVAK/ZAMJENA BEDRA RPR NON/Kr. Potpuni kliniksi pregled M/ILIAC/AUTOG BONE Mišićno-koštani sustav 27486 REVIZIJA/ZAMJENA ZGLOB KOLJENA REVJ TOTAL KNEE ARTHRP W/WO poderna autorizacija Common Potpuni kliniksi pregled ALGRFT 1 KOMPONENTA 27487 REVIZIJA/ZAMJENA ZGLOB KOLJENA ZGLOB KOLJENA Potpuni kliniksi pregled KOMPONENTA TIBIJE 27488 UKLANJANJE PROTEZE KOLJENA RMVL PROSTH TOT PROTEZA KOLJENA MMA Potrajan jajdni pomlini klinikni pregled W/WO INSJ SPACER 27495 POJAČANJE Bedro PROPH TX N/P/PLTWR W/WO WO Kirurški pregled punog CLMETURHED kirurško pregled musculature pokraj etalni sustav 27599 L NPR KIRURŠKI POSTUPAK NEPOZIVAN ZAHVAT NOGE/COLJENA Necessary permission Chirurgija topolnog klinikog pregled mišilno-koštanog sustava 27700 REVIZIJA GLEŽANJSKOG ZGLOBNA ARTROPLASTIKA GLEŽANJ Necessary permission Common Potpuni kliniki pregled 27702 REKONSTRUKCIJA GLEŽNJA JPLASTIKA autorizacija GLEŽANJ JPLIM Potpuni kliniki pregled 27703 REKONSTRUKCIJA GLEŽANJA LED ARTHR OPLASTIKA GLEŽNJA REVIZIJA UKUPNO Počas autorizacija Čest Potpuni klinični pregled GLEŽANJ 2770 4 UKLANJANJE IMPLANTATA U GLEŽANJU UKLANJANJE IMPLANTATA U GLEŽANJU Čečné odjekto Common Potpuni klinični pregled 27750 LIJEČENJE PRIJELOMA TIBIJE CLTX TIBIAL SHAFT FX U/O MEDIA 7CL FXuth 27750 BR. CLTX MEDIAL MALLEOLUS FX W/O Nije začnogo odženje MANIPULACIJA 27786 LIJEČENJE PRIJELOMA GLEŽNJA CLTX DSTL FIBULAR FX LAT MALLS W/O Nije zažnoje ženje MANJ 27899 KIRURŠKI POSTUPAK ZA NOGU/GLEŽANJ NIJE NA LISTI POSTUPAK POTREBAN ZA NOGU/GLEŽANJ Kirurški sustav DIO 1 REMO VAL METATARSALNE OSTECTOMIJE PRTL 5 METAR GLAVA Pričné objekto Potpuni kliníkní pregled Kirurgija SPX Mišićno-koštani sustav 28190 UKLANJANJE STOPALA UKLANJANJE STRANOG TIJELA UKLANJANJE STRANOG TIJELA STOPALO Nije pričné objektuje POTKOŽNO 28193 UKLANJANJE STRANOG TIJELA STOPALA 8 285 ISPRAVLJANJE STRANOG TIJELA STOPALA Pričné prječní Puni žald Kliníki pregled 282 86 POPRAVAK KOREKCIJSKOG PRSTA ČEKIĆA -UP 5. PRST NA STOPALU Продажа предложений программы пластични клиники преглед W/PLASTIČNO ZATVARANJE 28288 DJELOMIČNO UKLANJANJE KOSTI STOPALA OSTC PRTL EXOSTC/CONDYLC METAR Potpuni pregled 28 COJRIAD Potpuni pregled 28 O IMPLT HALLUX RIGIDUS M/CHEILECTOMY 1. approval праводний программы программы программы клиники преглед MP JT U/O IMPLT 28291 CORRJ HALUX RIGDUS W/IMPLT HALLUX RIGIDUS W/CHEILECTOMY 1ST Подробнее autorizacija Common Full Clinical Review W /RESCJ PROX PHAL 28295 ISPRAVAK HALLUX VALGUS CORRJ HALLUX VALGUS W/SESMDC Програница продажа Common Full Clinical Review M/PROX METAR OSTEOT 28296 CORRECTION JoRRLUX HALGUS VALGUS KOVALDC Autor Potpuni VALGUS VALGUS Dobiveni pregled M/DIST METAR OSTEOT 28297 CORR ECTION HALLUX VALGUS CORRJ HALLUX VALGUS W /SESMDC potrani autorizacija Uncommonly full clinical pregled M/1METAR MEDIAL CNF 28298 KOREKCIJA HALLUX VALGUS CORRJ HALLUX VALGUS W/SESMDC Autorizacija Potpuni kliniki pregled W/SESM Pregled P8/SESM Autorizacija W2 99 SMJER HALLUX VALGUS CORRJ HALLUX VALGUS W/SESMDC W/2 Autorizacija Potrajan jadni pomni klinikni pregled OSTEOT 28306 INCISION OF METATARSAL OSTEOT W/WO LNGTH SHRT/CORRJ 1st Authorization Required Common Full Clinical Review METAR 28307 METAR 28307 METATARSAL OSTEOT W/WO LNGTH SHRT/CORRJ 1st Common Potrajan pomni clinical review METAR XCP 1ST NOŽNI PRSTI 28308 REZ OF METATARSALS OSTEOT W/WO LNGTH SHRT/CORRJ REQUIRED Full Clinical Review METAR XCP 1ST EA 28309 INCISION OF METATARSALS OSTEOT W/WO LNGTH SHRT/CORRJ REQUIRED Full Clinical Review METAR XCP 1ST EA 28309 INCISION OF METATARSALS OSTEOT W/ WO LNGTH CRJ . METAR MLT 28450 TREAT MIDFOOT ČETKA SVAKI TX TARSAL BONE FX XCP TALUS&CALCN Nije potrana autorizacija U/O MANJ 28705 FUZIJA KOSTIJU STOPALA ARTRODEZA PANTALAR Potpuni autorizacija Joint Potpuni kliniksi pregled TRUSION 7OD 15 FOOT DEVELOPMENT TRUSION 28705 Joint Potpuni kliniksi pregled 28725 SPAJANJE KOSTIJU STOPALA ARTHRODESIS SUBTALAR 28730 FUSION OF BONES ARTHRD MIDTARSL/TARSOMETATARSAL

28735 FUSION OF FOOT BONES ARTHRD MIDTARSL/TARS Authorization Required Joint Full Clinical Review MLT/TRANSVRS M/OSTEOT 28737 REVISION OF FOOT BONES ARTHRD W/TDN LNGTH&ADVMNT Authorization Required Joint Full Clinical N2-7TCUARIF Full Clinical BONE ARTHRODESI MIDTARSOMETATARSAL Full Authorization Required. Joint Clinical Review SINGLE JOINT 28750 FUSION TOE ARTHRODESIS OF TOE TOE Need Approval Joint Full Clinical Review METATARSOFALGEAL JOINT 28755 FUSION OF TOE ARTHRODESIS COMPLETE TOE ARTHRODESIS Approval F7 APPLICATION OF TOE ARTHRD M/XTNSR HALLUCIS LONGUS Authorization Required Common Complete clinical examination TR 1ST METAR NCK 28820 TOE AMPUTATION TOE AMPUTATION Approval required Common Full clinical examination METATARSOFALGEAL JOINT 28825 PARTIAL AMPUTATION OF TOE AMPUTATION OF TOE AMPUTATION OF TOE 98 PARTIAL AMPUTATION OF TOE AMPUTATION OF FOOT INTERPHAL 9 ENRGY ESWTAR FASCIA ES WT HI NRG PHYS/QHP W/US GDN Authorization Full Clinical Examination Surgery Required INVG PLNTAR FASCIA Musculoskeletal System 28899 FOOT/TOE SURGICAL PROCEDURE NOT LISTED Full Clinical Examination Required Surgical Authorization MUSCULOSOLED APPLICATION APPLICATION 29075 ELBOW TOE FOR EJECTION Not authorization required SHORT ARM 29 125 APPLY FOREARM SPLIT APPLY SHORT ARM SPLIT No authorization required BELOW ARM- STATIC ARM 29405 APPLY SHORT LEG SPLIT APPLY SHORT LEG SPLIT BELOW No authorization required KNEE-TOE SHORT LEG SPLITS 25 No authorization required WALKING/ MOVEMENT 29515 APPLY LOWER LEG BRACKET APPLY SHORT LEG CALCULATOR No approval required FOOT 29540 ANKLE AND/OR FOOT BINDING ANKLE AND/FOOT BINDING No approval required 29799 CASTING/BONDING PROCEDURE REQUIRED APPROPRIATE CASTING/BONDING PROCEDURE Full REQUIRED MUS. culoskeletal system 29800 JAW ARTHROSCOPY/ARTHROS TEMPOROMANDIBULAR SURGERY JT DX joint authorization required Full clinical examination W/WO SYNVAL BX SPX 29804 JAW ARTHROSCOPY/TEMPOROMANDIBULAR ARTHROSCOPY SURGERY joint authorization required Full clinical examination J29804 JAW ARTHROSCOPY Y/ TEMPOROMANDIBULAR SURGERY ARTHROSCOPY NO approval required Joint Full clinical examination ARTHROSCOPY SHOULDER DX W/WO No Authorization Required Led SYNOVIAL BIOPSY SPX 29806 SHOULDER ARTHROSCOPY/SURGICAL SHOULDER ARTROSCOPY SURGICAL No Authorization Required Led CAPSULORRHAPHY 29807 ARTHROSCOPY/SHOULDER SURGERY ARTHROSCOPY SHOULDER SURGERY ICAL None Auth REPAIRCOSL 9 PY/SURGERY REQUIRED KA ARTHROSCOPY OF THE SHOULDER SURGICAL GIST No authorization required Joint removal LØS/FB 29820 ARTHROSCOPY/SHOULDER SURGERY ARTHROSCOPY SHOULDER REPLACEMENT No authorization required Led SYNOVECTOMY PARTIAL 29821 SHOULDER ARTHROSCOPY/SURGICAL ARTHROSCOPY SHOULDER REPLACEMENT No authorization required Led SYNOVECTOMY COMPLETE 29822 ARTHROSCOPY/SHOULDER SURGERY ARTHROSCOPY SHOULDER REPLACEMENT No approval required Led SYNOVE CTOMY COMPLETE 29822 SHOULDER ARTHROSCOPY/ SURGICAL int DEBRIDEMENT LIMITED 29823 SHOULDER ARTHROSCOPY/ SURGICAL SHOULDER ARTHROSCOPY REALIZATION No approval required Joint DEBRIDEMENT EXTENSIVE 29824 SHOULDER ARTHROSCOPY/ SURGICAL SHOULDER ARTHROSCOPY DISTAL No approval required Joint CLAVICULECTOMY 29825 SHOULDER ARTHROSCOPY/ SURGICAL AR THROSCOPY OF THE SHOULDER ACHESIOLISIS JOINT WHR2O9 PY/SURGICAL ARTHROSCOPY OF THE SHOULDER No authorization required ice M/CORACOACRM LIGMNT RELEASE 29827 ARTHROSCOPY ROTATOR CUFF REPR ARTHROSCOPY SHOULDER ROTATOR No authorization required Joint Cuff REPAIR 29828 ARTHROSCOPY BICEPS TENODESIS SHOULDER ARTHROSCOPY BICEPS No authorization required Joint TENODESIS 29830 E ELBOW ARTHROSCOPY ARTHROSCOUT Aquity BIOPSY SPX 29834 ARTHROSCOPY SCOPE/SURGERY ARTHROSCOPY ELBOW SURGERY No approval required joint W/REMOVAL LOOSE/FB 29835 ELBOW ARTHROSCOPY/SURGICAL ELBOW ARTROSCOPY SURGICAL No approval required Joint SYNOVECTOMY PARIAL 29836 ELBOW ARTHROSCOPY/SURGICAL ARTHROSCOPY ELBOW ARTHROSCOPY 8 COMP. 9 COMP. 7 ELBOW ARTHROSCOPY/SURGICAL ARTHROSCOPY ELBOW SURGICAL No Authorization Required Joint DEBRIDEMENT LIMITED 29838 ELBOW ARTHROSCOPY/SURGICAL ARTHROSCOPY ELBOW SURGICAL No Authorization Required JOINT DEBRIDEMENT EXTENSIVE 29840 WRIST ARTHROSCOPY JOINT DEBRIDEMENT DI AG W/WO No Authorization Required SYNOVIAL BIOPSY SPX 298 40 WRISTOSHROSPY WRIST/SURGERY SECTION no. Approval required JOINT WASHING AND DRAINAGE 29844 ARTHROSCOPY/SURGERY OF THE WRIST ARTHROSCOPY HAND SURGICAL No. Authorization Required Partial Joint Synovectomy 29845 ANKLE ARTHROSCOPY/SURGICAL ANKLE ARTHROSCOPY SURGICAL No Authorization Required Joint SYNOVECTOMY COMPLETE 29846 ANKLE ARTHROSCOPY/SURGICAL ARTHROS Joint& AuthBRST EXTR. 29847 WRIST ARTHROSCOPY/SUCTION WRIST SURGICAL ARTHROSCOPY INT FIXJ No Clearance Required Joint FX/INSTABILITY 29848 WRIST ENDOSCOPY/SURGICAL NDSC WRST SURG W/RLS TRANSVRS No Clearance Required Joint CARPL LIGM 29850 KNEE ARTHROSCOPY /SURGICAL ARTHROSCOPY ASSISTANT ARTHROSCOPY COL. JENA/SURGERY ART ROSCOPY HELP TX SPINE&/FX KNEE -approval required Usual Full Clinical Review M/FIXJ 29855 ARTHROSCOPY/SURGICAL TIBIAL ARTHROSCOPY/TIBIAL ARTHRS FRACTURE SURGICAL ASSISTANCE Required Usual Full Clinical Review PROXIMAL UNICONDYLAR 29856 TIBIAL ARTHROSYRKUS TIBIAL JOINT/SURG. Full Clinical Joint Examination UNICONDYLAR BICONDYLAR 29860 HIP ARTHROSCOPY DX ARTHROSCOPY HIP DIAGNOSTIC W/WO No approval required Joint SYNOVIAL BYP SPX 29861 HIP ARTHROSCOPY W/FB REMOVAL ARTHROSCOPY SURGICAL HIP No approval required Joint W/RE MOVAL LOO

29862 HIP ARTHR0 W/DEBRIDEMENT ARTHRS HIP BRIDERATION/SHAVE Authorization Required Common Full Clinical Review ARTICULAR CRTLG 29863 HIP ARTHR0 W/SYNOVECTOMY ARTHROSCOPY HIP SURGICAL No Authorization Required Joint W/CONTVECTOM W/CONTVECTOM 6/29866 PE ARTHROS COPY KONE OSTEOCHONDRAL Authorization Required Vet Led Full Clinical Review AGRFT MOSAICPLAST 29867 ALLGRFT IMPLNT KONE W/SCOPE KNEE ARTHROSCOPY OSTEOCHONDRAL Authorization Required Common Full Clinical Review ALLOGRAFT 29868 MENISCAL TRNSPL KNEEE W/SCPE KONE KONE WORTH REVISION TR0L Full Review K98RED Full MENISCAL KONE20 NO ARTHROSCOPY DX KNEE ARTHROSCOPY GNOSTI C Authorization required Led Full Clinical Review W /WO SYNOVIAL BX SPX 29871 KNEE ARTHROSCOPY/DRAINAGE ARTHROSCOPY KNEE INFECTION Authorization Required Common Full Clinical Review LAVAGE AND DRAINAGE 29873 KNEE ARTHROSCOPY/SURGICAL KNEE ARTHROSCOPY Full Review KNEE ARTHROSCOPY K8 9 4 KNEE ARTHROSCOPY/ SURGERY ARTHROSCOPY ODKL KNEE SWING Authorization required Common full clinical Review INJURY/FOREIGN BODY 29875 ARTHROSCOPY/SURGICAL KNEE SYNOVECTOMY KNEE Authorization required Joint Full Clinical Review LIMITED SPX 29876 ARTHROSCOPY/KNEE SURGERY KNEE ARTHROSCOPY/SURGICAL KNEE SYNOVECTOMY ARTHR 2/>RUM 2987 7 ARTHROSCOPY/KNEE SURGERY ARTHRS DEBRIDATION/SHAVING THE KNEE Full Approval Required Joint Clinical Review ARTCLR CRTLG 2987 9 ARTHROSCOPY/KNEE SURGERY ARTHRITIS ABRASION KNEE ARTHRP/MLT Approval Required Full Clinical Joint Examination DRLG/MICROFX 29880 ARTHROSCOPY/KNEE SURGERY ARTHRITIS KNEE ARTHRSKYR Full Clinical Joint Examination Required MED&LAT W / SHAVING 29881 ARTHROSCOPY/SURGERY KNEE ARTHRITIS KNEE SURGERY W/MENISCECTOMY Authorization Required Joint Full Clinical Review MED/LAT W/SHVG 29882 KNEE ARTHROSCOPY/SURGICAL KNEE ARTHROSCOPY LIND W/MENISCUS Authorization Full Review W/MENISCUS. 3 KNEE ARTHROSCOPY/KNEE SURGICAL ARTHROSCOPY W/MENISCUS RPR Approval Required Common Full Clinical Review MEDIAL & LATERAL 29884 KNEE ARTHROSCOPY/KNEE SURGICAL ARTHROSCOPY W/LYSE Approval Required Common Full Clinical Review ADHESIONS W/WO MANJ SPX 298 ARTHROSCOPY KN EE-W/LYSE NDRITIS- authorization required joint full clinical review DISSECANS GRFG 29886 KNEE ARTHRSCOPY/SURGERY ARTHRS KNEE DRILLING OSTEOHONDA Authorization required joint full clinical review DISSECANS LESIONS 29887 KNEE ARTHRSCOPY/SURGERY ARTHRS KONE DRLG OSTEOHONDA Review D8JISS Full approval D8E CHINESE 9. ARTHROSCOPY/SURGERY GIST SUPPORT ANT CROSSBEAT R Authorization Required Joint Full Clinical Review RPR/AGMNTJ/RCNSTJ 29889 ARTHRSCOPY/SURGICAL KNEE ASSISTANCE ARTHRS PST KRUSLIGG Authorization Required Joint Full Clinical Review RPR/AGMNTJ/RCNSTJ 29891 ARTHROSCOPY/SURGICAL ANKLE AuthHRS AUTHRS DF JOINT REQUIRED M/DRLG DFCT 29892 ANKLE ARTHROSCOPY HER /SURGICAL SKL HJ ELP RPR LES/TALAR DOME No approval required Joint FX/TIBL CEILING FX 29999 ARTHROSCOPY OF JOINTS UNEXAMINED PROCEDURE ARTHROSCOPY Approval required Joint Full Clinical Examination 30020 MEDICAL DRAINAGE OF NASE MAUT required. 30300 REMOVAL OF NASAL FOREIGN BODY REMOVAL OF FOREIGN BODY INTRANASAL No approval required OFFICE PROCEDURE 30400 RECONSTRUCTION OF NOSE RHINP PRIM LAT&ALAR CRTLGS&/ELVTN Approval required Respiratory Surgery Full Clinical Review of the NASAL TI System 30410 RECONSTRUCTION NE Atory Full Clinical Review System 30420 Reconstruction of Rhinoplasty Primary M /Need bigger approval Respiratory Surgery Full Clinical Review SEPTAL REPAIR System 30430 Revision Nasal Rhinoplasty REVISION NOSE RHINOPLASTY SECONDARY MAJOR Authorization Required Respiratory Surgery Full Clinical Review REVISION System 30460 REVISION NOSE RINP DFRM W/ COLUMN LENGTH TIP Approval Required Surgery of Respiratory Full Clinical Review 30460 REVISION NOSE RHINP DFRM W/ COLUMN LENGTH TYPE Authorization Required Surgery of Respiratory Full Clinical Review 30460 NOSE REVISION RHINP DFRM TH TYPE Authorization Required Respiratory Surgery Full Clinical Review SEPTUM System OSTEOT 30465 NASAL STENOSIS REPAIR NASAL VESTIBULAR STENOSIS REPAIR License Required Respiratory Surgery Full Clinical Review 30520 SEPTOPLASTY REPAIR NASAL SEPTUM/SUBMUCOSAL Surgical Review Respiratory/SUBMUCOSAL Approved GRF CARTILAGE System 30620 INTRANASAL RECONSTRUCTION TION SEPTAL/OTHER INTRANASAL Approval Required Respiratory Surgery Full Clinical Review System DERMATOPLASTICS 30630 REPAIR OF NASAL SEPTUM DEFECT REPAIR OF NASAL SEPTUM PERFORATION Approval Required Respiratory Surgery Full Clinical Review 30630 OF THE PRONASAL SEPTUM DEFECT Approval Required Respiratory System Full Clinical Review System Operation 31299 SINUS SURGERY NOT LISTED PROCEDURE ACCESSORIES Approval Request ed Respiratory Surgery Full Clinical Review SINUS System 31599 LARYNX SURGERY UNINVITED PROCEDURE LARYNX Authorization Required Respiratory Surgery NAVIGALB27 BCOSHPY Full COLINX SURGICAL PROCEDURE W /CPTR-ASST IMAGE- Authorization required Ventilator surgery Full clinical examination GUIDED NAVIGATION system 31660 BRONCHI THERMOPLASTY 1 LOBE BRONCHOSCOPE THERMOPLASTY ONE Authorization required Respiratory surgery Full clinical examination LOBE system 31661 BRONCHI THERMOPLASTY 2/> LABER Surgical BRONCHOSCOPE THERMOPLASTIC 2/> LOBER surgical respiratory respiratory authorization 2/> Complete BRONCHOSCOPY study. LOBES System 31899 RESPIRATORY SURGICAL PROCEDURE UNINVITED TRACHEA PROCEDURE Authorization required Respiratory surgery Full clinical examination BRONCHI system 32850 DONOR PNEUMONECTOMY DONOR PNEUMONECTOMY OD Authorization required Transplants and full clinical examination CADAVER DONOR Transplant-related services (including pre- and post-transplant testing )

32851 LUNG TRANSPLANT SINGLE LUNG TRANSPLANT 1 U/O approval required Transplants and full clinical examination BYPASS heart and lung transplant services (including pre- and post-transplant testing) 32852 LUNG TRANSPLANT WITH BYPASS Transplant/Cardi-LUNG Transplant/Requidlin transplantation and W /VASCULAR LUNG TRANSPLANTATION. Y BYPASS transplant related services (including pre- and post-transplant testing) 32853 LUNG TRANSPLANT DOUBLE LUNG TRANSPLANT 2 U/O approval Transplant and full clinical examination required Heart and lung transplant services BYPASS (including pre-transplant and post-transplant testing) 32854 LUNG TRANSPLANT REPLACEMENT 2 transplant. Transplants and full clinical examination with CARDIOPULMONARY BYPASS transplant-related services (including pre- and post-transplant testing) 32855 PREPARATION OF DONOR LUNG PREPJ SINGLE BKBENCH cadaver donor PREPJ Approval required Transplantation and full clinical examination LUNG ALLOGRAMPLANT Pre- and post-transplant services (including transplant) 32856 PREPARE DONOR LUNG DOUBLE BKBENCH PREPJ CADAVER DONOR Authorization Required Transplants and Full Clinical Review LUNG ALLOGRAFT BI Transplant Services (Including Pre- and Post-Transplant Testing) 32999 BREAST SURGICAL PROCEDURE UNUSED Surgical Review and Authorization Surgical Surgical Review System 33016 PERICARDIOCENTESE W/IMAGING PERICARDIOCENTESE W / IMG No approval required GUIDELINES WHEN PERFORMED 33017 PRCRD DRG 6YR+ U/O CGEN CAR PERQ PRCRD DRG 6YR+ U/O No approval required CAR ANNOUNCEMENT 33018 PR CRAND DRG 018 PRCRD DRG 6YR+ W/O 0- 5YR/AGE No approval required W / CGEN CAR ANOMALIES 33019 PERQ PRCRD DRG INSJ CATH CT PERQ PERICARDIAL DRG W/INSJ No Authorization Required NDWELLG CATH W/CT 33254 ABLATE ATRIA LMTD ABLATION ABLATION & RECONTRIAST Authorization of Surgical ABLATIONS & RECONTRIAST Authorization by System Surgical ABLATIONS Card LIMITED 33255 ABLATE ATRIA U /O BYPASS EXT ABLATION & RCNSTJ ATRIA EXTNSV U/O Authorization Required Surgery of Cardiovascular Full Clinical Review BYPASS System 33256 ABLATE ATRIA W/BYPASS EXTEN ABLATION & RCNSTJ ATRIA Authorization Required by Surgeon ATRIA EXTN. system 33257 ABLATE ATRIA LMTD ADD-ON ATRIA ABLATE & RCNSTJ W/OTHER authorization required Surgery of Cardiovascular Full Clinical Review PROCEDURE LIMITE system 33258 ABLATE ATRIA X10SV ADD-ON ATRIA ABLTJ & RCNSTJ Full surgical card authorization required PX card authorization. U/O BYP System 33259 ABLATE ATRIA W/BYPASS ADD-ON ATRIA ABLTJ & RCNSTJ W/OTHER PX Authorization Required Surgery of Cardiovascular Complete Clinical Review EXTEN W/BYPASS System 33265 ABLATE ATRIA LMTD ENDO NDST ABLATION ABLATION & RECORD CARD Surgical Card Full Clinical Review LIMITED U/O BYPAS System 33266 ABLATE ATRIA X10SV ENDO NDSC ABLATION & RCNSTJ ATRIA EXTEN Authorization Required Cardiovascular Surgery Full Clinical Review U/O BYPAS System 33285 INSJ SUBQ CARNTRQ INSTALLATION REQUIRED Cardiovascular Surgery Full Clinical Review MONITOR W /PR GRMG System 33286 RMVL SUBQ CAR RHYTHM MNTR REMOVAL SUBCUTANEOUS Heart authorization required Surgery of Cardiovascular Full Clinical Review RHYTHM MONITOR system 33289 TCAT IMPL WRLS P-ART PRS PLRS Authorization P-ART PRS- SNR SR-Red of Cardiovascular Full Clinical Review HEMODYN MNTR- system 3 3340 PERQ CLSR TCAT L ATR APNDGE PERQ CLSR TCAT L ATR APNDGE Authorization Required Cardiovascular Complete Clinical Examination Surgery W/ENDOCARDIAL IMPLNT System 33858 AS-AORT GRFJ WRFP/AORTAIC AORTIC No Authorization Required DISSECTION 33859 AS-AORT GRF F/DS OTH /THN DSJ AS -AORT GRF M/CARD BYP F/AORTIC DS No Authorization Required OTH/THN DSJ 33871 TRANSVRS A-ARCH GRF HYPTHARCH TRANSVRS A-/ CARD BYP No Authorization Required PRFD HYPOTHERMIA 33927 IMPLTJ TOT RPLCMT HRT SYS IMPLTJ TOTAL RPLCMT HEART SYS Authorization Required Surgery Cardiovascular full clinical review W/RCP HARDIECTOMY System 33928 RMVOTVAL & RPLCMT Sml Red Surgery of Cardiovascular Full Clinical Review HEART SYS System 33929 RMVL RPLCMT HRT SYS F/TRNSPL REMOVAL TOTAL RPLCMT HEART SYS Authorization Required Surgery of Cardiovascular Full Clinical Review FOR HEART TRNSPL System 33930 REMOVAL REQUIRED DONOR HEART/LUNG CARDIECATA Surgical cardio. OMY system 33933 PREPARE DONOR HEART/LUNG BKBENCH PREPJ CADAVER DONOR Approval required Transplant and full clinical examination ALOGRAMFT HEART/LUNG Transplant related services (including pre and post transplant testing) 33935 HEART/LUNG TRANSPLANT HEART-LUNG TRNSPLANT AND REQUIRED Full approval and required review CARDIECTOMY -PNUMEC transplant related services (including pre- and post-transplant testing) 33940 REMOVAL OF DONOR HEART DONOR CARDIECTOMY Authorization required Cardiovascular surgery Full clinical examination 33944 DONOR HEART PREPARATION BKBENVER DONOR DONOR TRANSPLANT REQUEST CADA Full examination and transplant CADA. transplant-related services (including pre- and post-transplant testing) 33945 HEART TRANSPLANT HEART TRANSPLANT W/WO RECIPIENT Authorization required Surgery of Cardiovascular Full Clinical Review HARDIECTOMY System 33975 IMPLANT VENTRICULAR DEVICE INSJ VENTRICLE ASSIST OF Surgical Card LE VENTRICLE system 33 976 IMPLANT VENTRICULAR DEVICE INSJ VENTRICLE ASSIST DEV XTRCORP Requires Authorization Surgery of the Cardiovascular Full Clinical Review of the BIVENTRICULAR SYSTEM 33999 CARDIAC SURGERY PROCEDURE UNLISTED CARDIAC SURGERY Requires Authorization Surgery of the Cardiovascular Full Clinical Review System

34712 TCAT DLVR ENHNCD FIXJ DEV TRANSCATHETER DLVR ENHNCD Authorization Required General Medicine - Full Clinical Review FIXATION DEVICES RS&I Hydration, Therapeutic, Prophylactic, Diagnostic Injections & Infusions, Chemotherapy & Other 34712 34712 TCAT DLVR ENHNCD TM OF A- ILIAC ART No NDGFT Authorization Required UNI 34718 EVASC RPR N/A A-ILIAC NDGFT EVASC RPR ILIAC ART I/A A-ILIAC ART No approval required NDGFT UNI 35702 EXPL N/FLWD SURG UXTR ART EXPLORATION N/A AUT. EXTREMITY ARTERY 35703 EXPL N/FLWD SURG LXTR ART EXPLORATION N/FLWD SURG LOWER EXTREMITY ARTERY INTRODUCTION 36000 PLACER NEEDLE/INTRACAT AND 36000 PLACER NEEDLE IN VENE INTRODUCTION No authorization required. CATH PLMT VEN SYS 2. No authorization required ORDER/ > SLCTV BRANC 36299 VASCULAR INJECTION PROCEDURE NOT IN PROCEDURE LIST VASCULAR authorization required Surgery of Cardiovascular Full Clinical Review INJECTION System 36400 BL DRAW < 3 YEARS FEM/JUGULAR VNPNXR

38206 HARVEST AUTO STEM CELLS BLD-DRV HEMATOP PROGEN CELL HRVG authorization required Transplantation and full clinical review TRNSPLJ AUTOL Transplant related services (including pre and post transplant testing) 38207 CRYOPRESERVE STEM CELLS TRNSPL PREPJ HEMATOPIC authorization and full clinical review by CPRJ HEMATOP . STOR Transplant-related services (including pre- and post-transplant testing) 38208 TUBE PREVERD STEM CELLS TRNSPL PREP HEMATOP PROGEN TØ Authorization required Transplantation and full clinical examination PREV HRV PER DNR Transplant-related services (including pre- and post-transplant testing) 38209 TSPWASH HSPELLRNVEST TSPELLARVEST HMATOP PROG THAW Authorization required Transplants and full clinical examination PREV HRV WSH PER DNR Services related to transplantation (including pre- and post-transplant testing) 38210 T-CELL DEPLETION OF HARVEST TRNSPL PREPJ HEMATOP PROGEN DEPLJ Authorization required Transplants and full CHRV Stu dies and Full CHRV transplant-related services (including pre- and post-transplant testing) 38211 TUMOR CELL DEPLETE OF HARVST TRNSPL PREPJ HEMATOP PROGEN TUM Authorization required Transplantation and full clinical examination CELL DEPLJ transplant-related services (including pre- and post-transplant testing) 38212 RBCPL HEPVJ transplant PROGEN RED Transplant authorization required and full clinical examination BLD CELL RMVL - Transplant related services (including pre- and post-transplant testing) 38213 DRUM BLAD PERFORMED BY HARVEST TRNSPL PREPJ HEMATOP PROGEN PLTLT Transplant authorization required and full clinical pre- and post-transplant examination (Transplant deplj) Trial ) 38214 Volume shift by harvest TRNSPL PREPJ HEMATOP PLSM-AUTHORIZATION Transplantation and full clinical examination vol. Transplant-related services (including pre- and post-transplant testing) 38215 Staml concentrate concentrate concentrate stampl harvest Trnspl. RATION PLSM Transplant-related services (including pre- and post-transplant testing) 38230 ALLOGENE BONE MARROW COLLECTION Authorization required Transplantation and full clinical examination ALLOGENE TRANSPLANT Transplant-related services (including pre- and post-transplant testing) 38232 BONE MARROW VEST REQUIRED Authorization BONE MARROWAR HARred and full clinical review TRANSPLANTATION AUTOLOGUE transplant-related services (including pre- and post-transplant testing) 38240 TRANSPLT ALLO HCT/DONOR TRNSPLJ ALLOGEN HEMATOPOETIC authorization required Transplants and full clinical review CELLS BY DONOR transplant-related services (including 821 T AUTOSPRAN transplant ) HCT/donor TRNSPLJ Autologous authorization required transplant and full clinical examination Hematopoietic cells by Donor Transplant-related services (including pre- and post-transplant testing) 38242 Transplt Allo Lymphocytes Allogenic Lymphocyte Infusions Authorizations required Transplantation and full clinical examination Transplant-related services (including testing pre and TRANSPLANTATION) 38243 TRANSPLJ HEMATOPOETIC BOOST TRNSPLJ BOOST HEMATOPOETIC CELLS Authorization Required Transplants and full clinical Review transplant related services (including pre- and post-transplant testing) 38589 LAPAROSCOPE PROC LYMPHATIC HEMATIC NON-INVITE PXLA Full surgical surgical authorization required CPXLA linical Review LYMPHATIC SYSTEMS 38999 BLOOD/LYMPH SYSTEM PROCEDURE NOT PLACED PROCEDURE HEMIC OR authorization required Surgery he mic and complete clinical examination LYMPHATIC SYSTEM lymphatic systems 39499 BREAST PROCEDURE NOT LISTED MEDIASTINUM PROCEDURE Authorization required Mediastinal surgery Full clinical examination 39499 CHEST PROCEDURE MEDIASTINUM. ISTED DIAPHRAGM PROCEDURE Approval required Mediastinal surgery Full clinical examination and diaphragm 40799 LIP SURGICAL PROCEDURE UNINVITED LIP PROCEDURE Approval required Gastrointestinal surgery Full clinical system examination 40800 DENERATION OF LESION MOLD DRG ABSC CST HMTMA VESTIBUL No approval required MOUTH H OF 40800 MOUTH 40800 MUD ST HMTMA VESTIBUL No approval required MUNDKOMP 40804 FOREIGN BODY REMOVAL OF MOUTH RMVL INSTALLED FB VESTIBULE No approval required ORAL SMPL 40899 ORAL SURGICAL PROCEDURE UNINVITED VESTIBULE PROCEDURE Approval required Gastrointestinal Surgery Full Clinical Examination ORAL MULDEN BSU TONGUE T System SUNGION Digestive Surgery Required Full Clinical Examination PERMANENT SEAM TQ system 41530 REDUCTION VOL. BASES OF THE TONGUE SUBMUCOSAL ABLTJ OF THE TONGUE RF 1/> Authorization required Gastrointestinal surgery Full clinical examination PLACES PR SESSION system 41599 TONGUE AND MOUTH SURGERY NO PROCEDURE LIST BOTTOM OF THE TONGUE Authorization required Oral surgery Digestive system

41820 EXCISION OF ZESNI EACH QUADRANT GINGIVECTOMY EXC GINGIVA EACH Approval required Gastrointestinal Surgery Full Clinical Examination QUADRANT System 41821 EXCISION OF LOBE ZESNI OPRCULECTOMY EXC PER CORONAL Approval required ISS. LESIONS OF THE GUM EXC FIBROUS TUBEROSITIES Permissions required Gastrointestinal Surgery Full Clinical Review DENTOALVEOLAR STRUX System 41823 EXCISION OF A LESION OF GUMS EXC OSS TUBEROSITIES Permissions Required Digestive System Surgery Full Clinical Review DENTOALVEOLAR STRUX SYSTEM 41825 EXCISION OF LESION DENI EXC OSS TUBEROSITIES Full Clinical Review DENTOALVEOLAR STRUX -system 418 25 CUTTING LESIONS RIGHT EXC OSS EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE EXCISE STRUX W/O RPR System 41826 LESION EXCISION RIGHT EXC LESIONS/TUM ORA DENTOLVEOLAR Authorization required Digestive surgery system Full Clinical Review STRUX W/SMPL RPR System 41827 EXCISION OF GUM LESION EXC DENTAL ALVEOLAR LESION/TUMOR Authorization Required STRUX/SPRX System Full Surgical Surgery R8PR System R8/4 8 EXCISION OF GUM LESION EXC HYPRPLSTC ALVEOLAR MUCOSA EA Authorization Required Gastrointestinal Surgery Full Clinical review QUADRANT SPEC system 41830 GUM TISSUE REMOVAL ALVEOLEXTOMY W/CURTG Authorization required Gastrointestinal Surgery Full Clinical Review OSTRETITOMA/RIGHT PART 18 DESTRUCTIVE LESION DENTOALVEULAR Approval required Digestive System Surgery Full Clinical Review STRUCTURE System 41870 GUM TRANSPLANT PERIODONTAL MUCOSA TRANSPLANT Authorization required Digestive Surgery Full clinical examination system 41872 GINGIVOPLASTY REPAIR EACH QUADRANT Authorization required Digestive System Surgery Complete Clinical System RV4 SPECOOK 74. LASTY EACH QUADRANT Approval Digestive Surgery Required Complete Clinical Examination SPECIFY System 41899 DENTAL SURGICAL PROCEDURE UNWRITTEN PROCEDURE Authorization Required Digestive System Surgery Complete Clinical Examination of DENTOALVEOLAR STRUCTURES System 42299 PALATE/UVULE SURGERY UNCLASSIFIED PALATE PROCEDURE C2 6-Surgeon. LIVER SURGICAL PROCEDURE NOT LISTED PX SALIVARY GLANDS/DUCTS Approval Required Digestive System Surgery Full Clinical Review System 42999 NECK SURGICAL PROCEDURE UNLISTED PHARYNGEAL PROCEDURE Approval Required Digestive System Surgery Full Clinical Review System 43191 ESOPHAGOSCOPY RIGID ESOPHAGOSCOPY Approval RIGID TRNACOPY PARKILI SERING required for code u group Full clinical examination DIAGNOSTIC BRUSH Applies to all codes within specific group 43192 ESOPHAGOSCP RIG TRNSO INJECT ESOPHAGOSCOPY RIGID TRANSORAL INJ Authorization required Endoscopy PA for code in group Full clinical examination SUBMUCOSAL Applies to all codes within specific group 43193 ESOPHAGOSCP RIG TRANSORAL INJ Authorization required ESOPHAGOSCP RIG TR NSO BIOPSCOPY for group code Complete clinical examination WITH BIOPSY Applies to all codes within specific group 43194 ESOPHAGOSCP RIG TRNSO REM FB ESOPHAGOSCOPY RIG TRANSORAL Authorization required Endoscopy PA for code in group Complete clinical examination FOREIGN BODY REMOVAL Applies to all codes within specific group EZOPHAGIDOSIGOPY RCOPHAGIDOSIGON RCOPHAGIDOSIGON TRANS ORAL Authorization required Endoscopy PA for code in group Complete clinical examination BALLOON DILATION Applies to all codes within specific group 43196 ESOPHAGOSCP GUIDE WIRE DILAT ESOPHAGOSCOPY RIG TRANSORAL Authorization required Endoscopy PA for code in group Complete clinical examination GUIDE WIRE DILATION Refers to specific ESOPHAGOSCOPY 3COPHOSCOPY Group1 97 FLEX DX BRUSH ESOPHAGOSCOPY FLEXIBLE authorization required Endoscopy PA for code in group Complete clinical examination TRANSNASAL DIAGNOSIS Refers to all codes within specific group 43198 ESOPHAGOSC FLEX TRNSN BIOPSY ESOPHAGOSCOPY FLEXIBLE Group authorization required CBI DOscopy a group authorization CBI WIRLIN Code for approx. applies to all codes within a specific group 43200 ESOPHAGOSCOPY FLEXIBLE BRUSH ESOPHAGOSCOPY FLEXIBLE TRANSORAL Authorization required Endoscopy PA for a code in Group Full Clinical Examination DIAGNOSIS Applies to all codes within a specific group 43201 ESOPH SCOPE W/SUBMUCOUS INJCOANSORAL PA Endoscopy required for a specific group in Group Full clinical Review W SUBMUCOUS INJ Applies to all codes within specific group 43202 ESOPHALISCOPY FLEX BIOPSY ESOPHAGOSCOPY FLEXIBLE TRANSORAL Authorization required Endoscopy PA for code in group Complete clinical examination WITH BIOPSY Applies to all codes within specific group 43204 ESOPHLERISCOPY IN ESOPHOSCOPE IN J/ESOPH Authorization required Endoscopy PA for Group Code Full Clinical Review INJECTION VARICES Applies to all codes within specific group 43205 ESOPHAGUS ENDOSCOPY/LIGATION ESPHGOSCOPY FLEX W/BAND LIGATION Authorization required Endoscopy PA for Group Code Full Clinical Review ESOPHGL VARICES Applies to all codes within for specific group ESOPH43206 OPTICAL ENDOMICROSCOPY ESOPHAGOSCOPY TRANSORAL Authorization required Endoscopy PA for code in group Full clinical examination W/OPTICAL ENDOMICROSCOPY Applies to all codes within specific group 43210 EGD ESOPHAGOGASTRC FNDOPLSTY EGD PARTIAL/COMPLICATED ENDOMICROSCOPY Full group approval required for endoscopy group PLASTIC Applies to all codes within specific group 43211 ESOPHAGOSCOP MUCOSAL RESECT ESOPHAGOSCOPY FLEXIBLE TRANSORAL Authorization required Endoscopy PA for code in group Full clinical review MUCOSAL RESEXN Applies to all codes within specific group 43212 ESOPHAGOSCOP STENT PLACEMENT Endoscopy STENT PLACEMENT Group Full clinical review LOCATION Applies to all codes within specific group specific group 43213 ESOPHAGOSCOP Y RETRO BALLON ESOPHAGOSCOPY RETROGRADE DILATE Authorization required Endoscopy PA for group code Full clinical examination BALLON/OTHER Applies to all codes within specific group 43214 ESOPHAGOSC DILATE BALLON 3 PA for group code full clinical examination BALLON 30 MM Applies to all codes within specific group 43215 ESOPHAGOSCOPY FLEX REMOVE FB ESOPHAGOSCOPY FLEXIBLE REMOVAL Authorization required Endoscopy PA for code in group Full clinical examination BODY SIDE Applies to all codes within specific group EPH32AGOS 6 EX LESION REMOVAL Authorization required Endoscopy PA for code in to group Full clinical review HOT BX FORCEPS Applies to all codes within specific group 43217 ESOPHAGOSCOPY SNARE LES REMV ESOPHAGOSCOPY FLEXIB LESION Authorization required Endoscopy PA for code in group Full clinical review within application group TUMOR SNARE 43220 ESOPHAGOSCOPY PALLON

43226 ESOPH ENDOSCOPY Esophagoscopy Dilation Flexible Endoscopy Authorization PA The Court Code of Dilation is applied to all codes in a specific Esophagoscopy of the Flexible Code Flexible Flexible Control applies to all codes within specific group 43229 ESOPHAGOSCOPY ABLATE LESIONS ESOPHAGOSCOPY FLEX TRANSORAL Authorization required Endoscopy PA for code in group Complete clinical examination ABLATION OF LESIONS Applies to all codes within specific group 43231 ESOPHAGOSCOPY ULTRASOUND EXAMINATION TRANSORAL Authorization required for and Group Complete clinical examination ULTRASOUND EXAMINATION Applies to all codes within specific group 43232 ESOPHAGOSCOPY W/US NEEDLE BX ESOPHAGOSCOPY INTRA/TRANSMURAL authorization required Endoscopy PA for code in group Complete clinical review NEEDLE ASPIRATIONS/BX Applies to all codes within specific group EGD B32ALLO3 DMM B32ALLO30 EGD BALLOON ESOPHAGAL DILATION Authorization required Endoscopy PA for code in group Complete clinical examination 30 MM OR LARGER Applies to all codes within special group 43235 EGD DIAGNOSTIC WASHING BRUSH ESOPHAGOGASTRODUODENOSCOPY No authorization required D Code in group TRANSOR special group for approx. 43236 UPPR GI SCOPE W/SUBMUC INJ ESOPHAGOGASTRODUODENOSCOPY Authorization required Endoscopy PA for code in group Full clinical examination SUBMUCOAL INJECTION Applies to all codes within specific group 43237 ENDOSCOPIC WITH EXAMINATION ESOPH ESOPHADENGO Full clinical examination SUBMUCOS INJECTION Applies to all codes within specific group Clinical review SCOPE W/ ADJ STRXRS Applies to all codes within specific group 43238 EGD US FINE NEEDLE BX/ASPIR EGD INTRMURAL US NEEDLE Authorization required Endoscopy PA for code within group Full clinical review ASPIRAT/BIOPSI ESOPHAGS Applies to all codes within specific group 43239 EGLEMULT TRANSORAL BIOPSY No authorization required Endoscopy PA for code in group ONE/MORE Applies to all codes within specific group 43240 EGD W/TRANSMURAL DRAINAGE CYST EGD TRANSORAL TRANSMURAL Authorization required Endoscopy PA for code in group Complete clinical examination All codes within specific DRAINAGE PSEU TO DRAINAGE group 43241 EGD TUBE INSERTION/KATH EGD INTRALUMINAL TUBE/CATHETER Authorization required Endoscopy PA for code in group Complete clinical examination INSERTION Applies to all codes within specific group 43242 EGD US FINE NEEDLE BX/ASPIR EGD PA INTRMURAL NEEDLE Endoscopy required for code in the group Complete clinical examination ALTERED ANATOMY Applies to all codes within the specified group 43243 EGD INJECTION VARICES EGD INJECTION SCLEROSIS Authorization required Endoscopy PA for the code in the group Complete clinical examination ESOPHGL/GASTRIKE VARICES Applies to all codes within the specified group 4324S ELIGATION VARICES 4324S LIGATION Authorization required Endoscopy PA for group code Complete clinical examination ESOPHAGAL/STOMACH VARICOSIS Applies to all codes within specific group 43245 EGD DILATA STRICTURE EGD GASTRIC/DUODENAL DILATION Authorization required Endoscopy PA for code in group Complete clinical examination STRICTURE Applies to all codes Group 43246 EGD site Gastrostomy tube EGD Percutaneous placement authorization required Endoscopy PA for code in group Full clinical examination Gastrostomy tube Applies to all codes within specific group 43247 EGD Foreign body removal EGD Flexible foreign body removal Authorization required Endoscopy PA for code in group Full clinical overview Applies to all codes within the specified group 43248 EGD GUIDE WIRE INSERTION EGD INSERTION GUIDE WIRE DILATOR Authorization required Endoscopy PA for the code in the group Complete clinical examination ESOFAGAL PASSAGE Applies to all codes within the specified group 43249 ESOPH EGD DILATION

43266 EGD ENDOSCOPIC STENT PLACEMENT EGD ENDOSCOPIC STENT PLACEMENT Authorization required Endoscopy PA for code in group Complete clinical examination W/WIRE & DILATION Applies to all codes within specific group 43270 EGD LESION ABLATION EGD TUMOR ABLATION POLYP/Required in group Endoscopy PALYP/authorization required in group Clinical examination W/DILATION& WIRE Applies to all codes within specific group 43273 ENDOSCOPIC PANCREATOSCOPY ENDOSCOPIC CANNULATION OF PAPILLA Authorization required Endoscopy PA for code in group Full clinical examination BILE/PANCREAS Applies to all codes within specific group 4327CT STCPPLENTER STCPPLENT 4327CT ST. requested PA endoscopy for code in group Full Clinical Examination BALL/PANCREAS Applies to all codes within specified group 43275 ERCP REMOVE FORGN BODY DUCT ERCP REMOTE FOREIGN BODY/STENT Authorization required Endoscopy PA for code in group Full Clinical Examination BILDURY/PANC within specified code group 43276 ERCP STENT EXCHANGE W/DILAT ERCP BILIARY/PANC DUCT STENT Approval required Endoscopy PA for code in group Full clinical review EXCHANGE W/DIL&WIRE Applies to all codes within specific group 43277 ERCP EA DUCT/AMPULIA B DALL DUCT/AMPUL / PANC Authorization required Endoscopic PA for code in group Complete clinical examination DUCT/AMPULE EA Applies to all codes within specific group 43278 ABLATION ERCP LESION W/DILATION ERCP ABLATION OF TUMOR/POLYP/LESION Authorization required Endoscopy PA for code in group Complete clinical examination W / DILATION&WIRE Applies to all codes within a specific group 43284 LAPS ESOPHGL SPHNCTR AGMNTJ LAPS ESOPHGL SPHNCTR AGMNTJ PLMT Authorization required Gastrointestinal surgery Full clinical review DEV CRRPL system 43285 RMVL ESOPHGL SPHNCTR AGMNTJ LAPS ESOPHGL SPHNCTR AGMNTJ PLMT Authorization required Gastrointestinal surgery tive system Full clinical system overview DEV CRRPL system 43285 RMVL ESOPHGL SPHNCTR. Clinical Review AGMNTJ DEVICE System 43289 LAPAROSCOPE PROC ESOPH UNINVITED LAPAROSCOPIC PROCEDURE Authorization Required Digestive System Surgery Complete Esophagus Clinical Review System 43499 ESOPHAGEAL SURGERY UNINVITED ESOPHAGICAL PROCEDURE Authorization Required Digestive System Surgery Full Clinical G-4499 ESOPHAGUS SURGICAL PROCEDURE LA PS GSTR RSTCV PX W/ BYP ROUX -EN-Y Approval required Bariatric surgery Full clinical examination LIMB

44390 COLONOSCOPY FOR FOREIGN BODIES COLONOSCOPY STOMA M/RMVL No authorization required Colonoscopy PA for code in group FOREIGN BODIES Applies to all codes within a specific group 44391 COLONOSCOPY FOR CLEAN COLONOSCOPY STOMA CONTROL required for code in group B Code does not require authorization Special group 44392 COLONOSCOPY and POLYPECTOMY COLONOSCOPY STOMA RMVL LES BY No authorization required Colonoscopy PA for code in group HOT BIOPSY FORCEPS Applies to all codes within specific group 44394 COLONOSCOPY W/SNARE COLONOSCOPY REQUIRED COLONOSCOPY STOMA W/STOMA COLONOSCOPY STOMA W/CODE W. POLYP/ANDEN LES S Applies NARE to all codes within specific group 44401 COLONOSCOPY WITH ABLATION COLONOSCOPY ABLATION STOMA No authorization required Colonoscopy PA for code in group LESION Applies to all codes within specific group 44402 COLONOSCOPY WITH ABLATION COLONOSCOPY WITH STENT APPLICATION PLCIC Colonoscopy PA for code in group STENT PLCMT Applies to all codes within specific group 44403 COLOSCOPY W/RESECTION COLONOSCOPY STOMA W/ENDOSCOPY No authorization required Colonoscopy PA for code in group MUCOSAL RESCJ Applies to all codes within specific group 44404 COLONY COLONY COLONY COLONY STOMA No authorization required Colonoscopy PA for code in group M/ SUBMUCOSAL INJECTION Applies to all codes within specific group 44405 COLONOSCOPY W/EXTENSION COLONOSCOPY STOMA W/BALLON No authorization required Colonoscopy PA for code in group EXTENSION Applies to all codes within specific group COLON406 COLON406 /ULTRASONIC COLONOSCOPY STOMA W/ENDOSCOPY No authorization required Colonoscopy PA for group code ULTRASOUND EXAMINATION Applies to all codes within specific group 44407 COLONOSCOPY W/NDL ASPIR/BX COLONOSCOPY STOMA W/US GID NDL Group A code required /BX Applies to all codes within specific group 44408 COLONOSCOPY W/DECOMPRESSION COLONOSCOPY THROUGH STOMA WITHOUT REQUIRED AUTHORIZATION. Review Transplant Services DONOR BOWEL (Including Pre- and Post-Transplant Testing) 44720 PREP DONOR BOWEL/VENOUS BKBENCH RCNSTJ INT ALGRFT VEN Authorization Required Transplants and Full Clinical Review ANAST EA Transplant Related Services (Including Pre- and Post-Transplant Testing DONOR2 INTEREST ) ARTERY BKBENCH RCNSTJ INT ALGRFT ARTL Authorization required Transplants and full clinical examination ANAST EA Transplant-related services (including pre- and post-transplant testing) 44799 UNINVITED PX COLON UNINVITED SMALL PROCEDURE Authorization required Complete surgical treatment 44799 PROCEDY 44799 PROCE DURES DURE UNISTED PX MECKEL'S DIVERTICUL Authorization required Gastrointestinal Surgery system Complete clinical review and system MESENTERY 44979 LAPAROSCOPE PROC APP UNINVITED LAPAROSCOPIC PROCEDURE Approval required Gastrointestinal surgery Complete clinical review APPENDIX system 45378 DIAGNOSTIC COLONOSCOPY WF/DIAGNOSTIC NO. Colonoscopies PA authorization required for code in group WHEN PFRMD Applies to all codes within specified group 45379 COLONOSCOPY W/FB REMOVAL COLONOSCOPY FLX W/REMOVAL No authorization required Colonoscopy PA for code in group BODY SIDE Applies to all codes within specified group 45380 COLONOSCOPY / NOBIOCOSICO I NO. Colonoscopies PA authorization required for code in group SINGLE/MULTI Applies to all codes within specified group 45381 COLONOSCOPY SUBMUCOUS NJX COLSC FLX WITH DIRECTED No authorization required Colonoscopy PA for code in group SUBMUCOS NJX ALL 4 codes in SBST Applies within certain COLOS SBST CONTROL BLEED COLSC FLEXIBLE W/BLEED CONTROL No authorization required Colonoscopy PA for code in group ANY METHOD Applies to all codes within specific group 45384 COLOSCOPY W/LESION REMOVAL COLSC FLX W/LESION REMOVAL HOT No authorization required for code in group BX Colonoscopy Forceps Applies to all codes within specific group 45385 COLOSCOPY W/REMOVAL OF COLSC FLX LESION W/RMVL TUMOR POLYP No authorization required Colonoscopy PA for code in group SNARE LESIONS TQ Applies to all codes within specific group 45386 COLONOSCOPY W/FLIBLE /TRANSENDOSCOPIC None authorization required Colonoscopy PA for code in group BALLON DILAT Applies to all codes within specific group 45388 COLONOSCOPY W/ABLATION COLONOSCOPY FLX ABLATION TUMOR No authorization required Colonoscopy PA for code in group POLIP/OTHER Code in specific group LES58 Colonoscopy with stent PLCMT -colonoscopy FLX with endoscope no authorization required colonoscopy PA for group stent placement code applies to all codes within specified group 45390 Colonoscopy w/resection Colonoscopy FLX w/endoscopic no author All codes within specified group 45391 COLONOSCOPY W/ENDOSCOPE US COLSC FLX W/NDSC US XM RCTM ET AL No PA Approval Required for Colonoscopy for Group Code LMTD&ADJ STRUX Applies to All Codes Within Specific Group 45392 COLONOSCOPY W/ENDOSCOPIC GUIDE NDL ASPIR/BX No PA Approval Required for Colonoscopy for Group Code W/US RCTM ET AL Applies to all codes within a specific group 45393 COLONOSCOPY WITH/DECOMPRESSION COLONOSCOPY FLEXIBLE S No authorization required Colonoscopy PA Codes for code in group DECOMPRESSION Specific group 45398 COLONOSCOPY S/BAND LIGATION COLONOSCOPY FLEXIBLE WITH BAND No authorization required Colonoscopy PA for code in group LIGATION (ER) Applies to all codes within specified group 45399 UNINVITED COLON PROCEDURE UNINVITED PROCEDURE REQUIRED Full surgical examination of the COLON COLON.

45499 LAPAROSCOPE PROC RECTUM NOT LISTED LAPAROSCOPIC PROCEDURE Approval Required Digestive System Surgery Complete Clinical Examination RECTUM System 45999 RECTAL SURGICAL PROCEDURE NOT LISTED RECTUM PROCEDURE Approval Required Digestive System Surgery 45900 LES 45999 RECTAL SURGICAL PROCEDURE LESION ANUS SINGLE CHEMICAL No approval required 4 691 0 DESTRUCTIVE ANAL LESION(S) DSTRJ LESION ANUS SMPL No approval required ELTRDSICCATION 46924 DESTRUCTIVE ANAL LESION DSTRJ LESION ANUS EXTENSIVE No approval required 46948 INT HRHC TRANAL DARTLZJHRID AuthentlZJ 2+ DARTLZJ 2+ W/US GDN 46999 SURGICAL PROCEDURE ANUS EDURE UNINVITED PROCEDURE ANUS Permissions required Digestive Surgery o.g system System Complete clinical examination System 4 7133 REMOVAL OF THE DONOR LIVER DONOR HEPATECTOMY CADVER Authorization required Gastrointestinal surgery Complete clinical examination DONOR system 47135 LVRTLJON REPLANTATION TRANSFER/TRANSPLANTATION LVRTLJ. required Gastrointestinal Surgery Full Clinical Review DON ALL AGE System 47140 PARTIAL LIVER REMOVAL DONOR HEPATECTOMY LIVING DONOR Authorization Required Digestive System Surgery Full Clinical Review SEG II & III System 47141 PARTIAL REMOVAL DONOR LIVE DONOR HEPATECTOMY LIVING DONOR Full DONOR C1 Rev. . 42 PARTIAL LIVER REMOVAL DONOR HEPATECTOMY LIVING DONOR Approval required Gastrointestinal surgery Complete clinical examination SEG V VI VII & VI system 47143 WHOLE LIVER DONOR PREPARATION BKBENCH CASSADY DONOR PREPARATION Approval required Transplantation and full pre-clinical examination of transplant related services and postincl4 transplant (post - includ4 transplant) PREP DONOR LIVER 3-SEGMENT BKBENCH PREPJ CADAVER WHOLE LIVER Authorization required Transplants and full clinical review GRF I&IV VII Transplant-related services (including pre- and post-transplant testing) 47145 PREP DONOR LIVER LOBE SPLIT BKBENCH DON REQUIRED Transplant approval and CHLIN LVR GRF I&V VI Transplant-related services (including pre- and post-transplant testing) 47146 PREP DONOR LIVER/VENOUS BKBENCH RCNSTJ LVR GRF VENOUS required Transplant approval and full clinical review ANAST EA Transplant-related services (including pre- and post-transplant testing) /ARTERIAL BKBENCH RCNSTJ LVR GRF ARTL ANAST Authorization required Transplants and full clinical examination EA services related to transplantation (including pre- and post-transplant testing) 47379 LAPAROSCOPIC PROCEDURE OF THE LIVER UNLIS LAPAROSCOPIC PROCEDURE Authorization required Clinical examination of the LIVER C47 Complete surgical intervention in digestive surgery C47 97 ULID LIVER PROCEDURE clearances required Transplants and full clinical review of transplant-related services (including pre- and post-transplant testing) 47579 LAPAROSCOPE PROC BILIARY UNEXAMINED LAPAROSCOPIC PROCEDURE Permissions required Gastrointestinal Surgery. Authorization Required Gastrointestinal Surgery Full Clinical Review System 48550 DONOR-PANCREATECTOMY DONOR PNCREATECTOMY DUODENAL Authorization Required Transplantation and Full Clinical Review SGM TRANSPLANT Transplant Related Services (Including Pre- and Post-Transplant Testing) 48551 PREP DONOR PANCREAS BKBENCH Full Review DONOR PANCREAS BKBENCH Full Review PANCREAS BKBENCH. REAS ALLOGRAFT Transplant-related services (including pre- and post-transplant testing) 48552 PREP DONOR ABDOMIN SCORE/VENOUS BKBENCH RCNSTJ CDVR PNCRS ALGRFT Requires Transplant authorization and full clinical examination VEN ANAST EA Transplant-related services (including pre- and post-transplant testing) 48554 TRANSPLANTATION Authorization PANCRELOGRAFT REPLANTATION REPLANTATION with and full clinical review ALLOGRAFT transplant-related services (including pre- and post-transplant testing) 48556 ALLOGRAFT PANCREAS REMOVAL RMVL Transplanted pancreas Approval Necessary transplants and full clinical review ALLOGRAFT transplant-related services (including pre- and post-transplant Plant testing) Required authorization Gastrointestinal Surgery Full Clinical Review System 49013 PRPERTL PEL PAK HEMRRG TRMA PREPERITONEAL PEL PAK F/HEMRRG No Authorization Required ASSOC PEL TRMA 49014 PELVIC ULCER REDUCTION REEXPL PEL WND W/RMVL None PREPERITAL PREPERITAL 9 PROPERIT 9 PROPERIT 3C DM/PER / OMMENT UNLISTED LAPAROSCOPIC PX ABD Authorization Required Digestive Surgery Full Clinical Review PERTONEUM & OMENTUM System 49659 LAPARO PROC HERNIA REPAIR UNLIS LAPS PX HRNAP HERNIORRHAPHY Authorization Required Digestive System Surgery Full Clinical Digestive System PROCEDUROMY STYR99 PRODOMEN49 U 99. CEDURE ABDOMEN Authorization Required Digestive System Surgery Full Clinical Review PERITONEUM & OMENTUM System 50300 REMOVED CARCASS DONOR KIDNEY cadaver DONOR NEPHRECTOMY Authorization required Transplants and full clinical examination DONOR UNI/BILATERAL Transplant-related services (including pre- and post-transplant testing)

50320 REMOVE KIDNEY LIVING DONOR DONOR NEPHRECTOMY OPEN LIVING Authorization required Transplantation and full clinical review DONOR transplant-related services (including pre- and post-transplant testing) 50323 PREP CADAVER RENAL ALLOGRAMFT BKBENCH PREPARATION J CADAVER CDAVER transplant Transplant-related services required (including pre- and post-transplant testing) 50325 PREP DONOR RENAL GRAFT BKBENCH PREPJ LIVING KIDNEY DONOR Transplant approval required and full clinical review ALLOGRAFT transplant-related services (including pre- and post-transplant testing) 50327 PREP RENAL GRAFT/VENOUS REQUIDATED RENAL GRAFT/VENOUS Full clinical review VENOUS ANAST Transplant-related EA services (including pre- and post-transplant testing) 50328 PREP RENAL GRAFT/ARTERIAL BKBENCH RCNSTJ RENAL ALLOGRAFT Authorization required Transplants and full clinical examination ARTERIAL ANAST EA Transplant-related services (including PR0329 transplant) (including PR0329) RENAL GRAFT/URETERAL BKBENCH RCNSTJ ALGRFT URETERAL Transplant authorization required and full clinical review ANAST EA Transplant-related services (including pre- and post-transplant testing) 50340 NEPHRECTOMY REMOVAL OF KIDNEY RECIPIENTS SEPARATE transplant-related authorization and full transplant-related authorization and transplant-related PROCEDURE required after transplant testing ) 50360 KIDNEY TRANSPLANTATION KIDNEY ALTRNSPLJ IMPLTJ GRF U/O RCP authorization required Transplants and complete clinical examination NEPHRECTOMY Transplant-related services (including pre- and post-transplant testing) 50365 TRANSPLANTATION ALTRNSPJ. and full clinical examination NEPHRECTOMY Transplant-related services (including pre- and post-transplant testing) 50370 REMOTE KIDNEY TRANSPLANT RMVL TRNSPLED RENAL ALLOGRANFT Transplantation approval required and full clinical examination of transplant-related services (including pre- and post-transplant testing) 50 ization of transplant required and full clinical review KIDNEY Transplant Services (including pre and post transplant testing) 50436 DILAT XST TRC NDURLGC PX PERQ DILATION XST TRC Authorization Required Urinary Surgery Full Clinical Review ENDOUROLOGIC PX W/IMG System 504STCS TRCILATION DQ 504STRCILATION XST TRC NEW ACCESS Authorization Required Urinary Surgery Full Clinical Review RENAL COLTJ SYS System 50549 LAPAROSCOPE PROC RENAL UNINVITED LAPAROSCOPIC PROCEDURE Authorization Required Urine Surgery Full Clinical Review RENAL COLTJ SYS System 50949 PROC LAPAROSCOPY Authorization Required Gery Urine Full Clinical Review URETER System 517 01 INSERTED BLADDER CATHETER INSJ NON-NDWELL BLADE No Authorization Required CATHETER 51702 INSERT TEMP BLADDER CATH INSJ TEMP NDWELLG BLADE No approval required CATHETER SIMPLE 51703 CATHERINST INSERT AMPLEX NDBLAD uth CATHETER COMPLICATED required 51705 BLADDER EXCHANGE CYSTOSTOMY TUBE SIMPLE No approval required 51710 BLADDER EXCHANGE CYSTOSTOMY TUBE TUBES No approval required COMPLICATED 517 98 US URINE CAPACITY MEASUREMENT AFTER NETTING RESIDUES No authorization required URINE i/BLADDER CAP BLAPAROSCONL 9 Authorization required Urinary surgery Complete clinical examination URINARY BLADDER System 53854 TRURL DSTRJ PRST8 TISS RF WV TRUL DSTRJ PRST8 TISS RF WV Authorization required Urinary surgery Complete clinical examination THERMOTHERAPY System 53860 TRANSURETHRAL RF TREATMENT TRURL RF FEMALE BLADDER NECK STRS Approval required URINE Clinical examination of the urinary system 53860 TRANSURETHRAL RF TREATMENT. SURGICAL PROCEDURE UNINVITED PROCEDURE URINARY Authorization Required Urinary Surgery Full Clinical Examination SYSTEM 54050 DESTRUCTION PENISLESION(S) DSTRJ PENISLESION(S) SIMPLE CHEMICAL No Authorization Required 54055 DESTRUCTION PENISLESION(S) DSTRJ PENISLESION SIMPLE No AUTRO4PECCOSI Required 9C T 54055 PENILE DESTRUCTION PROCEDURE(S) ISA UNINVITED LAPAROSCOPIC PROCEDURE Authorization required Male genital surgery Full clinical examination TESTIS system 54900 SPERM VOLUME JOINT EPIDIDYMOVASOSTOMY ANAST Authorization required Infertility testing or full clinical examination EPIDIDIMIS UNI Treatment 54901 SPERM VOLUME JOINING EPIDIDYMOVASOSTOMY ANAST Authorization Infertility study or full clinical examination EPIDIDYMIS UNI -treatment 54901 SPERM DUCT CONNECTION EPIDIDIMIS EPIDOMITY Infertility or EPIDOMITY authorization CEPIDYMIS ical Review EPIDIDYMIS BI Treatment 55100 SCROTAL ABSCESS DRAINAGE Drainage Scrotal Wall Abscess No author Review Treatment 55400 VASOVASOSTOMY REPAIR SEMINAR VASOVASORRHAPHI Approval Required Male Genital Surgery Full Clinical Review System 5555 9 LAPARO PROC SPERMATIC WORD UNLISTED LAPROSCOPY PROCEDURE Authorization Full Clinical Genital C8 6 Clinical Review System 6 PLACER RT DEVICE/MARKER PRO PLMT INTERSTICIAL DEV RADIAT TX Approval Required Male Genital Surgery Full Clinical Review PROSTATE 1/MULT System

55899 GENITAL SURGICAL PROCEDURE NOT LISTED MALE GENITAL PROCEDURE Permission required Male genital surgery Full clinical examination SYSTEMIC system 55970 SEX TRANSFORMATION MALE FEMALE INTERSEX SURGERY MALE FEMALE Authorization required Reconstructive Full clinical examination 55970 SEX TRANSFORMATION Required 55970 ive Full clinical examination 5642 0 DRAIN AGE GLAND ABSCESS I& D BARTHOLLIN'S GLAND ABSCESS No approval required 56501 DESTROY VULVA LESIONS SIM DESTROY VULVA LESIONS SIMPLE No approval required 56515 DESTROY VULVA LESION/DEP Auth. 7061 DESTROY VAG LESIONS SIMPLE DESTRUCTION OF VAGINAL LESION No authorization required SIMPLE 57065 DESTROY VAG LESIONS COMPLEX DESTRUCTION OF VAGINAL LESION No authorization required COMPREHENSIVE 57500 CERVICAL BIOPSY CERVICAL BIOPSY SINGLE/MULTI/EXCISION No. Authorization required Lezija 57500 Bio Cervix Biopsy Cervix Single / Multi / Excission No Approval by Lesion 58000 SPX / WO Endocervix IUD Dilat Spx 58300 Understanding Intrauterine Device Removing Intrauterine Device IUD is not authorization required 5832 1 ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION ICAL system 58322 ARTIFICIAL INSEMINATION ARTIFICIAL INSEMINATION INTRA- Approval required Female genital surgery Full clinical examination UTERIN system 58323 SPERM FLUSHING SPERM FLUSHING ARTIFICIAL Approval required Female genital surgery Full clinical review INSEMINATION system 5 8578 LAPARO PROC UTERUS UNLISTED LAPAROSCOPY Test PROCEDURE Full review C7US Rev. 9 HYSTEROSCOPY PROCEDURE NOT LISTED HYSTEROSCOPY PROCEDURE Approval required Female genital surgery Full clinical examination UTERUS System 58679 LAPARO PROC OVIDUCT-OVARY NOT LISTED LAPAROSCOPIC PROCEDURE Approval required Infertility testing or full clinical examination Treatment OVIDUCT/OVARY 58750 OVARIAN REPAIR DUCT-OVARY Full surgical review OVIDUCT-OVARIAN TUBA STYR female clinical examination system 58752 OVARIAN TUBE REVISION (S) TUBOUTERIN IMPLANATION Approval required Infertility testing or full clinical review of treatment 58760 FIMBRIOPLASTICS FIMBRIOPLASTY approval required infertility testing or full clinical review of treatment 58970 OOCYTE FOLLICAL PUNCH Female clinical review ANY METHOD system 58974 TRANSFER E MBRYO EMBRYO TRANSFER INTRAUTERINE Approval Required Authorization Female Genital Surgery Full Clinical Review System 58976 EMBRYO GAME ZYGOTE/EMBRYO OGGLE TRANSFER Authorization Required Female Genital Surgery Full Clinical Review TRANSFER ANY METH System 58999 FEMALE GENITAL TRANSFER By PKR. Red Infertility Test or Full Clinical Examination Non-O-O-O-O-O-O-O-O-O-O-O 59025 Fetal Non-Stress Fetal Non-Stress Test No-Stress Test No Authorization Required 59030 Fetal Main Blood Specimen Pooling Test No Authorization Required 59866 Execution 59866 Abortion (MPRE Required ) MPR authorization meeting. Care Full Clinical Exam & Delivery 59897 Fetal Invas PX W/Us Undoubtedly Invasive PX Authorization Maternity Surgery Required for Full Clinical Exam w/Ul & Delivery 59898 Laparo Proc ob ob ob Obrom/Liver w/o Relaxed Laparoscopic Authorization Parent & Delivery Surgery Required CARE CARE C9DELIVITY Complete Labor Care C & 9 Neuro Unvalued Procedure Required Permissant Surgery Current Clinical Overview Care & Portability Endocrine Styredure Sy Stem Endocrine DuceDura Endocrine DuceDure Endocrine System Twelve Weeks Procedures 606 OCRINE Authorization required Endocrine surgery Full clinical review SYSTEMIC system 61531 BRAIN ELECTRODE IMPLANT SUBDURAL IMPLTJ ELECTRODE FIXTURES Authorization required Nerve surgery Full clinical review MONITORING system 61533 BRAIN ELECTRODE IMPLANT CRANI OT SUBDURAL IMPLT ELCTRD ELCTRD surgical authorization of nerve 61533 60 BRAIN ELECTRODE IMPLANT STR TCTC IMPLTJ ELTRD CEREBRUM Authorization required Nervous system surgery Full clinical review ASPECT MONITORING System 61850 NEUROELEKTRODE IMPLANT ANGER/BURR HUL IMPLTJ NSTIM ELTRD authorization required Nervous surgery Full clinical review CORTICAL system 61860 IMPLANT N REQUIRED EUROELEKTRODE NEUROELEKTRODE IMPLANT NEUROELEKTRODE EMPLTJ CERGERYLT REQUIRED CRNECJ CERSTERYLT Clinical Review of the CORTICAL system 6 1863 IMPLANT NEUROELECTRODE STRTCTC IMPLTJ NSTIM ELTRD U/O Authorization Required Nerve Surgery Full Clinical Review RECORD 1ST ARRAY System 61864 IMPLANT NEUROELECTRDE ADDL STRTCTC IMPLTJ NSTIM ELTRD U/O Authorization Required Nervous System Surgery Full Clinical Review N8EUROELECTRAY 61864 TRTCTC IMPLTJ NSTIM ELTRD Authorization Required Neurosurgery Full Clinical review W/REKORD 1ST ARRAY system 61868 IMPLANT NEUROELECTRDE ADDL STRTCTC IMPLTJ NSTIM ELTRD Authorization required Neurosurgery Full Clinical Review W/REKORD EA ARRAY System 61870 IMPLANT NEUROST REQUIRED Nerve Surgeons Full Clinical Review CEREBELLAR CORTICAL System 61880 REVISER/REMOVE NEUROELECTRODE REVJ/RMVL INTRACRANIAL Authorization Required Operation of Nervous Full Clinical Review NEUROSTIMULATOR ELTRDS System 61885 INSRT/REDO NEUROSTIM 1 ARRAY CRANIAL NEUROSTIM REQUIRED Surgery INSJIAL NO. SEE GENERATOR System 61886 IMPLANTING NEUROSTIM ARRAYS INSJ/RPLCMT CRANIAL NEUROSTIM Authorization Required Complete Nerve Surgery Clinical Review GENER 2/> ELTRDS System 61888 REVISER/REMOVE NEURORECEIVER REVJ/RMVL NEUROSTIMULATOR PULSE Authorization Required Complete Nerve Surgery Clinical Review GENER 2/> ELTRDS System 61888 6 PRIDESStories 6 PridesSories 61 ER Epidural Adhesions Multi Authorization Required Spinal Care Combined with Full Clinical Examination Sess 2/> Given Neck and Back Conditions Including: 62264 One Day Epidural Lysis Epidural Lysis Required Multi Authorization in Compound in Compound Full Clinical Examination SESSIONS 1 DAY, including: 62270 DX LMBR SPI PNXR LUMBAR SPINE DIAGNOSIS No approval required PUNCTURE 62287 PERCUTANEOUS DISCECTOMY DCMPRN PERQ NUCLEUS PULPOSUS 1/> Approval required Spine Care related to Complete Clinical Examination of Spine Levels: 0JLUMBAR, NJLUMB AR LEVELS: 2 MIN. AR CRV/THRC NJX DX/THER SBST INTRLMNR Approval required Spine care combined with a full clinical CRV/THRC U/O IMG GDN neck and back condition including:

62321 NJX INTERLAMINAR CRV/THRC NJX DX/THER SBST INTRLMNR Authorization Required Spinal Care Combined with Full Clinical Exam CRV/THRC W/IMG GDN Neck and Back Conditions Including: 62322 NJX INTERLAMINAR LMBR/SAC LMBR/SAC NJERNRX Authorization Required Combined Care with full clinical review LMBR/SAC U/O IMG GDN neck and back conditions including: 62323 NJX INTERLAMINAR LMBR/SAC NJX DX/THER SBST INTRLMNR Authorization required Spinal Care combined with full clinical review LMBR/SAC W/IMG GDN neck and back conditions, including: 62324 NJX INTERLAMINAR CRV/THRC NJX DX/THER SBST INTRLMNR Authorization required Spine care combined with full clinical exam CRV/THRC U/O IMG GDN Neck and back conditions, including: 62325 NJX DXTHRC/CRV /THER SBST INTRLMNR Spine Care Authorization Required Combined with Full Clinical CRV/THRC W/IMG GDN Neck & Back Conditions Including: 62326 NJX INTERLAMINAR LMBR/SAC NJX DX/THER SBST INTRLMNR Spine Care Authorization Required Combined with Complete C/Linear Examination LMBR-a SAC U/O IMG GDN neck and back conditions, including: 62327 NJX INTERLAMINAR LMBR/SAC NJX DX/THER SBST INTRLMNR Authorization required Spinal Care combined with full clinical examination LMBR/SAC W/IMG GDN neck and back conditions, including: 62328 DX LMBR SPI PNXR M /FLUOR/CT DIAGNOSTIC LUMBAR SPINAL No authorization required PUNCTURE W/FLUOR OR CT 62329 THER SPI PNXR CSF FLUOR/CT THERAPEUTIC SPINAL PNXR DRAINAGE No authorization required CSF W/FLUOR CSF 62329 THER SPI PNXR CSF W/FLUOR CSF 62J3LT REVJ/RPSG ITHCL. EDRL CATH Authorization Required Spinal Care Combined with Full Clinical Exam PMP U/O LAM Neck & Back Including: 62351 IMPLANT SPINAL CANAL CATH IMPLTJ REVJ/RPSG ITHCL/EDRL CATH Authorization Required Spinal Care Combined with Full Clinical Exam W/LAM neck and back Conditions, including: 62380 NDSC DCMPRN 1 NTRSPC LUMBAR NDSC DCMPRN SPINAL CORD 1 Approval required Spine Care combined with full clinical exam W/LAMOT NTRSPC LUMBAR Neck and Back, including: 63001 REMOTE SPINE 1/2CRVL/2 O FACETEC FORAMOT /DSKC 1 /2 authorization required Spine care associated with full clinical review VRT SEG CRV of neck and back conditions including: 63003 REMOVE SPINE LAMINA 1/2 THRC LAMINECTOMY U/O FFD 1/2 VERT SEG Nursing authorization required for full clinical examination of THORACIC SIDE neck and back conditions including: 63005 REMOVE SPINE LAMINA 1/2 LMBR LAMINECTOMY U/O FFD 1/2 VERT SEG Authorization required Spine care combined with full clinical examination LUMBAR neck and back conditions including: REMOVE SP011 LAMINA 1/2 2 SCRL LAMINECTOMY U/ O FFD 1/2 VERT SEG Authorization required Spinal Care combined with full clinical examination of SACRAL neck and back conditions including: 63012 REMOVE LAMINA/FACETER LUMBAR LAMINECTOMY W/RMVL Requires ABNORMAL Authorization Clinical examination of FACETER LUMBAR conditions of neck and back, including: 63015 REMOVE SPINE LAMINA >2 CRVCL LAMINECTOMY U/O FFD > 2 VERT SEG approval Required spine care combined with full clinical examination of CERVICAL neck and back conditions, including: 63016 REMINA THRC LAMINECTOMY U/O FFD > 2 VERT SEG approval Spine care required in conjunction with full clinical examination THORACIC neck and back conditions including: 63017 REMOVE SPINE LAMINA >2 LMBR LAMINECTOMY U/O FFD > 2 VERT SEG Carization required for full spine authorization required Clinical examination LUMBAR neck and back conditions, including: 63020 CERVICAL SPINE DISPLACEMENT SURGERY LAMNOTMY INCL M/DCMPRSN NRV authorization required Spine care combined with full clinical examination ROOT 1 INTRSPC CERVC neck and back conditions including: 63030 SURY WY LOW BRYGGER DCMPRSN NRV authorization required Spine care combined with full clinical examination by review ROOT 1 INTRSPC LUMBR neck and back conditions including: 63035 SUPPLEMENT TO SPINAL DISC SURGERY LAMNOTMY W/DCMPRSN NRV EACH authorization required Spine Care combined with full CRV neck and ADLM NRV cervical spine conditions including: 63040 LAMINOTOMY SINGLE CERVICAL LAMOT PRTL FFD EXC DISC REEXPL 1 Authorization required Spine Care in conjunction with a full clinical NTRSPC CERVICAL neck - and back condition, including: 63042 LAMINOTOMY LAMPLE EXPLC DISC DISC. Spine care associated with full clinical NTRSPC LUMBAR neck and back conditions including: 63043 LAMINOTOMY ADDL CERVICAL LAMOT PRTL FFD EXC DISC REEXPL 1 Authorization required Spine care associated with full clinical NTRSPC EA CRV neck and back conditions including: 63043 PRTL FFD HRNA8 REEXPL 1 Approval required Spine care combined with full clinical examination NTRSPC EA LMBR of neck and back condition, including: 63045 REMOVAL OF SPINE LAMINA 1 CRVL LAM FACETECTOMY AND FORAMOTOMY 1 Approval required Spine Clinical examination of spine Clinical examination of back and spine condition, including : 63046 REMOVE SPINE LAMINA 1 THRC LAM FACETECTOMY & FORAMOTOMY 1 Authorization required Spine care combined with full clinical exam THORACIC SEGMENT neck and back conditions including: 63047 REMOVE SPINE LAMINA 1 LAMINA LMECTOMY 1 LAM FACET LMECTOMY spine and 1 author's full clinical exam required Clinical examination of SEGMENT LUMBAR neck and back conditions, including: 63048 REMOVE SPINAL LAMINA ADD-ON LAM FACETECTOMY&FORAMTOMY 1 Approval required Spine care combined with full clinical examination of SGM EA CRV THRC/LMBR neck and back conditions, including: COPER3VEGLS050. LAMOP CERVICAL W/DCMPRN SPI CORD Clearance Required Spinal care combined with full clinical exam 2/> VERT SEG neck and back conditions including: 63051 C-LAMOPLASTY W/GRAFT/PLATE LAMOPLASTY CERVICAL DCMPRN CORD Clearance required for full cervical exam CORD by . 2/> SEG RCNSTJ neck and back conditions, including: 63055 DECOMPRESS SPINAL CORD THRC TRANSPEDICULAR DCMPRN SPINAL Approval required Spinal Care in conjunction with a full clinical exam CORD 1 SEG THORACIC neck and back conditions, including: 63056 SPEDICULAR DECOMPRESS SPINAL Author: Spine Care in along with a complete clinical examination clinical examination CORD 1 SEG LUMBAR neck and back conditions including:

63057 spinal cord decompression add transpedicular dcmprn 1 seg ea authorization required spine care related to full clinical examination of thoracic/lumbar neck and back condition including: 63064 decompression dorsal border of spinal cord thrc costovertebral dcmprn required spine authorization related to full clinical examination thoracic cord cord thrc costovertebral dcmprn spinal authorization 1 SEG neck and back conditions, including: 63066 SPINAL CURRENT DECOMPRESSION ADDITIONAL COSTOVERTEBRAL DCMPRN SPINAL CONTROL Spine care authorization required in combination with full clinical exam CORD THORACIC EA SEG neck and back conditions, including: 63075 CERVICAL SPINE DISC SURGERY REQUIRED DISC SURGERY Endorsement Spine Care Related to Full Clinical Review CERVICAL 1 NTRSPC Neck and Back Conditions Including: 63076 CERVICAL SPINE DISCECTOMY ANT DCMPRN CORD Endorsement Required Spine Care Related to Full Clinical Review CERVICAL EA NTRSPC Neck and Back Conditions, S3AXORTHYGER incl. DISCECTOMY ANT DCMPRN CORD Approval required Spine Care combined with full clinical exam THORAC 1 NTRSPC conditions of neck and back, including: 63078 DISC SURGERY THORAX DISCECTOMA ANT DCMPRN CORD Approval required Spine Care combined with THORACRS conditions, including THORACPC conditions, including THORACPC- conditions : 63610 SPINAL CORD STIMULATION STRTCTC STIMJ SPI CORD PRQ SPX Authorization required Spine care combined with full clinical exam N/FLWD OTH SURGICAL neck and back conditions including: 63620 SRS SPINAL LESION REQUIRING STEREOTACTIC RADIATION Full RADIATION SP1. LESIONS neck and back conditions, including: 63650 NEUROELECTRODE IMPLANT PRQ IMPLTJ NSTIM ELECTRODE ARRAY Authorization required Spine care combined with full clinical examination EPIDURAL neck and back conditions, including: 63655 NEUROELECTRODE IMPLANT REQUIRED IMPLANT REQUIRED IMPLANT IMPLANT IMPLANT IMPLANT IMPLANT. PLATE /PADDLE EDRL neck and back clinical examination, including: 63662 FERN SPINE ELTRD PLATE RMVL SPINAL NSTIM ELTRD Approval required Spine care combined with full PLATE/PADDLE INCL FLUOR neck and back clinical examination, including: 63663 REVJPER INCL SPINE LARMSTAY ELTRD PRQ - authorization required Spine Care in combination with full clinical examination RA INCL FLUOR of neck and back conditions, including: 63664 REVISE BACK PLATE ELTRD REVJ INCL RPLCMT NSTIM ELTRD authorization required Spine Care in combination with full clinical examination PLT/PDLE INCL FLUOR, PLT/ PDLE INCL FLUOR including: 63685 INSRT/REDO SPINE N GENERATOR INSJ/RPLCMT SPI NPGR DIR/INDUKIVE Authorization required Spine care combined with full clinical exam FUSION neck and back condition including: 63688 REVISE/REMOVE NEURORECEIVER REVJORCEIVER REVJERING/RMVIN Requires Spine Requilating for Full Clinical Review Neurostim Generator Neck & Back Conditions Including: 64405 NJX AA &/STRD GR OCPL NRV Injection AA &/STRD Major Authorization Required Nerve Surgery Full Clinical Review Occipital Nervous System 64451 NJX AA &/STRD NRVTG SI JT Injection AA &/ ST NRVTG SI No Author Associated Full Clinical Review CRV/THRC 1 LVL Neck & Back Conditions Including: 64480 INJ FORAMEN EPIDURAL APPENDIX NJX ANES&/STRD W/IMG TFRML EDRL Authorization Required Spinal Care Associated Full Clinical Review CRV/THRC EA LV Neck Conditions including: 64483 INJ FORAMEN EPIDURAL L/S NJX ANES&/STRD W/IMG TFRML EDRL Spinal Care approval required in conjunction with full clinical exam LMBR/SAC 1 LVL neck and back conditions including: 64484 INJ FORAMEN EPIDURAL ADDURAL /STRD W /IMG TFRML EDRL authorization required Spine care associated with full clinical examination LMBR/SAC EA LV neck and back conditions including: 64490 INJ PARAVERT F JNT C/T 1 LEV NJX DX/THER AGT PVRT FACET JT authorization required associated with full clinical examination CRV /THRC 1 LEVEL neck and back conditions, including: 64491 INJ PARAVERT F JNT C/T 2 LEV NJX DX/THER AGT PVRT FACET JT Approval required Back Care in conjunction with full clinical examination CRV/THRC 2ND NEK LEVEL and back conditions, including : 64492 INJ PARAVERT F JNT C/T 3 LEV NJX DX/THER AGT PVRT FACET JT authorization required Spine care combined with full clinical examination CRV/THRC 3+ LEVEL neck and back condition including: 64493 INJ PARAVERT F JNT L/ S 1 Authorization required LEV NJX DX/THER AGT PVRT FACET JT Spine Care Combined with Full Clinical Exam LMBR/SAC LEVEL 1 Neck and Back Conditions Including: 64494 INJ PARAVERT F JNT L/S 2 Authorization LEV NJX DX/THER AGT PVRT FACET JT Spine Care Required combined with a full LMBR/SAC LEVEL 2 clinical review of neck and back conditions including: 64495 INJ PARAVERT F JNT L/S 3 LEV NJX DX/THER AGT PVRT FACET JT Authorization required for a full LMBR/SAC LEVEL 3 clinical treatment review + conditions neck and back, including: 64505 N BLOCK SPHENOPALATINU GANGL INJECTABLE ANESTHETIC Approval required Nerve surgery Complete clinical examination SPHENOPALATINU GANGLI system 64520 N BLOCK LUMBAR/THORACIC LUMBAR/THORACIC BLOCK Nervous surgeon approval. Clinical Review PARAVERTBRL SYMPATHETIC System 64553 NEUROELECTRODE IMPLANT PRQ IMPLTJ NEUROSTIMULATOR ELTRD Authorization Required Nerve Surgery Complete Clinical Review CRANIAL NERVOUS System 64555 NEUROELECTRODE IMPLANT REQUIRED NEUROELECTRODE IMPLANT REQUIRED IMPLATOR surgeon. Review PERIPHERAL NERV System 64561 IMPLANT NEUROELECTRODES PRQ IMPLTJ NEUROSTIM ELTRD SACRAL Approval Required Nerve Complete Clinical Exam Surgery NERVE W/IMAGING System 64566 NEUROELTRD STIM POST TIBIAL POST TIB NEUROSTIMULATION PRQ Approval Required Nerve Complete Clinical Exam NEEDLE System ELECTRODE 64568 INC FOR VAGUS N ELECT IMPLTRIM REQUIRED Approval NEUROSTIMULATION IMVCRNL. gery of nerve Complete clinical examination PULSEGENER system 64569 REVISER/REPLIT VAGUS N ELTRD REVISION/REPLMT NEUROSTIMLATOR Authorization required Surgery of nerve Complete clinical examination ELTRD CRANIAL NERV system 64575 IMPLANT NEUROELECTRODES INCLUDING TOR ELTRD system

64580 IMPLANT NEUROELECTRODES INC IMPLTJ NSTIM ELTRD Authorization Required Nerve Surgery Complete Clinical Examination of the NEUROMUSCULAR System 64581 IMPLANT NEUROELEKTRODES INC IMPLTJ NEUROSTIMULATOR ELTRD Authorization Required Nervous System Surgery 64581 IMPLANT NEUROELECTRODES INC . /GASTR STIMUL INSERTION/RPLCMT Authorization Required Nerve Surgery Full Clinical Review PERI FERAL/ GASTRIC NPGR System 64595 REVISE/RMV PN/GASTR STIMUL REVISION/RMVL PERIPHERAL/STOMACH Authorization Required Nerve Surgery Full Clinical Review NPGR System 64624 DSTRJ NULYT Aquinr. AR NERVE W/IMG 64625 RF ABLTJ NRV NRVTG SI JT RADIO FREQUENCY ABLTJ NRV NRVTG SI No authorization required JT W/IMG GDN 64633 DESTROY CERV/THOR FACET JNT DSTR NROLYTC AGNT PARVERTEB FCT FCT authorization surgical/cgl. 64634 DESTROY C/TH FACET JNT ADDL DSTR NROLYTC AGNT PARVERTEB FCT Authorization Required Nerve Surgery Full Clinical Review ADDL CRVCL/THORA System 64635 DESTROY LUMB/SAC FACET JNT DSTR NROLYTC AGNT PARVERTEB FCT Authorization Required Full ClinBRAL Surgery 4SA/6SA Nervous System 64635 ROY L/ S FACET JNT ADDL DSTR NROLYTC AGNT PARVERTEB FCT Authorization Required Nervous System Surgery Full Clinical Review ADDL LMBR/SACRAL System 64999 NERVOUS SYSTEM SURGERY UNLISTED NERVOUS PROCEDURES AUTHORIZATION REQUIRED Nervous System Surgery Full Clinical Review FOR205 NERVOUS SYSTEM F65 REYGN SYSTEM F65 ophthalmic conjunctiva No approval required SURFACE 65210 REMOVE FOREIGN BODY FROM EYE RMVL FB XTRNL EYE EMBED No approval required SCJNCL/SCLERAL NONPERFOR 65220 REMOVE FOREIGN BODY FROM EYE RMVL FB XTRNLIT WEYE A5 RquiSLIT WEYE A5 Rquid 2 OVE FOREIGN BODY FROM EYE RMVL FB XTRNL CORNEA EYE W/SLIT No Approval Required LAMP 65235 REMOVE FOREIGN BODY FROM EYE RMVL FB INTRAOCULAR ANT CHAMBER No Approval EYE/LENS 65260 REMOVE FOREIGN BODY FROM EYE RMVL FB IO FROM X POST SEG R6T R6T ASS NO. REMOVE FOREIGN BODY FROM EYE RMVL FB IO FROM POST SEG No approval required NONMAGNETIC XTRJ 65771 RADIAL KERATOTOMY RADIAL KERATOTOMY Approval required Eye and ocular surgery Full clinical adnexal exam 65772 RADIAL KERATOTOMY eye surgery and eyepiece and eyepiece required full clinical exam ASTIGMATISM adne xa 65775 CORRECTION OF ASTIGMATISM CRNL WEDGE RESCJ CORRJ INDUCED Authorization required Eye and ocular surgery Complete clinical examination ASTIGMATISM adnexa 66830 LENS LESION REMOVAL RMVL SEC MEMBRANOUS CTRC Surgical Surgical surgeon 65775 Necessary 65775 40 LENS MATERIAL REMOVAL RMVL LENS MATERIAL ASPIR TQ 1/> No eye surgery authorization required and ocular stages of the adnexa 66850 Removal of lens material Anager y eye and eyepiece W/WO VITRECTOMY of the adnexa 66920 LENS REMOVAL RMVL LENS MATERIAL INTRACAPSULAR No authorization required Surgery of the eye and ocular adnexa 66930 LENS REMOVAL LENSEMATRL INTRACAPSULAR surgical eye and eye surgeon 6 940 MATTER REMOVAL JALA FOR REMOVING THE LENS No approval required Eye and ocular surgery EXTRA CAPSULE adnexa 66982 XCAPSL CTRC RMVL CPLX WO ECP XCAPSL CTRC RMVL INSJ IO LENSES No approval required Eye and ocular surgery PROSTH CPLX WO ECP 9A ADnexa ST 66 9 8 8 1 2 CATARACT XTRJ INSJ IO LENSES Not required approval Eye and ocular surgery PRSTH 1 STG adnexa 66984 XCAPSL CTRC RMVL U/O ECP XCAPSL CTRC RMVL INSJ IO LENS No approval required Eye and ocular surgery PROSTH U/O ECP adnexa 6698 PROSJENSTHES INSERTISJENSTHES LENSES No app roval Eye and ocular surgery W/ SIMULTANEOUS RMVL adnexa 66987 XCAPSL CTRC RMVL CPLX W/ECP XCAPSL CTRC RMVL INSJ IO LENS No Authorization Required PROSTH CPLX W/ECP 66988 XCAPSL W/ECP R AMVCLEN uth Required PROSTH W/ECP 66999 EYE S URGENT PROCEDURE NOT ON ANTERIOR PROCEDURE LIST Authorization Required Eye and eye surgery Complete clinical examination SEGMENT EYE SURGICAL PROCEDURE NOT LISTED surgical intervention and eye examination required. 67399 PX OUTSIDE THE OCULAR MUSCLE NOT LISTED EXTRA-OCULAR PROCEDURE Approval Needed Eye and Ocular Surgery Full Clinical Examination MUSCLE Adnexa 67599 ORBITAL SURGICAL PROCEDURE NOT LISTED ORBITAL PROCEDURE Approval Required Eye and Ocular Surgery Full Clinical Adnexal Examination 67700 EYE SURGICAL PROCEDURE UNLISTED CEDURE ORBIT Required permission Surgery of the eye and eyepiece Complete clinical examination of the adnexa 67700 EYEBROW DRAIN ADRENA ADRENA OF THE EYE Required EYE CAP 67900 EYEBROW DEFECT REPAIR EYEBROW PTOSIS REPAIR authorization required Eye and eyepiece surgery Complete clinical examination of the adnexa 67901 EYEBROW DEFECT REPAIR RPR BLEPHAROPTOSIS FRONTALIS MU SC Authorization required of eye and ocular learning Complete clinical examination SUTR/ANDEN MATREL adnexa 67EYPREPROPHA REPTROFRONT 902 REPTROFRONT 902 Required ization Eye and ocular surgery Complete clinical examination AUTOL FASCAL SLING adnexa 67903 REPAIR OF VEDICA DEFECT RPR BLEPHAROPTOSIS LEVATOR Authorization required Eye and ocular surgery Complete clinical examination RESCJ/ ADVMNT INTERN adnexa 67904 EYEBROW DEFECT REPAIR REQUIRED surgical eyelid defect and eyelid defect Eye Disorder required cular Full Clinical Examination RESCJ/ADVMNT XTRNL adnexa 67906 EYEBROW DEFECT REPAIR RPR BLEPHAROPTOSIS SUPERIOR Authorization Required Eye and Ocular Surgery Full Clinical Examination RECTUS FASCIAL SLIP adnexa 67908 REPAIR EYE DEFECT EXPERIENCE RPR BLPOS CONJUNCTIVO-TAR authorization of ophthalmologist and surgeon. TOR RESCJ adnexa 67909 REVISER EYEBROW DEFECT REDUCTION OVERCORRECTION PTOSIS Authorization required Eye and ocular surgery Complete clinical examination of the adnexa 67911 REVISER CORRECTION OF EYEBROW DEFECTS LOW RETRACTION Authorization required Eye and ocular surgery Complete clinical examination of the adnexa 67912 LJOPRECTION LJOPLAG Authorization required Eye and ocular surgery Complete clinical examination EYELID FLAP LOAD adnexa 67914 CAPEK REPAIR DEFECT ECTROPY SUTURE Authorization required Eye and ocular surgery Full clinical examination of adnexa 67915 CAPEK REPAIR ECTROPION SUTURE Full authorization of eye and eye examination and eye examination. 67916 EYEBROW DEFECT REPAIR ECTROPIUM REPAIR TARSAL MOTION EXCISION Required Approval Ocular and Ocular Surgery Full Clinical Examination of WEDGE Adnex

67917 REPAIR DEFECT EYELLAD REPAIR ECTROPION EXTENSIVE Authorization required Eye and Ocular Surgery Complete clinical examination of the adnexa 67921 REPAIR DEFECT EYELLAD REPAIR ENTROPION SAVITE Authorization required Eye and Ocular Surgery Complete clinical examination of the adnexa 67921 Authorization required Eye and Ocular Surgery Complete clinical examination of the adnexa THERMOCAUTERIZATION 67 92 3 REPAIR EYEBROW DEFECT REPAIR TARSAL EYEBROW EXCITING Authorization required Eye and ocular surgery Complete clinical examination of WEDGE adnexa 67924 EYEBROW DEFECT REPAIR EYEBROW AND ENTROPION REPAIR Complete examination of eyelid adnexa. 67999 EYEBROW REVISION UNINVITED PROCEDURE OPHTHALMISTS Approval Eyes Eye and Ocular Surgery Full Adnexal Clinical Examination 68399 EYEBROW TREATMENT SURGERY UNINVITED CONJUNCTIVATIVE PROCEDURE Permissions Required Eye and Ocular Surgery Full Adnexal Clinical Examination 68899 LACRIMAL SYSTEM SURGERY REQUIRED SURGICAL AUTHORIZATION NO PROCEDURE REQUIRED o REQUIRED Ø gene screening . adnexa system 69000 DRAINAGE OF EXTERNAL EAR LESION DRAINAGE OF EXTERNAL EAR No approval required APSCESS/HEMATOM SIMPLE 69005 DRAINAGE OF EXTERNAL EAR LESION EXTERNAL EAR DRAINAGE No approval required APSCESS/HEMATOM CMPLX 69020 EXTERNAL EAR DRAINAGE CANOUN No. approval required APSCESS 69090 EAR LOBE PIERCING EAR PIERCING Authorization required Reconstructive Full clinical examination 69200 CLEAR EXTERNAL CANAL RMVL FB XTRNL AUDITORY CANAL U/O No approval required ANES 69209 REMOVE EARWAX UNI REMOVAL IMPACTED CERUMEN No approval required IRRIGATION/LVG UNILAT REMMEN IMPAXED UNILAT 69 No approval required INSTRUMENTATION UNILAT 6930 0 OTOPLASTY REVISION EXTERNAL EAR PROVINATED EAR W /WO Approval required Reconstructive Full Clinical Exam SIZE RDCTJ 69399 SURGICAL PROCEDURE OF EXTERNAL EAR NOT LISTED EXTERNAL EAR PROCEDURE Approval required C4RINGof Hearing System 69300 Y ASPIR&/EUSTACHIAN TUBE Approval required NFLTJ 6971 0 IMPLANTER/REPLACEMENT HEARING AID IMPLTJ/RPLCMT EMGNT BONE CNDJ Authorization Required Surgery Auditory Full Clinical Exam DEV TEMPORAL BONE System 69711 HEARING AID REMOVAL/REPAIR RMVL/RPR EMGNT BONE CNDJ DEV Authorization Required Auditory System B9IM1 Auditory System 69711 MYRE TEMPLE BONE W/STIMUL IMPLTJ OSSEOINTEGRATE TEMPORAL Authorization required Auditory work Full clinical examination BONE W /MASTOID system 69715 TEMPLE BNE IMPLNT W/STIMULAT IMPLJ OSSEOINTEGRATE TEMPORAL Authorization required Full surgery BNE IMPLNT 69715 MPLE BONE IMPLANT REVISION RPLMCT OSSEOINTEGRATE IMPLNT U/O Authorization required Auditory surgery Full clinical examination MASTOIDECTOMY system 6971 8 REVISION OF TEMPLE BONE IMPLANTS RPLMCT OSSEOINTEGRATE IMPLNT Approval Required Auditory Full Clinical Review Surgery W/MASTOIDECTOMY System 69718 DONE PRODUCED PRODUCED SYSTEM BOARD 6979 CEDURE MELLEMØRE Authorization Required Auditory Full Clinical Review Surgery System 69930 IMPLANTED COLLAR DEVICE IMPLANT INSTALLATION KOL EARN DEVICE Full approval required Auditory Clinical Review Surgery W/WO System MASTOIDECTOMY 69949 INNER EAR SURGICAL PROCEDURE UNINVITED PROCEDURE INTERNAL EARLIN EXAMINATION System 96 Full Surgical Review System 96 SURGERY UNPLUGD PREVIOUS PROCEDURE Authorization Required Auditory Surgery Full Clinical Review MIDDLE FOSSA BONES System 69990 MICROSURGICAL ADDITIONAL MICROSURGE TQS REQ IN SE OPERATIONS No authorization required Surgery MICROSCOPE 70010 CONTRAST X-RAY BRAIN IMAGE MYELOGRAPY POST 7 FOSSA NO. POSITIVE CONTRAST CISTERNOGRAPHY No. RS&I approval required 70030 X-ray PRECISION FOR FOREIGN BODIES RADIOLOGICAL EXAMINATION EYE DETECTOR No approval required FOREIGN BODIES 70100 X-ray EXAMINATION OF JAWS

70336 MAGNETIC IMAGE OF THE JAW JOINT MRI TEMPOROMANDIBULAR LED Radiological Full Clinical Review Required Effective January 2021 Temporary Change: Network Validation Review 70350 ORTHODONTICS HEAD X-RAY CEPHALOGRAM ORTHODONTICS OF 70 Xlin-5 Radiological Authorization Required 70 JAW ORTHOPANTOGRAM Authorization Required Radiological Complete Clinical examination 7 0360 X-RAY DOOR EXAMINATION RADIOLOGIC EXAMINATION THROAT FINE No approval required TISSUE 70370 X-RAY THROAT AND FLUOROSCOPY RADEX PHARYNX/LARX No approval required W/FLUOR&/MAGNIFICATION T1Q7EX37 COMP. PHARYNGEAL&SP EVAL No approval required C/V REC 70380 X-ray EXAMINATION OF SALIVARY GLANDS RADIOLOGIC EXAMINATION SPRAY No approval required Glandular Calculus 70390 X-ray examination of salivary glands SIALOGRAPHY RS&I No approval required 70450 CONDITIONAL HV//B RYT H// ST Authorization required Radiology - Diagnostic full clinical review of MATERIALS radiology Valid Jan. 2021 Temporary Change: Network Validation Review 70460 CT HEAD/BRAIN W/COLOR CT HEAD/BRAIN W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL radiology Change Jan 21 Temporary Jan 20 : Network Validation Review 70470 CT HEAD/BRAIN U/U & U/COLOR CT HEAD/BRAIN U/V/CONTRAST Authorization required Radiology - Diagnostic full clinical examination MATERIAL radiology Valid Jan. 2021 Temporary Change: Network Validity Review 70480 CT ORBIT /EAR/FOSSA U/COLOR CT ORBIT SELLA/POST FOSSA/ØR U/O No Approval Required Radiology - Diagnostic CONTRAST MATRL Radiology 70481 CT ORBIT/EAR/FOSSA W/COLOR CT ORBIT SELLA /POST FOSSA/EAR Authorization Required Radiology - Diagnostic Full Clinical Examination M/CONTRAST MATRL Radiology Effective January 2021 Temporary Change: Network Validity Review 70482 CT ORBIT/EAR/FOSSA W/O&W/COLOR CT ORBITA SELLA/POST FOSSA/EAR U/O Authorization Required Radiology - Diagnostics Complete Clinical Exam & W/CONTR MATR Radiology Valid Jan. 2021 Temporary Change: Network Validation Review 70486 COLOR CT MAXILLOFACIAL U/O CT CONTRAST MAXILLOFACIAL U/O Approval Required Radiology - Diagnostic Full Clinical Review MATERIAL Radiology Effective Jan. 2020 70 Network Validation 48 Change CT MAXILLOFACIAL W/COLOR CT MAXILLOFACIAL W/CONTRAST Authorization required Radiology - diagnostics Full clinical review MATERIALS radiology Valid Jan. 2021 Temporary Change: Network Validation Review 70488 CT MAXILLOFACIAL W/O & W/COLOR CT W/MAXILLOFACIAL Authorization - Required MAXILLOFACIAL Diagnostic Full Clinical Exam W/CONTRAST MATERIAL Radiology Effective Jan. 2021 Temporary change: Network validation review 70490 CT SOFT TISSUE NECK U/O STAIN CT SOFT TISSUE NECK WITHOUT CONTRAST Authorization required Radiology - diagnostic full clinical examination MATERIAL January 2021. Temporary Change: Network Validation Review 70491 NECK SOFT TISSUE CT W/COLOR Neck Soft Tissue CT W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Exam MATERIAL radiology Valid Jan. Temporary Change 2021: Network Validation Review 70492 NCK WOTS & NCK WOTS & NCK SFT W/COLOR CT SOFT TISSUE NECK U/O & Authorization Required Radiology - Diagnostic Full Clinical Exam W/CONTRAST MATERIAL Radiology Effective January 2021 Temporary change: Network validation review 70496 HEAD FOR CT ANGIOGRAPHY CT ANGIOGRAPHY Clinical HEAD Diagnostic authorization required. /CONTRAST/NO CONTRAST radiology 70498 CT ANGIOGRAPHY NECK CT ANGIOGRAPHY NECK No Clearance Required Radiology - Diagnostic W/CONTRAST/NO CONTRAST Radiology 70540 MRI ORBIT/FACE/NECK U/O COLOR MRI ORBIT W FACE &/NEC Full Radiology/ FACE &/NEC Required /NO Clinical examination CONTRAST radiology Applies January. 2021 Temporary Change: Network Validation Review 70542 MRI ORBIT/FACE/NECK W/COLOR MRI ORBIT FACE AND NECK W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Exam MATERIAL Radiology Effective Jan. 2021 Validation Review 70543 MRI ORBT/FAC/NCK U/O &W/COLOR MRI ORBITA FACE & NECK U/O & Authorization Required Radiology - Diagnostic Complete Clinical Review W/CONTRAST MATRL Radiology Effective January 2021 Temporary Change: MR Network Validation Review 70544 MR ANGIOGRAPH HEAD U/O MRA COLOR HEAD U/U CONTRAST MATERIAL Approval Required Radiology - Diagnostics Complete Radiology Clinical Review Effective January 2021 Temporary Change: Network Validation Review 70545 MR ANGIOGRAPH HEAD W/COLOR MRA HEAD W/CONTRAST MATERIAL authorization Full radiology authorization Clinical examination radiology 70546 MR ANGIOGRAPHY HEAD U/O&W/COLOR MRA HEAD U/U & U/CONTRAST Authorization required Radiology - Diagnostic full clinical examination MATERIAL radiology 70547 MR ANGIOGRAPHY NECK NO COLOR MRA REQUIRED MATERIAL CONTR. diagnostics Complete clinical examination radiology 70548 MR ANGIOGRAPH DOOR W/U COLOR MRA DOOR W/CONTRAST MATERIAL Authorization required Radiology - diagnostics Complete clinical examination radiology 70549 MR ANGIOGRAPH DOOR U/O&V/COLOR MRA DOOR U/O & W/REQUIRED AU & W / D authorization. Clinical examination MATERIJAL radiology 70551 MRI BRAIN STEM WITHOUT STAIN MRI BRAIN STEM WITHOUT CONTRAST Authorization required Radiology - diagnostics Complete clinical examination MATERIJAL radiology Valid Jan. 2021 Temporary Change: Network Validation Review 70552 MRI BRAIN STEM BRAIN STEM W/DY STEM W/CONTRAST authorization required Radiology - Diagnostic Full Clinical Review MATERIAL radiology Valid Jan. 2021 Temporary Change: Network Validation Review 70553 MRI BRAIN COLLECTION U/U & W/COLOUR BRAIN STEM MRI U/U authorization required Radiology - Diagnostic Full Clinical Exam W/CONTRAST MATERIAL radiology Effective Jan. Interim change 2021: Review of network validity

70554 FMRI BRAIN BY TECHNICAL MRI BRAIN FUNCTIONAL U/O authorization required Radiology - diagnostics Complete clinical examination PHYSICIAN ADMINISTRATION radiology 70555 FMRI BRAIN BY PHYSICAL/PSYCHOLOGICAL MRI BRAIN FUNCTIONAL W/PHYSICIAN - authorization required radiology 20 Jan. Temporary Change: Network Validation Review 70557 MRI BRAIN WITHOUT STAIN MRI BRAIN OPEN INTRAcranial PX Authorization Required Radiology - Diagnostic Full Clinical Review W/O CONTRAST MATL Radiology Effective January 2021 Temporary Change: Network Validation Review 70558 MRI MRI BRAIN W/ DYE INTRACRANIAL PX Authorization Required Radiology - Diagnostics Full Clinical Exam W/CONTRAST MATL Radiology Valid sj. 2021 Temporary Change: Network Validation Review 70559 MRI BRAIN U/O & W/COLOR MRI BRAIN OPEN INTRAcranial PX Approval Required Radiology - Diagnostic Full Clinical Review O & W/CONTRAST Radiology Effective Jan. 2021 Temporary Change: Network Validity Review 71045 X-RAY EXAMINATION COAST 1 VIEW RADIOLOGIC EXAMINATION COAST SINGLE VIEW No approval required 71046 X-RAY EXAMINATION COAST 2 VIEW RADIOLOGICAL EXAMINATION 2 VIEW RADIOLOGICAL EXAMINATION 7 COUNCIL RADIOLOGICAL EXAMINATION 7 REV 7 -COAST EXAMINATION 3 VIEW RADIOLOGICAL EXAMINATION CO AST 3 VIEWS No approval required 71048 X-RAY EXAMINATION COAST 4+ VIEWS RADIOLOGY EXAMINATION COAST 4+ VIEWS No approval required 71100 X-RAY EXAMINATION VIEW RIBS R UNI EXRI 7 VIS RIBS R UNI EXRI 7 Red 1101 X-RAY EXAMINATION UNILAT RIBS/CHEST RADEX REBRA UNI M/POSTEROANT CH Approval not required MINIMUM 3 VIEWS 71110 X-RAY EXAM RIB CAR 3 VIEWS RADEX RIBS BILATERAL 3 VIEWS No approval required 711111111111 XRI/XRI->RAY111111 XRI/XRI/X4 RIBS BI M/PO STEROANT CH No approval required MINIMUM 4 VIEWS 71120 X-RAY EXAM BRE ASTBONE 2/ >VWS RADEX STERNUM MINIMUM 2 VIEWS No authorization required 71130 X-RAY STRENOCLAVIC JT 3/>VWS RADEX STERNUM Obtained 3 VIEWS 71250 CT THORAX U/O COLOR CT TORAX U/O CONTRAST MATERIAL Authorization required Radiology - Diagnostic full clinical examination Radiology In effect from January 2021 Temporary change: Network validation review 71260 CT CHEST W/COLOR CHEST CLAIM CHEST S/CONTR. diagnostic full clinical review radiology Effective January 2021 Temporary change: Network Validation Review 71270 CT THORAX U/U & W/COLOR CT THORAX U/U & W/CONTRAST Authorization required Radiology - diagnostic full clinical review MATERIALS radiology Effective from January 2021. Temporary change: Network Validation examination 71275 CT ANGIOGRAPHY OF THE CHEST CT ANGIOGRAPHY OF THE CHEST Authorization required Radiology - diagnostics Complete clinical examination W/CONTRAST/NO CONTRAST radiology 71550 MRI OF THE CHEST WITHOUT COLOR MRI OF THE BREAST WITHOUT CONTRAST MATERIAL - Authorization required C Radiological performance Radiology Jan. 2021 Temporary Change: Network Validation Review 71551 MRI CHEST MRI W/COLOR MRI CHEST W/CONTRAST MATERIAL Authorization Required Radiology - Diagnostic Complete Clinical Review Radiology Effective January 2021 Temporary Change: Network Validation Review 71552 MRI CHEST MRI U/ O & W. CHEST U/U & U/CONTRAST Authorization required Radiology - diagnostics Complete clinical examination MATERIALS radiology Valid Jan. 2021 Temporary Change: Network Validity Review 71555 MRI ANGIO SPINE NO STAIN MRA BUST U/U & U/CONTRAST Authorization Required Radiology - Diagnostic Complete Clinical Review MATERIAL Radiology 72020 X-ray SPINE EXAMINATION 1 VIEW RADEX BACK 1 VIEW DETERMINE LEVEL No. Authorization required 7204 0 X-ray CERVICAL SPINE 2-3 VW RADEX SPINE CERVICAL VIEW 2 OR A205 required 2 OR A205RA CERVICAL SPINE VIEW 4/5VWS RADEX SPINE CERVICAL 4 OR 5 VIEW No authorization required 72052 X-ray CERVICAL SPINE 6/ > VWS Radex Spine spine 6 or more no approval required know views 72070 spine spine or ex-thorvic 2 views No approval required 72072 x-ray exam thoracic spine 3VWS Radex spine Thoracic 3 View Approval required 72074 x-ray exam spine Spine4/>> VW RADEX SPINE THORACAL MINIMUM 4 No Approval Required 7200SAM-200MB-200MB VW RADEX RUG THORACOLUMBAR No Approval Required JUNCTION MIN 2 VIEW 72081 X-RAY EXAM FULL SPI 1 VW RADEX WHOLE THRC LMBR CRV SAC SPI No Approval Required W/SKULL 1 VW 72082 X-RAY EXAM 2/3 X-RAY EXAM. SCR PI No Clearance Required W/SKULL 2/3 VW 72083 X-RAY EXAM FULL SPI 4/5 VW RADEX FULL THRC LMBR CRV SAC SPI No Clearance Required W/SKULL 4/5 VW 72084 X-RAY EXAM FULL SPI 6 FULL THRC LMBR CRV SAC SPI No Approval Required W/SKULL 6/> VW 72100 X-RAY EXAM L-S SPINE 2/3 VWS RADEX SPINE LUMBOSACRAL 2/3 VIEWS No Approval Required 72110 X-RAY EXAM SPINE L-2V RADEX SPINE LUMBOSACRAL MINIMUM No Approval Required 4 VIEWS 72114 X-RAY EXAM L-S S SPINE BEND RADEX SPINE LUMBSCRL COMPL No Authorization Required W/BEND VIEWS MIN 6 72120 X-RAY ONLY RBOSA BEND RBOSA SPINE BEND RBOSA SPIN 2 /3 VIEWS 72125 CT CERVICAL SPINE NO STAIN CT CERVICAL SPINE NO CONTRAST Authorization Required Radiology - Diagnostics Full Clinical Review MATERIALS Radiology Valid Jan. 2021 Temporary Change: Network Validation Review 72126 CT SPINE W/DYE SPINE Authorization W/DYE SPINE CERV Required Radiology - Diagnostic Full Clinical Review MATERIAL Radiology Effective Jan. Temporary Change 2021: Network Validity Review 72127 CT GARDEN SPINE U/U & W/COLOR CT GARDEN SPINE U/O & W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIALS radiology Effective 2021 Temporary Change: Review network validations 72128 CT CHEST U/O COLOR CT THORACIC HYGGRAD U/O CONTRAST Authorization required Radiology - Diagnostic full clinical examination MATERIAL Radiology Effective January 2021 Temporary change: Network validation review

72129 CT OF THE THORACIC SPINE W/COLOR CT OF THE THORACIC SPINE W/CONTRAST Authorization required Radiology - diagnostics Complete clinical examination MATERIALS radiology Valid Jan. 2021 Temporary Change: Network Validation Review 72130 THORACIC SPINE NO-COLOR CT W/OACIC THORACIC & Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTRAST MATERIAL radiology Effective January. 2021 Temporary Change: Network Validity Review 72131 CT LUMBAR SPINE U/O COLOR CT LUMBAR SPINE U/O CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Performance MATERIAL Jan. Temporary Change 2021: Network Validation Review 72132 CT LUMBAR SPINE W/COLOR CT LUMBAR SPINE W/CONTRAST Authorization Required Radiology - Diagnostic Complete Clinical Review MATERIAL radiology Effective January 2021 Temporary Change: Network Validation Review SPINE W/CONTRAST 72133 W/COLOR CT LUMBAR SPINE U/ O & W/CONTRAST Authorization required Radiology - diagnostics Full clinical examination MATERIALS radiology Valid sj. 2021 Temporary Change: Network Validation Review 72141 CERVICAL SPINE MR NO COLOR MRI CERVICAL SPINE CERVICAL SPINE Clearance required without radiology - diagnostic full clinical exam Radiology CONTRAST MATRL Effective Jan. Interim Change 2021: Network Validation Review 72142 MR CERVICAL SPINE W/COLOR MRI SPINAL CERVICAL Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTRAST MATRL January 2021 Network Validation Review 72146 THORANIC SPINE U/O MRI SPINE MR SPINAL CANAL Authorization Required Radiology - Diagnostic full clinical examination CONTRAST MATRL radiology Valid Jan. 2021 Temporary Change: Network Validation Review 72147 MRI THORACO SPINE W/DINAC Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTRAST MATRL Radiology Effective January 2021 Temporary Change: Network Validation Review 72148 MRI LUMBAR SPINE U/O IN COLOR MRI OF SPINAL CANAL LUMBAR U/O Approval required Radiology - diagnostics Complete clinical examination CONTRAST Jan. 2021 Temporary Change: Network Validation Review 72149 MRI LUMBAR SPINE W/DYE MRI SPINAL CANAL LUMBAR CANAL Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTRAST MATERIAL radiology Effective January 2021 Temporary Change: Network Validation SPINE MRI72NEONK & W /COLOR MRI OF SPINAL CANAL CERVICAL U /O & Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTR MATRL Radiology Effective January 2021 Temporary Change: Network Validity Review 72157 MRI BURST SPINE U/U & W/COLOR MRI OF SPINAL CHANNEL U/O and Authorization Required Radiology - Diagnostic Full Clinical Review M/CONTR MATRL Radiology Valid Jan. 2021 Temporary Change: Network Validity Review 72158 MRI LUMBAR SPINE U/O & W/COLOR MRI SPINAL CANAL LUMBAR U/O & Authorization Required Radiology - Diagnostic Full Clinical Review M/CONTR MATRL Radiology Effective January 2021 Temporary Change : Network Validation Review 72159 MR ANGIO SPINE W/ O&W/COLOR MRA Spinal Canal W/Wo Contrast Authorization Required Radiology-Diagnostic Full Clinical Exam Material X-Ra-72y70am Pelvic Radiology Radiology Examination Pelvis 1/2 No Authorization Required Exams 72190 X- ray Investigation of the pelvis 3 VIEWS 72191 CT ANGIOGRAPH DEVELOPMENT OF THE PELVIS AND KVIV. Complete clinical examination W /CONTRAST/WITHOUT CONTRAST Radiology 72192 CT PELVIC WITHOUT COLOR CT PELVIC WITHOUT CONTRAST MATERIAL Approval required Radiology - Diagnostics Complete clinical examination Radiology Valid Jan. 2021 Temporary Change: Network Validation Review 72193 CT PELVISTRA W/DYE W/DYE Authorization Required Radiology - Diagnostic Full Clinical Review Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 72194 CT PELVIS U/O & W/COLOR CT PELVIC U/O & W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 72195 PELVIS MRI WITHOUT COLOR MRI PELVIS WITHOUT CONTRAST MATERIAL Authorization Required Radiology - Diagnostic Full Clinical Review Radiology Effective January 2021 Temporary Change: Network Validation Review 72196 MRI PELDVISY PELVIS MRI /CONTRAST MATERIAL Required authorization Radiology - Diagnostic Complete Clinical Review Radiology Applicable January 2021 Temporary Change: Network Validation Review 72197 MRI BOWL U/U & W/COLOR MRI BOWL U/O & W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL radiology Valid January . 2021 Temporary Change: Network Validity Review 72198 MR ANGIO PELVIC U/O & W/COLOUR MR PELVIC U/WO CONTRAST Requires Authorization Radiology - Diagnostic Full Clinical Exam MATERIAL Radiology 72200 X-ray EXAMINATION SIIO EXAM SIEXASILOGIC X-ray TENTI Needed JNTS VWS RADIOLOGIC SACROILIAL JOINT EXAMINATION No authorization required know 3 /MORE VIEWS 72220 X-RAY EXAMINATION SACRUM COCEDIUM RADEX SACRUM & COCCYX MINIMUM 2 No authorization required VIEWS 72240 MYELOGY MYELOGY 72240 MYELOGY Authorization required 72255 MYELOGY TORA CIC MYELOGY SPINE THORACIC RS&I No authorization required 72265 MYELOGY L-S KRA LEŽNICE MY ELOGRAPHY LUMBOSACRAL RS&I It is not authorization required 72270 MYELOGPHY 2/> SPINE REGIONS MYELOGGRAPHY 2/MULTI REGIONS RS&I No authorization required 72275 EPIDUROGRAPHY EPIDUROGRAPHY EPIDUROGRAPHY EPIDUROGRAPHY 2 Auth 5 DISCOGRAPHY CERV/THOR SPINE D ISCOGRAPHY CERVICAL/THORACIC RS&I No authorization required 72295 X-ray NEDERRYWAY DISCOGRAPHY JA LUMBAR RS&I Not required authorization

73000 X-ray EXAM RADEX COLLAR BED KIT No approval required 73010 X-ray examination RADEX SCAPULA KIT No approval required 73020 X-ray examination SHOULDER ROW 3 REQUIRED 3 YRA SHOULDER ROW1. SHOULDER EXAMINATION RADEX SHOULDER COMPLETE No approval required MINIMUM 2 VIEWS 73040 CONTRAST X-RAY SHOULDER RADEX ARTHROGRAPHY OF THE SHOULDER No RS&I approval required 73050 X-RAY EXAM RADEX A-C JOINT A/7 REQUIRED W/JWEBI UD X-RAY HUMERUS EXAM RADEX HUMERUS MINIMUM 2 VIEWS No authorization required 73070 X-ray EXAM ALBUW RADEX ELBOW 2 VIEWS No authorization required 73080 X-ray EXAM ALBUW RADEX ELBOW COMPLETE MINIMUM 3 No authorization required X-ray EXTRA EXTRA EXTRA 5Y VIEWS 5Y VIEWS ARTHROGRAPHY PHY RS&I No authorization required 73090 FOREARM EXAM RADEX FOREARM 2 VIEWS No authorization required 73092 X-ray examination HANDS PEDESTRIAN RADEX THINNING OF UPPER LIMBS No approval required MINIMUM 2 VIEWS 73100 X-ray examination EXAMINATION OF THE FEET. 110 WRIST EXAMINATION RADEX WRIST SET MINIMUM 3 No approval required VIEWS 73115 WRIST CONTRAST X-RAY RADEX WRIST ARTHROGRAPHY RS&I No approval required 73120 WRIST EXAMINATION RADEX RADEX HAND 7-3 required HAND 7-3 AND RADEX ARM MINIMUM 3 VIEWS FINGER No approval required 73140 X-ray EXAMINATION OF FINGER(S) RADEX FINGERS AT LEAST 2 VIEWS No authorization required 73200 CT UPPER EXTREMITY U/O COLOR CT UPPER EXTREMITY U/O CONTRAST Apparatus Radiological effect Diagnostics Required C radiological effect Authorization required. 2021 Temporary Change: Network Validation Review 73201 CT UPPER EXTREMITY W/DYE CT UPPER EXTREMITY W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Exam MATERIAL radiology Valid Jan. CT UPPER U/O & authorization required Radiology - diagnostics Full clinical examination W/CONTRAST MATERIAL radiology Valid Jan. 2021 Temporary Change: Network Validation Review 73206 CT ANGIO UPR EXTRM W/O&W/COLOR CT ANGIOGRAPHY UPPER Authorization Full Radiology UPPER Diagnosis Clinical Review Radiology 73218 UPPER EXTREMITY MRI U/O COLOR MRI UPPER EXTREMITY EXCEPT JT Authorization Required Radiology - Diagnostic Full Clinical review U/O KONTR MATRL Radiology Effective January 2021 Temporary Change: Network Validity Review 73219 MRI 73219 MRI 73219 MRI EXTREMITIES EXCEPT JT Authorization Required Radiology - Diagnostic Full Clinical Review M/CONTR MATRL Radiology Effective January 2021 Temporary Change: Network Validation Review 73220 MRI UPPR EXTREMITY W/O&W/COLOR MRI UPPER EXTREMITY EXCEPT C JT Approval Required Full Radiology Diagnostics - U/U & U/CONTRAST Review Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 73221 MRI JOINT UPR EXTREM U/O COLOR MRI ANY JT U/O UPPER EXTREMITIES Authorization Required Radiology - Diagnostic Full Clinical Review CONTRAST MATRL January 2021 Temporary Change: Network Validity Review 73222 MRI JOINT UPR EXTREM W/COLOR MRI ANY JT UPPER EXTREMITY Authorization Required Radiology - Diagnostic Full Clinical Exam W/CONTRAST MATRL Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 732222/PRW& /COLOR MRI ANY JT UPPER EXTREMITY U/O & Authorization Required Radiology - Diagnostic Full Clinical Review W/CONTR MATRL radiology Effective January 2021 Temporary Change: Network Validation Review 73225 MR ANGIO UPR EXTR W/ O&W/DYE MRA UPPER W/WO Authorization required Radiology - Diagnostic full clinical exam CONTRAST MATERIAL Radiology 73501 X-ray EXAMINATION HIP UNI 1 VIEW RADEX HIP UNILATERAL WITH PELVIS 1 No authorization required EXAM 73502 X-ray EXAM HIP UNI 2-3 VIEWS PLAVISEL RADALEX HIP2 No 3 VIEWS required 735 03 X-RAY HIP EXAMINATION UNI 4/> VIEW RADEX HIP UNILATERAL WITH PELVIS No approval required MINIMUM 4 VIEWS 73521 X-RAY HIP EXAMINATION BI 2 VIEWS RADEX HIP BILATERAL BILATERAL 2WI2YRA 3SA 2YRA 3SA 5G EXAM KOVIUK BI 3- 4 VIEWS RADEX HIPS BILATERAL WITH PELVIS 3-4 No authorization required VIEWS 73523 X-RAY EXAMINATION HIPS BI 5/> VIEWS RADEX HIPS BILATERAL WITH PELVIS No authorization required MINIMUM 5 X-ray VIEW MINIMUM 5 X 5 2 VIEW HIPPER GRAPH RS&I No authorization required 73551 X-ray EXAMINATION FEMU 1 RADIOLOGIC EXAMINATION FEMUR 1 No authorization required fox VIEW 73552 X-RAY EXAMINATION OF THE THIGH 2/> RADIOLOGIC EXAMINATION OF THE THIGH No authorization required MINIMUM 3Y6EOR VIEW 73552 2 RADIOLOGIC EXAMINATION OF THE KNEE 1/2 No authorization required VIEWS 73562 X-RAY EXAMINATION OF THE KNEE 3 RADIOLOGIC EXAMINATION OF THE KNEE 3 Not required approval SHOW 73564 KNEE X-RAY EXAMINATION 4 OR MORE REQUIRED KNEE X-RAY EXAMINATION/3 5 EXAMPLE 5Y EXA. AM KNEE RADIOLOGIC EXAMINATION BOTH KNEE No approval required STANDING ANTEROPOST 73580 CONTRAST X-RAY KNEE JOINT RADIOLOGIC EXAMINATION KNEE No approval required ARTHROGRAPHY RS&I 73590 X-ray KNEE JOINT EXAMINATION RADIOLOGIC KNEE No approval required ARTHROGRAPHY RS&I 7 3590 RADIO FOR X-RAY EXAMINATION T BULA 2 EXAM 73592 X-ray EXAMINATION INFANT LEGS RADEX LOWER EXTREMITIES INFANTS No authorization required MINIMUM 2 VIEWS 73600 X-ray ANKLE EXAMINATION RADIOLOGIC ANKLE EXAMINATION 2 No authorization required VIEWS 73610 X-ray ANKLE EXAMINATION LE COMP. 15 CONTRAST X-RAY ANKLE RADEX ARTHROGRAPHY ANKLE RS&I No authorization required 73620 X-RAY EXAMINATION OF THE FOOT RADIOLOGIC EXAMINATION FOOT 2 No authorization required VIEWS 73630 X-RAY EXAMINATION OF THE FOOT RADEX FOOT Required COMPLETE MINIMUM

73650 HEEL EXAMINATION RADEX CALCANEUS MINIMUM 2 VIEWS No approval required 73660 TOE X-RAY EXAMINATION(R) RADEX RADEX TOE MINIMUM 2 VIEWS No approval required 73700 CT OF LOWER EXTREMITIES Author W/LOWER EXTREMITIES Author Complete radiological - diagnostic clinical examination required MATERIAL radiology Na effective from Jan. 2021 Temporary Change: Network Validation Review 73701 CT LOWER EXTREMITY W/DYE CT LOWER EXTREMITY W/CONTRAST Authorization Required Radiology - Diagnostic Complete Clinical Review MATERIAL Radiology Change: Network Validation Jan 21 Review 73702 CT LWR W/O&W/DYE CT LOWER EXTREMITY EXTREMITY U/O & Authorization Required Radiology - Diagnostic Full Clinical Exam W/CONTRAST MATRL Radiology Effective January 2021 Temporary Change: Network Validation Review 73706 CT EXTRANGIO LOWWR. CT ANGIOGRAPHY OF THE LOWER EXTREMITIES Authorization required Radiology - diagnostics Complete clinical examination radiology 73718 MR OF THE LOWER EXTREMITIES U/O COLOR MRI LOWER EXTREMITIES OTH/THN JT U/O authorization required Radiology - diagnostics Complete clinical examination CONTR MATRL Valid from January 2021 Validation Review 73719 MRI LOWER EXTREME W/COLOR MRI LOWER EXTREME OTH/THN JT authorization required Radiology - Diagnostic Full Clinical Review W/CONTRAST MATRL radiology Valid Jan. 2021 Temporary Change: Network Validation Review 73720 MRIEXOWWER/MRI LWR/KONTRASTMATRL EXTREM OTH/THN JT U/O Authorization Required Radiology - Diagnostic Full Clinical Exam & W/CONTR MATR Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 73721 MRI JNT OF LWR EXTREME U/O COLOR MRI ANY JT LOWER EXTREME W/O Authorization Required Radiology - Diagnostic Full Clinical Review CONTRAST MATRL Radiology Effective Jan. 2021 Temporary Change: Network Validity Review 73722 MRI SPOJ LWR EXTR W/DYE MRI ANY JT LOWER EXTREM Authorization Required Radiology - Diagnostic Full Clinical Exam Jan. 2021 Temporary Change: Network Validation Review 73723 MRI JOINT LWR EXTR U/O&W/COLOR MRI ANY JT LOWER EXTREM U/O & Authorization Required Radiology - Diagnostic Full Clinical Exam W/CONTRAST MATRL Radiology Effective Jan. 2021 Network Validation 73725 MR ANG LWR EXT W OR U/O FYE MRA LOWER EXTREMITIES W/WO Authorization Required Radiology - Diagnostic Full Clinical Exam CONTRAST MATERIAL Radiology 74018 X-RAY EXAM ABDOMEN 1 SEE RADIOLOGY EXAM ABDOMEN 1 VIEW No. 2 VIEWS RADIOLOGICAL EXAMINATION OF THE ABDOMEN 2 VIEWS No authorization required 74021 X-ray EXAMINATION OF THE ABDOMEN 3+ VIEWS RADIOLOGICAL EXAMINATION OF THE ABDOMEN 3+ No authorization required VIEWS 74022 X-ray EXAMINATION OF THE COMPLETE ABDOMEN RADIOLOGY SERIES 1 0 CT ABDOMEN U/U DYE CT ABDOMEN U/O CONTRAST Authorization required Radiology - diagnostics Complete clinical examination of MATERIALS radiology Valid Jan. Interim Change 2021: Network Validation Review 74160 CT ABDOMEN W/FYE CT ABDOMEN W/CONTRAST Material Authorization Required Radiology - Review Diagnostic Performance Jan 2021 Interim Change: Network Validation Review 74170 CT ABDOMEN W/O & W/DYE CT ABDOMEN W/ O & W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL radiology Effective January 2021 Temporary Change: Network Validation Review CT 74IO174 ABD&PELV W/ O&W/ COLOR CT ANGIO ABD&PLVIS CNTRST MTRL Authorization Required Radiology - Diagnostic Full Clinical Review W/WO CNTRST IMG Radiology 74175 CT ANGIO ABDOM U/O & W/COLOR CT ANGIOGRAPHY ABDOMEN - Authorization Required CCONST. /NONCTRAST Radiology 74176 CT ABD & PELVIC W/O CONTRAST CT ABDOMEN & PELVIS NON-CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIALS Radiology Effective January 2021 Temporary Change: Network Validity Review 74177 CT ABCONTRAST & PELVCT & PELVIS W/CONTRAST Authorization required Radiology - Diagnostic Full clinical review MATERIALS radiology Effective Jan. 2021 Temporary Change: Network Validation Review 74178 CT ABD & PELV 1/> REGNS CT ABDOMEN & PELVIC U/O CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review 1/> BODY RE Radiology Effective Jan. 2021 Temporary Change: Network Validity Review 74181 ABDOMINAL MRI WITHOUT COLOR MRI ABDOMEN WITHOUT CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL Radiology Effective Jan. 2021 Temporary Change: Network Validation 74182 MRI ABDOMEN W/FYE MRI ABDOMEN W/CONTRAST Authorization Required Radiology - Diagnostics Full Clinical Review MATERIALS radiology Valid Jan. 2021 Temporary Change: Network Validity Review 74183 MRI ABDOMEN U/O & W/COLOR MRI ABDOMEN U/O & W/CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review MATERIAL Radiology Valid Jan. 2021 Temporary Change: Network Validity Review 74185 MRI ANGIO ABDOM W ORW/O FYE MRA ABDOMEN W/WO CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Exam MATERIAL 0AM RTG RENDGEN9 PERITONEUM PERITONEOGRAM RS&I No Authorization Required 74210 X-RAY XM PHRNX&/CRV E SOPH C+ RADIOLOGIC EXAMINATION PHRNX&/CRV No Authorization Required ESOPH CONTRAST STUDY 74220 X-RAY XM ESOPHAGIUM Requested No Auth CONTRAST STUDY 74221 X-RAY XM ESOPHAGUS 2CNTRST RADIOLOGIC EXAMINATION EQUATION No Authorization Required EXAM DOUBLE CONTRAST 74230 X -RAY XM SWLNG FUNCJ C+ RADIOLOGIC PREG LED SWALLOW No approval required FEATURE CONTRAST STUDY 74235 REMOVE EQUATION OBSTRAP EQUATION OBSTRAP EQUATION USED/ CATH RS&I

74240 X-RAY XM UPR GI TRC 1CNTRST RADIOLOGIC EXAMINATION UPR GI TRC SINGLE No authorization required CONTRAST STUDY 74246 X-RAY XM UPR GI TRC 2CNTRST RADIOLOGIC EXAM UPR GI TRC DOUBLE CONTRAST STUDY- required 7 Auth-8 RU STD RADIOLOGY COLON FOLL OW -UP - No Authorization Required G STUDY 74250 X-RAY XM SM INT 1CNTRST STD RADIOLOGIC EXAMINATION SMALL INT SINGLE No Authorization Required CONTRAST STUDY 74251 X-RAY XM CNTRST STD NO. uth CONTRAST STUDY REQUIRED 74261 CT COLONOGRAPHY DX CT COLONOGRAPHY DX IMAGE Authorization Required Radiology - Diagnostics Full Clinical Review POSTPROCESS WITHOUT CONTRAST Radiology 74262 CT COLONOGRAPHY DX W/COLOR CT COLONOGRAPHY DX IMAGE Authorization Required Radiology - Diagnostics Review 74262 CT COLONOGRAPHY DX W/COLOR CT COLONOGRAPHY DX IMAGE Authorization Required Radiology - Diagnostic Screening 74262 CT COLONOGRAPHY PHY SCREENING CT COLONOGRAPHY IMAGE SCREENING Authorization Required Radiology - Diagnostics Full Clinical Radiology Exam POST TREATMENT 74270 RENDGEN XM COLON 1CNTRST STD RADIOLOGY EXAMINATION OF COLON ONE No authorization required CONTRAST EXAMINATION 74280 RTG XM COLON STAD COLON RADIOLOGICAL EXAMINATION OF THE COLON ONE No authorization required CONTRAST EXAM 74280 X-RAY XM COLON STAD 2CN COLON AUT. TRUST STUDY 74283 THER NMA RDCTJ INTUS/OBSTRCJ THERAPEUTIC ENEMA RDCTJ No approval required INTUSUSCEPTION/OBSTRCJ 74290 CONTRAST X-ray GALLBLADDER CHOLECYSTOGRAM ORAL CONTRAST No approval required 74300 BILE DUCT/PANCREATIC EDGES/PANCIS REA EDGES required OP RS&I 74301 X-rays WITH OPERATIONAL ADD CHOLANGIO&/PANCREATOGRAPHY No Approval Required ADDL KIT INTRAOP RS 74328 BILE DUCT ENDOSCOPY ENDOSCOPIC BILE DUCT CATHJ No Approval Required SYSTEM RS&I 74329 BULLET CORRECTION X-RAY DUAC ENDOSCOPY Required Y S RS&I 74330 BILE/PANK ENDOSCOPY CMBN NDSC CATHJ BILIARY& PNCRTC No approval required DUCTAL SYS RS&I 74340 GI TUBE INTRO LONG GI TUBE W/MULT FLUORO X-ray GUIDE No approval required & PHOTOS RS&I 74355 X-ray GUIDE INTERNET GUIDE LYSE TUBE RS&I 74360 X-ray GUIDE GI DILATION INTRALUMINAL DILATION No approval required STRICTURES&/OBSTRCJS RS&I 74363 DILATA BILE DUCT X-ray PRQ TRANSHEPATC BILE DUCT DILATION No approval required STRICT RS&I 74400 TRANSTRWINA DUCT/X-RAY CONTRWINA W/X-RAY CONTRWINA O No approval required TOMOGRAPHY 7 4410 CONTRAST X-RAY UROGRAPHY INFUSION DRIP &/BOLUS No approval required TECHNIQUE 74415 CONTRAST X-RAY URINARY TRACT UROGRAPHY INFUSION DRIP &/BOLUS No Authorization Required TECHQ W/WO X-RAY TOMO TECHQ W/4420 TRINAURY EXAMINATION TRINAURY RY TRACT NO Authorization Required CONTRAST ST MATERIAL 74425 CONTRAST X-RAY UROGRAPHY URINARY INDUCTION ANTEGRADE RS&I No Authorization Required 74430 CONTRAST X-RAY BLADDER IMAGING CYSTOGRAPHY MINIMUM 3 REPORT RS&I no. Auth. 74430 RE required Authorization required VESICULOGRAPHY/EPIDIDIMOGRAPHY RS&I 74445 X-RAY PENIS CORPORA CAVERNOSOGRAPHY RS&I No authorization required 74450 X-RAY URETHRA/URINARY BLADDER RETROGRADE URETHROCISTOGRAPHY No authorization required RS&I 74455 X-RAY URETHRA/URINARY BLADDER URETHRA/URINARY BLADDER/ URINARY BLADDER URETHROCID AUT 7 X-RAY URETHRA/URITHROCID A-0 RENAL LESION EXAMINATION RADEX RENAL CY STUDY No approval required TRANSLUMBAR RS&I 74485 DILATION URTR/URT RS&I DILATION OF URETER/URETHRA RS&I No approval required 74710 REMEASUREMENT X-RAY PELVIC UROTRIUM W/WOPLACENTAL No approval required 74 71ST2 POISON 74710 MFETALIZATION MFETALIZATION. MR W/PLACNTL MATRNL PLVC Authorization Required Radiology - Diagnostic Full Clinical Exam IMG SING/1ST GES Radiology 74713 MRI FETAL EA ADDL GESTATION FETAL MRI W/PLACNTL MATRNL PLVC Authorization Required Radiology - Diagnostic Full Clinical Exam IMG EA ADDL GES Radiology 74775 RENDGEN EXAMINATION BR . HEART MRI FOR MORPH MORPHOLOGY HEART MRI & Authorization Required Radiology - Diagnostic Full Clinical Examination FUNCTION WITHOUT CONTRAST radiology Effective Jan. 2021 Temporary Change: Network Validation Review 75559 CARDIAC MRI W/STRESS IMG CARDIAC CONTRAST Authorization No Radiology Required No Full Clinical Review W/STRESSIMAGING Radiology Effective Jan. Interim Change 2021: Network Validation Review 75561 Cardiac MRI FOR MORPH W/COLOR Cardiac MRI W/WO CONTRAST & Authorization Required Radiology - Diagnostic Full Clinical Review ADDITIONAL Interim SEQ Jan 2021 : Network Validation Review 75563 CARD MRI W/STRESS IMG & DYE CARDIAC MRI W/W/O CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Review W/STRESS Radiology Effective January 2021 Temporary Change: Network Validation Review 75565 CARFL MRIAPPING VELOC VELOC FLOW MRI Authorization Required Radiology - Diagnostic Full Clinical review MAPING radiology Valid Jan. 2021 Temporary Change: Network Validation Review 75571 CT HRT U/O COLOR W/CA TEST HEART CT WITHOUT CONTRAST QUANTUM EVAL Authorization Required Radiology - Diagnostic CORON C. CALCIUM Radiology Effective Jan. 2021 Temporary Change: Network Validation Review 75572 CT HRT W/3D-IMAGE CT CARDIAC CONTRAST EVAL Cardiology Authorization Required Radiology - Diagnostic Full Clinical Review STRUCTURE AND MORPHO Radiology Effective Jan. 2021 Network Validation 73 W3D 75 Network Validation 3D Image Congen CT HRT Contrast Cardiac Authorization Required Radiology - Diagnostic Comprehensive Clinical Review Structure and Morph Cong HRT D Radiology Effective 2021 Temporary Change: Network Validation Review: CT Angio HRT M/3d Image CTA HRT CORT BYP Full Radiology Approval GRF ART/BYP Clinical Review CONTRST 3D POST Radiology

75600 CONTRAST EXAMINATION OF THE THORACIC AORTA AORTOGRAPHY THORACIC U/O No authorization required SERIOLOGRAPHY RS&I 75605 CONTRAST EXAMINATION OF THE THORACIC AORTA AORTOGRAPHY THORACIC No authorization required SERIOLOGRAPHY AORTA AORTA 75605 PHY ABDOMINAL No authorization required SERIOLOGRAPHY RS&I 75630 X-RAY AORTA BEN ARTERIES AORTOGRAPHY ABDL BI ILIOFEM LAV None authorizations required EXTREM CATH RS&I 75635 CT ANGIO ABDOMINAL ARTERIES CTA ABDL AORTA&BI ILIOFEM Authorization required Radiology Full Clinical Exam W/CONTRAST&POSTP 75705 X-ray ARTERIES X-ray ANGIOGRAPHY SPINE Authentication SPINAL SELECTION X05 ANGIOGRAPHY ARM/LEG EXTREMITY UN ILATERAL No authorization required RS&I 75716 ARTERY RØ NTGEN ANGIOGRAPHY OF THE HAND /LEGS EXTREMITIES BILATERAL No approval required RS&I 75726 X-ray ARTERY BUMEN ANGIOGRAPHY VISCERAL No approval required SLCTVRS&3 SUPRASILCANGY5 GRENEN 75726 IOGRAPHY ADRENAL UILATERAL No approval required SLCTV RS&I 75733 ARTERY X-ray BU RNAL ANGIOGRAPHY BURNS BILATERAL No approval required SLCTV RS&I 75736 ARTERY RØ NTGEN X-ray ANGIOGRAPHY OF THE PELVIS PELVIS No approval of SLCTV / Supraslctv RS & I 75741 RTG RTG RTG RTG RTG Angiography Lungs Bilaterally No approval of SLCTV RS & I 75746 Lungs Angrph Lung NJX RS & I 7575 6 Artery Ringgens CASTANGIOGRAPHY INTERNAL TO MOM No authorization required 757YRSHANGR 75756 SLCTV EA VSL STUDIED No authorization required BASIC XM RS&I 75801 RLYMPHANGIOGRAPHY OF ARM/LEG EXTREMITY ONLY LYMPHANGIOGRAPHY UNILATERAL RS&I 75803 LYMPHANGIOGRAPHY OF ARM/LEG REQUIRED EXTREMITY LYMPHANGIOGRAPHY 75805 LYMPHANGIOGRAPHY OF THE TRUMPET LYMPHANGIOGRAPHY No approval required PELVIS / ABDOMINAL UNILAT RS&I 75 807 TRUNK LYMPHANGIOGRAPHY LYMPHANGIOGRAPHY No Authorization Required PELVIS/ABDOMEN BILATERAL RS&I 75809 NOVASCULAR SHUNT X-RAY SHUNTOGRAM INTERNAL NONE Auth-5 COURSE 1 SLEEVE 1 AIR SPLENOPORTOGRAPHY SPLEEN/LIVER RS&I No Authorization Required 75820 ARM/LEG VEIN X-RAY VENOGRAPHY OF THE EXTREMITIES UNILATERAL No authorization required RS&I 75822 X-ray VENUS ARM/LEG VENOGRAPHY EXTREME BILATERAL No authorization required RS&I 75825 X-ray VENUS TRUK TRUK Auth I 75827 X-ray VENUS COASTAL VENOGRAPHY CAVAL SUPERIOR No authorization required SERIALOGRAPHY RS&I 75831 VENUS X-ray KIDNEY VENOGRAPHY RENAL UNILATERAL No authorization required SELECT IVE RS&I And 75833 X-ray VEINS TRUNK NTGEN KIDNEY VENOGRAPHY BILATERAL BILATERAL ADRENAL 7 SELECTIVE & SELECTIVE 80I required VENOGRAPHY ADRENAL UNILATERAL No authorization required SELECTIVE RS&I 75842 X-ray VENOGRAPHY GLAND BURIAL GLAND BURIAL VENOGRAPHY BILATERAL No authorization required SELECTIVE RS&I 7586 0 VEIN X-RAY VENOGRAPHY NECK VENOUS SINUS/JUGULAR Not required authorization CATH RS&I 75870 X-ray VEIN Auth US RS &I 75872 X-ray VEIN CRABIEPIDURAL VENOGRAPHY EPIDURAL RS&I No authorization required 75880 X-ray OCULAR VEIN VENOGRAPHY ORBITAL RS&I No authorization required 75885 X-ray LIVER VEIN W/HEMODYNA M PRQ TRANSHEPATC PORTOGRAPHY 5 & 7 Required no. 8EMODI Y LIVER WITHOUT HEMODYN PRQ TRANSHEPATC PORTOGRAPHY U/O No approval required HE MODYN EVL INTRP 75889 VENE X-RAY LIVER W/HEMODYNAM HEPATC VNGRPH WDG/FR HEMODYN No approval required EVAL RS&I 75891 VENE X- RAY LIVER HEPATC VNGRPH 8 /8 3 CATHETER VENOUS SAMPLING VENOUS SAMPLING THROUGH CATH W/WO No approval required ANGIOGRAPHY RS& 75894 X-RAY GEN TRANSCATH THERAPY TRANSCATHETER EMBOLIZATION POSSIBLE No approval required METH RS&I 75898 AFTER CATHETHERAPY AFTER uth Request ed. END THROMBYLSIS 75901 REMOVE CVA DEVICE OBSTRUCTION MECHANICAL RMVL PERICATHETER No approval required OBSTR MATRL RS&I 75902 REMOVE CVA LUMEN OBSTRUCTION MECHANICAL RMVL INTRALUMINAL No approval required. TA No Authorization Required SUBCLAV ORIG RS&I 75957 XRAY ENDOVASC THOR AO REPR EVASC RPR DESCND THORCIC AORTA No Authorization Required CELIAC ORIG RS&I 75958 XRAY PLACE PROX EXT THOR AO PLMT PROX XTN PRSTH EVASC DESC No Authorization Required THORACIC AORTA RS&I 75959 X-ray Place Aorta Euth Pk the Fox Torak Aorta RS & 75970 Vascular Biopsy RS & I No Approval Needs 75984 Change Prq Pipe / Drainage Cath W No Clear Abscess During X-ray Radiological Development Required Radiological Guide W0MT. 00 FLUOROSCOPY

76098 X-RAY EXAMINATION SURGICAL SPECIMEN RADIOLOGIC EXAMINATION No Approval Required SURGICAL SPECIMEN 76100 X-RAY EXAMINATION BODY PART RADEX 1 FULL BODY PART OTHER/THN No Approval Required W/61O0GRAPHY W/61001 COMP. CPLX MOTION BDY SCTJ Auth Required OTH/THN UROGRAPHY UNI 76102 X-RAYS OF COMPLEX BODY PARTS RADEX CPLX MOTION BDY SCTJ Auth Required OTH/THN UROGRAPHY BI 76120 CINE/VIDEO X-RAYS CINERADIOGRAPHY/VIDEOGRAPHY XVIDRACPT WH2EOYS Required CH 2 DD -ON CINERADIOGRAPHY/VIDEOGRAPHY Approval not required ROUTINE EXAM 76140 X-RAY CONSULT CONSLTJ X-RAY XM DONE ELSEWHERE Approval not required WRTTN REPRT 76376 3D RENDER W/INTRP POSTPROCESSOR REQUIRED Author W/INTRP POSTPROCESSOR 3D Clin CROC. ESS SUPERVISION 76377 3D Render w/intrp post process 3D Render w/Interp & Postproc No Authorization Required Radiology Diff Work Station 76380 CAT Scan Follow-up Exam CT Limited/Localized Follow-up Authorization Required Radiology - Diagnostic Full Clinical Exam Exam Radiology Effective from Jan. . 2021 Temporary Change: Network Validation Review 76390 MR SPECTROSCOPY Authorization Required MR SPECTROSCOPY Radiology - Diagnostic Full Clinical Review Radiology 76391 MR ELASTOGRAPHY MAGNETIC RESONANCE ELASTOGRAPHY Authorization Required Radiology Full Clinical Review 76496 FLUOROSCOPY PROCEDURE Full Radioscopic PROCEDURE F FLUOROSCOPY PROCEDURE Full Radiological Review Procedure 7 64 97 CT PROCEDURE COMPUTED TOMOGRAPHY NOT POSTED Approval required Radiology - diagnostic Complete clinical examination PROCEDURE radiology 76498 MRI PROCEDURE NOT POSTED MAGNETIC RESONANCE Authorization required Radiology - diagnostics Full clinical examination PROCEDURE radiology 76499 RADIOGRAPHIC PROCEDURE NOT POSTED DIAGNOSTIC RADIOGRAPHIC Authorization required radiology PROCEDU 6 EKS 76 Complete overview of clinical examinations. Real Time Ephalography No Imaging Approval Required 76510 OPHTH US B & KUNT A OPH US DX B-SCAN & QUAN A-SCAN SM NO Approval Required PT INCTR 76511 OPHTH US LIBRARY OPHTHALMIC Ultrasound only DX QUAN A- NO Approval Only 76512 OPHTH B W / NOH QUANT NO A OPHAT-QUANT. Authorization required M/WO A-SCAN 76513 ECHO EXAMINATION OF EYES OPH US DX ANT SGM US Immersion B- No authorization required SCAN/HR BIOM 76514 ECHO EXAMINATION OF EYE THICKNESS OPHTHALMICS US DX Auth. HO ECHOGRAPHY A-SCAN 76519 ECHO ECHO EXAMINATION OPH BMTRY US ECHOGRAPHY A-SCAN IO No Clearance Required LENS PWR CAL 76529 ECHO ECHO EXAM ECHO EYE EXAM IZATION Required 76536 WITH HEAD AND NECK EXAMINATION US SOFT TISSUE HEAD AND NECK REAL No Authentication Required IMAGE TIME DOCM 76604 US EXAM COAST US BUST REAL TIME WITH IMAGE None Auth required DOCUMENTATION 76641 BREAST ULTRASOUND COMPLETE US BREAST UNIRAD break COMPLETE ATH 6 TIME REQUIRED ATH B7 AST LIMITED US BREAST REAL TIME WITH IMAGE No authorization required LIMITED 76 700 US EXAM ABDOM COMPLETE US ABDOMINAL REAL TIME W/IMAGE No Authorization Required DOCUMENTATION 76705 ECHO ABDOMINAL EXAMINATION US ABDOMINAL REAL TIME W/IMAGE ABquien US Authen Auth Auth DOMINAL AORTA REAL TIME No Authorization Required SCREEN EXAMINATION AAA 76770 US EXAM ABDO BACK WALL COMP US RETRO PERITONEAL REAL TIME Br Authorization Required M/IMAGE COMPLETE 76775 US EXAM ABDO POSTERIOR PUBLIC LIM US RETROPERITONEAL REAL TIME W/IMAGE US 7AM EX REQUIRED W/DOPPLER US TRNSPLNT KIDNEY REAL TIME No Authorization Required M/IMAGE DOCMTN 76800 US EXAM SPINAL CANAL ULTRASOUND SPINAL CANAL & No Authorization required CONTENTS 76801 OB US < 14 WKS SINGLE FETUS US PREGNANT 14 W TRANSSTUS NO. 76802 OB US < 14 WKS ADDL FETUS US PREG UTERUS 14 WK TRANSABDL No approval required EACH GESTATION 76805 OB US >/= 14 WKS SNGL FETUS US PREG UTERUS AFTER 1ST TRIMESTER No approval required 1/1. GESTACIJA 1OB 76810 DR. FETUS US PREG UTERUS > 1ST TRIMESTER No approval required ABDL EA GESTATIO 76811 OB US DETAIL SNGL FETUS US PREG UTERUS W/DETAIL FETAL No approval required ANAT 1ST GESTATION 76812 OB US DETAIL PREGAMET ADDED FETUS DETAILED ADDL UTALFETUS required EA GESTAT 7681 3 OB US NUCHAL MEASURES 1 GEST US FETAL NUCHAL TRANSLUCENCE 1ST No authorization required GESTATION 76814 OB US NUCHAL MEAS ADDENDUM US FETAL NUCHAL TRANSLUCENCE EA No authorization required ADDL GESTATION OB 7681SMITUS US 768115) 1/> No authorization required FOSTER 76816 OB US FOLLOW -UP PR. FOTUS US PREG UTERUS REALTIME F/U No approval required TRNSABDL PR FETUS 76817 TRANSVAGINAL US PREG UTERUS REALTIME W/IMAGE No approval required D76817 TRANSVAGINAL US PREG UTERUS REALTIME W/IMAGE No approval required D76 TRANSVAG D76817 FOSTER BIOPHYS ICAL PROFILE NO- No approval required STRESS TEST 76819 FETAL BIOPHYSICAL PROFILE U/U NST FOSTER BIOPHYSICAL PROFILE U/U NON- No authorization required STRESS TEST 76820 UMBILICAL ARTERY VECHO DOPPLER Auth

76821 ECHO DOPPLER HARD VELOCITY FETAL INTERMEDIATE No approval required CEREBRAL ART 76825 ECHO FETAL HEART EXAM ECHO FETAL CARDIOVASC W/WO M- No approval required ECHO MODE RECORDING ECHO 8 EXAM. TAL CARDIOVASC W/WO M- No Authorization Required MODE REPEAT STD 76827 ECHO EXAM FETAL HEART DOPPLER ECHO FETAL SPECTRAL No Authorization Required DISPLAY COMPLETED 76828 ECHO EXAM FETAL DOPPLER HEART ECHO FETAL PULSE SPECTRAL No Authorization/8 OBL. TRANSVAGINAL Clearance not required 76831 UTERUS EXAMINATION BY SALON PLANT INFUSION SONOHYSTEROGRAPHY No Clearance required W/COLOR DOPPLER 76856 PELVIC EXAMINATION INVITE COMPLETED US PELVIC NEOOBSTETRICAL REAL TIME No Clearance Required IMAGE COMPLETED 76857 PELVIC EXAMINATION LIMITED NO PELVT N LIMITED US /U 76 870 US SCROTUM EXAMINATION US SCROTUM & CONTENTS No authorization required 76872 US TRANSRECTAL US TRANSRECTAL No authorization required 76873 ECHOGRAP TRANS R PROS STUDY US TRANSRCT PRSTATE VOL BRACHYTX No authorization required PLNNING SPX 76881 US COMPL JOINT R-COMPLETE R-KOMPLEG JOINT R- KUMENTATION 7688 2 US LMTD JT / NONVASC XTR STRUX US LMTD JOINT/OTH NONVASC XTR No Approval Required STRUX R-T W/IMG 76885 US INSPECTION HIPS DYNAMIC US INFT HIPS R-T IMG DYNAMIC REQUEST PHYSMAN 8 EXAM US 8 EXAM Required 8 INSPECTION 6 PS STATIC OS INFT HIPS R-T IMG LMTD STATIC No Authorization Required PHYS/QHP MANJ 76932 ECHO GUIDE TO HART BIOPSY US ENDOMIOCARDIAC BIOPSY RS&I No Authorization Required 76936 ECHO GUIDE TO ARTERY REPAIR US CMPL 7 Auth 6937 US VASCULAR ACCESS GUIDE US VASC ACCESS SIT VSL PATENT Y NDL No Authorization Required ENTRY 76940 US Guide Tissue ABLACY US & MNTR PARNCOMCOMING TYPE NO ARRIVALIZATION Authorization 76941 ECHEHO guide to transfusion US INTRAUTERINNI FTL No Authorization Tfuj/6c Guide S76941 OPSY UNDA GOOR IMG SUBJECT NO AUTHORIZATION SA & 76945 ECHO VILUSE APPLICATION No Auth Required SAMPLING IMG S&I 76946 ECHO US AMNIOCENTESY GUIDE AMNIOCENTESY GUIDE IMG S&I No Auth Required No Auth Required S&I 76965 ECHO GUIDE RADIOTHERAPY US GUIDELINES INTERSTICIAL No Auth Required RADIO ELEMENT APP 76970 ULTRASOUND EXAM FOLLOW-UP US STUDY FOLLOW-UP No Auth Required 76975 GI ENDOSCOPIC ULTRASOUND GI ENDOSCOPIC US S&I No Authorization Required 7 BSU DENSITY US BSU DENSITY NO Authorization Required PERIPH ANY METO 76978 US TRGT DYN MBUBB 1ST LES ULTRASOUND TRGT DYNAMIC Authorization Required Radiology Full Clinical Review MICROBUBBLE 1ST LESION 76979 US TRGT DYN MBUBB EA ADDL ULT RASOUND TRGT DYNAMIC Authorization required Radiology Full clinical examination MICROBUBBLE EA ADRENCH81 Y Authorization required Radiology Full clinical examination PARENHYMA 76982 USE 1. ULTRASOUND ELASTOGRAPHY TARGET LESION FIRST Authorization required Radiology Full clinical examination 76983 USE EA ADDL ULTRASOUND ELASTOGRAPHY TARGET LESION EA ADDL Authorization required Radiology full Clinical examination TAKEN LESION 76983 USE TAKEN IN LESION 6 INTRAOPERATIVE 76 999 ECHO EXAMINATION PROCEDURE NOT LISTED US PROCEDURE Authorization Required Radiology Full Clinical Review 77001 FLUORESCENT VENOUS DEVICES FLUORO CENTRAL VENOUS ACCESS DEV No Authorization Required LOCATION 77002 X-RAY NEEDLE LOCATION FLUOSC OPIC GUIDING NEEDLE Approval not required000 ECT FLUOR NEEDLE/CATH No authorization required SPINAL/PARASPINAL DX/ THER ADDON 77011 CT SCAN LOCATION CT STEREOTACTIC GUIDE Authorization required Radiology Full Clinical Exam LOCALIZATION 77012 CT NEEDLE BIOPSY CT SCAN GUIDE NEEDLE PLACEMENT No authorization required Radiology CT APPLICATION 77013 TE CHNICAL GUIDE 77013 SC TISS Authorization Required Radiology Complete Clinical Review ABLATION 77014 CT SCAN FOR TREATMENT LINGS GUIDE CT - GUIDELINES RADIATION THERAPY No authorization required. Radiology FLDS PLACEMENT 77021 MRI GUIDE NDL PLMT RS&I MRI GUIDE NEEDLE PLACEMENT Approval Required Radiology Full Clinical Review RS&I Supplement Jan 77 RNCHYMA TISS ABLTJ MRI GUIDELINES FOR PARENCYMA Radiology Approval Required Full Clinical Review TISSUE ABLATION Effective Jan . 2021 Temporary Change: Network Validation Review 77046 BREAST MRI C- SINGLE-SIDED BREAST MRI WITHOUT CONTRAST Radiology Approval Required Full Clinical Review MATERIAL SINGLE-SIDED 77046 Network Validation 77046 BREAST C- BILATERAL BREAST MRI NON-CONTRAST Radiology Approval Required Full Clinical Review MATERIALS BIL ATERAL Valid Jan . 2021 Temporary Change: Network Validity Review 77048 BREAST MRI C-+ W/CAD UNI BREAST MRI W/UD&MED Necessary CONTRAST W Authorization CAD UNILATERAL Valid Jan. 2021 Temporary Change: Network Validity Review 77049 BREAST MRI C-+ W/CAD BI BREAST MRI BEZ&BEZ authorization required Radiology Full Clinical Review CONTRAST W/CAD BILATERAL Effective Jan. 2021 Network Validation 5 XRA-70 Network Validation 5 XRA DUCTOGRAM MMAMARY DUCT MMAMARY OR No approval required GALACTOGRAM SINGLE

77054 X-ray MAMMARY DUCT MMARY DUCTOGRAM OR No approval required GALAKTOGRAM MULTIPLE 77061 BREAST TOMOSYNTHESIS UNI DIGITAL BREAST TOMOSYNTHESIS No approval required UNILATERAL 77062 BREAST DITALISOM AYNTHESIS Required BILATERAL 77063 BREAST TOMOSYNTHESIS BI DIGITAL BREAST SCREENING No approval required TOMOSYNTHESIS E BI 77065 DX MAMMO INCL CAD UNI DIAGNOSTIC MAMMOGRAPHY No approval required COMPUTER SUPPORTED DETCJ UNI 77066 DX MAMMO INCL CAD BI DIAGNOSTIC MAMMOGRAPHY No approval required COMPUTER SUPPORTED DETCJ BI 77067 SCR MAMMO SquiEEN red BREAST INC CAD 77071 X-RAY STRESS DISPLAY MANUAL APPL ST RESS PFRMD No approval required PHYS/ QHP JOINT FILMS 77072 X-rays for bone age examinations Approval not required 77073 X-rays bone length examinations Bone length examinations Bone length examinations 770 LI required 77070 RADIOLOGIC BONE EXAMINATION No approval required EXAMINATION LIMITED 77075 X-ray BONE EXAMINATION COMPLETE RADIOLOGIC EXAMINATION OSSOUS no approval required EXAMINATION COMPL 770 76 X-RAY EXAMINATION OF BONE THINNING EXAMINATION NO. 077 OBJECT OBLIGATION ONE ASSEMBLY OBJECTS ONE ASSEMBLY 2 OR No MORE NO ARRIVALATION 77078 CT BONE DENSION AXIAL CT BOOK DENSION 1/> RADIOLOGY AUTHORIZATION COMPLETE Clinical SITS SITS AXIAL SKA 77080 DXA BONE OF BONE AXIAL DXA BONE STUDY E E 1/> Bone Resistance Study 1/7a Curishment 7A 7A D00 Bone density Bone density ITY/Peripheral DXA 1/> Location Authorization No Appendiclr Skel 77084 Magnetic Bone Core Sepature Spening Core Required Authorization Radiologically complete Clinical Review 77085 DXA BLAGGE BLOGY DENSITY SCEL 7 APPLICATION 7 A BONE DENSITY 7 AUT 6 HOURS ASSESSMENT BY DXA VERTEBRAL FREQUENCY ASSESSMENT BY DXA Clearance Not Required 77261 RADIATION THERAPY PLANNING THERAPEUTIC RADIOLOGY TX PLANNING Clearance Required Radiation Therapy Full Clinical Exam ONE Including Gamma Knife 7 7262 RADIATION THERAPY PLANNING THERAPEUTIC RADIOLOGY RADIOLOGY TX PLANNING Complete RADIOLOGY REQUIREMENTS INTERNET RADIOLOGY INSTRUCTIONS Complete Radiology Review Knife 77263 RADIOLOGY PLANNING GNING THERAPEUTIC RADIOLOGY TX SCHEDULING No Approval Required Radiation Therapy, COMPLEX Including Gamma Knife 77280 RADIATION THERAPY FIELD SET THER RAD SIMULATION AUXILIARY FIELD No Appr oval Required Radiation Therapy, SETTING SIMPLE including Gamma Knife THER RAD SIMULAJ-ASSISTED FIELD WORK. radiation therapy required, Complete clinical examination SETUP INTERMED including gamma knife 77290 RADIOTHERAPY FIELD SET THER RAD SIMULATION-ASSISTED FIELD No approval required Radiotherapy, SETUP COMPLEX incl. gamma knife 77293 RESPIRATORY DRIVE MGMTOR SIMUL RESPIMENTER INCL gamma knife 77295 3-D RADIOTHERAPY PLAN 3-D RADIOTHERAPY PLAN DOSING- No approval required Radiotherapy, VOLUME HISTOGRAMS including gamma knife 77299 RADIOTHERAPY PLANNING UNLIS PX THER RADIOL CLINICAL TX Approval required, Complete radiation therapy P70 radiation therapy incl. DIAL THERAPY DOSAGE PLAN BASIC RADIATION DOSIMETRY No approval required Radiation therapy, CALCULATION incl. gamma knife 77301 RADIOTHERAPY DOSE PLAN IMRT NTSTY MODUL RADTHX PLN DOSE-VOL No authorization required Radiation therapy, HISTOS incl. gamma knife PLAN7P06 ISOPL TLAN7P06 ISOPL 77301 Authorization required SMPL Radiation therapy, full clinical examination W/DOSIMETRIC CALCULATION incl. gamma knife 77307 TELETHX ISODOSE PLAN CPLX TELETHX ISODOSE PLN CPLX M/BASIC Approval required Radiation therapy, full clinical review DOSIMETRY including gamma knife 77316 Required PACHYTX ISODOSE BRACHY TX ISODOSE BRACHY Therapy, full clinical review W/DOSIMETRY CAL including gamma knife 77317 B RACHYTX ISODOSE INTERMED BRACHYTX ISODOSE PLN INTERMED Approval Required Radiation Therapy Full Clinical Review W/DOSIMETRY CAL incl. gamma knife 77318 BRACHYTX ISODOSE COMPLEX PLN REQUIRED CPLTX/ISO WORLD REQUIRED DOSIMETRY CAL incl. gamma knife 77321 SPECIAL TELETX PORT PLAN SPEC TELETHX PORT PLN PARTS No approval required Radiotherapy, HEMIBDY TOT BDY including gamma knife 77331 SPECIAL RADIATION DOSIMETRY SPEC DOSIM PRESCRIPTION ONLY, OBSOLETE NO. 7332 DESIGN & CONSTRUCTION OF RADIATION TREATMENT ASSISTS TX UNIT No approval required Radiotherapy ONE including gamma knife 77333 DESIGN & CONSTRUCTION OF RADIATION TREATMENT ASSISTS TX UNIT No approval required Radiotherapy MEDIUM including gamma knife ADIV KNIFE A7333ICERA4 DESIVS (77 333) GN & CONSTRUCTION None approval required Radiation Therapy, COMPLEX including gamma knife 77336 RADIATION PHYSICS CONSULTATION CONTINUED MEDICAL PHYSICS No approval required Radiation Therapy, CONSLTJ PR WK including gamma knife 77338 IMRT DEVICE DESIGN MLC & Auth IMRT PLAN including gamma knife 77370 RADIATION PHYSICS CONSULTATION SPEC MEDICAL RADJ PHYSICS CONSLTJ No authorization for fox radiation therapy, including gamma knife 77371 SRS MULTISOURCE RADIATION DELIVERY STEREOTACTIC authorization required Radiation therapy, Full gamma C 72Knife. AR BASED RADIATION STEREOTACTIC DELIVERY Authorization required Radiotherapy Full clinical review CRANIAL LINEAR including gamma knife 77373 SBRT DELIVERY STEREOTACTIC BODY RADIATION No authorization required Radiotherapy DELIVERY including gamma knife 77385 NTSTY MODUL RAD TX DLVR SMPL INTENSITY MODULATED RADIRP Review SIMPL INTENSITY M ODULATED RADIrap Author including gamma knife 77386 NTSTY MODULE RAD TX DLVR CPLX INTENSITY MODULATED RADIATION TX No approval required Radiation therapy, DLVR COMPLEX incl. gamma knife 77387 GUIDE FOR RADJ TX DLVR GUIDE FOR LOCLZJ TARGET VOL No approval required Radiation therapy, DLknife incl. NAL RADIATION DOSIMETRY UNLIS MEDICAL RADJ DOSIM TX DEV Authorization Required Radiotherapy Full Clinical Review SPEC SVCS Including Gamma Knife 77401 RADIATION TREATMENT ADMINISTRATION RADIATION ADMINISTRATION TX Authorization Required Radiotherapy Full Clinical Review SURFACE AND/ORTHO APPLICATION 77401 RADIATION TREATMENT INCLUDING TREATMENT DELIVERY 1 Authorization Required Radiotherapy , MEV+ SIMPLE drunk clinical review including gamma knife

77407 RADIATION TREATMENT RADIATION TREATMENT 1 MEV => Authorization required Radiotherapy, full clinical examination MEDIUM, including gamma knife 77412 RADIATION TREATMENT RADIATION TREATMENT 1 No Authrapy incl. Radiation, incl. 23 NEUTRON BEAM TX COMPLEX HIGH ENERGY NEUTRON RADJ TX DLVR authorization required Radiotherapy, Full clinical examination 1/> ISOCENTER incl gamma knife 77424 IO RAD TX DELIVERY X-RAY BY AIR INTRAOP RADIO TX DELIVERY X-RAY BY BEAM X-RAY BY BEAM Authorization required Radiotherapy, full TX -4 KNIFE incl. . RAD TX LIVER OF ELCTRNS INTRAOP RADIAJ TX LIVER Approval required Radiotherapy, full clinical review ELECTRONS SNGL TX SESS incl gamma knife 77427 RADIATION MANAGEMENT TX X5 RADIATION MANAGEMENT No approval required, 7 gamma 1 radiation incl. RADIATION THERAPY MANAGEMENT RADIATION THERAPY MGMT 1/2 Authorization required Radiotherapy, full clinical review FRACTIONS ONLY including gamma knife 77432 STEREOTACTIC RADIATION TRMT STERETCTC RADIATION TX Authorization required Radiotherapy, full clinical review CRANIAL LESION TREATMENT including BEREOTACTIC RADIATION STEREOTACTIC STEAL NO. Radiotherapy required, MANAGEMENT including Gamma Knife 77469 IO RADIATION TREATMENT INTRAOPERATIVE RADIATION Approval required Radiotherapy, full clinical review TREATMENT MANAGEMENT including Gamma Knife 77470 SPECIAL RADIATION TREATMENT SPECIAL TREATMENT PROCEDURE 77470 SPECIAL RADIATION TREATMENT SPECIAL TREATMENT URE 77470 U at PY MANAGEMENT PROCEDURE NON-THERAPEUTIC Approval required Radiotherapy , full clinical review RADIOLOGY TX MGMT including gamma knife 77520 PROTON TRMT SIMPLE U/O COMP PROTON TX DELIVERY SIMPLE U/O Approval required Radiotherapy, full clinical review FEE including gamma knife 77522 PROTON TRMT SIMPLE W/ COMPLE Author required EASY PURCHASE Radiation therapy, Complete clinical examination W/COMPENSATION including gamma knife 77523 PROTON TRMT INTERMEDIATE PROTON TX DELIVERY INTERMEDIATE Authorization required Radiation therapy, Complete clinical examination including gamma knife 77525 PROTON TREATMENT COMPLEX PROTON TX DELIVERY Incl. 77600 TREATMENT OF HYPERTHERMIA EXTERNALLY GENERATED No approval required SURFACE 77605 TREATMENT OF HYPERTHERMIA EXTERNALLY GENERATED No approval required DEEP 77610 HYPERTHERMIA PROVITER red 5/< APPLICATORS 77615 HIPERTH ERMIA TREATMENT OF HYPERTHERMIA INTERSTEEL PROBE 5/> No approval required APPLICATORS 7 7620 TREATMENT REDUCTION OF HYPERTHERMIA HYPERTHERMIA INTRACAVITARY Probe approval is not required 77750 INFUSER RADIOACTIVE MATERIALS NFS/INSTLJ RADIOELMNT SLN 3 MO Approval required Radiation therapy, full clinical examination RANGE OF MONITORING including gamma knife 77761 APPLY INVOLVING INVOLVING RADIATION Author. rapy, Full Clinical Review APPLICATION SIMPLE including Gamma Knife 77762 APPLICATION OF INTRACAVITE RADIATION SOURCE INTRCAV RADIAT INTERM Approval Required Radiation Therapy, Full Clinical Review APPLICATION INTERMED including Gamma Knife 77763 APPLICATION OF INTRACAVITE RADIATION SOURCE INTRCAV RADIAT COMPL Required. gamma knife 77767 HDR RDNCL SKN SURF BRACHYTX HDR RDNCL SKN SURF BRACHYTX LES Approval required Radiotherapy, Full clinical examination 2CM&2CHAN/MLT LES including gamma knife 77770 HDR RDNCL NTRSTL/ICAV BRCHTX HDR RDNCL NTRSTL/INTRCAV Approval required Radiotherapy 77770 HDR RDNCL NTRSTL/ICAV BRCHTX . HDR RDNCL NTRSTL/ICAV BRCHTX HDR RDNCL NTRSTL/INTRCAV No authorization required Radiation therapy, BRACHYTX 2-12 CHANNEL incl. gamma knife. 77778 APPLY INTERSTIT RADIAT COMPL INTERSTITIAL RADIATION SOURCE Approval required Radiation therapy, full clinical review APPLY COMPLEX including gamma knife 77789 APPLY SURF LDR RADIONUCLIDE SURFACE APPLICATION LOW DOSE RATE approval SUCDE RATE approval SUCDE RATE approval Incl. amma knife 77790 RADIATION HANDLING SUPERVISION HANDLING CHARGING Approval required Radiation therapy, Full clinical examination RADIATION SOURCE including gamma knife 77799 RADIO/RADIOISOTOPE THERAPY NOT LISTED PROCEDURE CLINICAL Approval required Radiation therapy, Full clinical examination BRACHYTHERAPY incl. gamma knife 780CEDUNECRINE 78099 X NUCLEAR Clearance Required Radiology - Nuclear Full Clinical Exam MEDICINE medicine 78199 BLOOD/LYMPH NUCLEAR EXAMINATION UNLIS HEMATOP Approval Required Radiology - Nuclear Full Clinical Exam RET/ENDO&LYMPHATIC DX NUC With Medicine 78299 GI NUCLEAR PROCEDURE UNLISTED GASTROINTESTIN AL Required authorization Radiology - Nuclear Full MEDICINE PX DCLIN Authorization - Required 78399 MUSCULOSKELETAL ATOMIC REVIEW NOT LISTED MUSCULOSKELETAL PX DX Authorization Required Radiology - Nuclear Full Clinical Review NUCLEAR MEDICINE medicine 78429 MYOCRD IMG PET 1 STD W/CT MYOCRD IMG PET METAB EVAL SIMPLE Authorization Required Full clinical examination STUDY CNCRNT CT 78430 MYOCRDYO MPRJET/PRJET/PRJET/PRJET/PRJ. 1STD approval required Full clinical examination REST/STRESS CNCRNT CT 78431 MYOCRD IMG PET RST&STRS CT MYOCRD IMG PET PRFUJ MLT STD approval required Full clinical examination RST&STRS CNCRNT CT 78432 MYOCRD PRÄV ITRACMG PETMG/ Full clinical examination required DUAL RADIOTRACER 78433 MYOCRD IMG PET 2RTRACER CT MIOKRD IMG PET PRFUJ W/METAB Authorization Required Full Clinical Review 2RTRACER CNCRNT CT 78434 AQMBF PET REST & RX STRESS AQMBF PET REST AND Authorization Required SCOTRESS 7SC 7SC 4 SCMU IMAGE SPECT SING MYOCARDIAL SPECT SINGLE STUDY KL Authorization Required Radiology - Nuclear Full Clinical Review REST OR STRESS medicine 78452 HT MUSLE IMAGE SPECT MULTI MYOCARDIAL SPECT MULTIPLE EXAMS Authorization required Radiology - nuclear Full clinical medical examination 78453 HT MUSCLE IMAGE SPECT MULTI MYOCARDIAL SPECT MULTIPLE EXAM Authorization required Radiology - nuclear Full clinical medical examination 78453 HT MUSCLE IMAGE PLAN REQUIRED Radiology - nuclear Full Clinical Review Medicine 78453 HT PLAN MUSCLE IMAGING PLANAR NOW 1 Full Clinical Review REST/STRESS STUDY Medicine 78454 HT MUSCLE IMAGING PLANAR MULTI MYOCARDIAL PERFUSION PLANAR Approval Required Radiology - Nuclear Full Clinical Review MULTIPLE STUDIES Medicine 78459 MYOCRD IMG PET SING LE STUDY MYOCRD IMG PERFUSION STUDY Full Overview STUDIJA five METAB EVAL Author STUDIJA STUDIJA METAB EVAL. 78466 HEART INFARCTION IMAGE MYOCARD INFARCT AVID Authorization required Radiology - Nuclear Full Clinical Examination PLANAR QUAL/QUAN Medicine 78468 HEART INFARCTION IMAGE (EF) MYOCRD IMG INFARCT AVID PLNR EJEC Authorization required Radiology - Nuclear Full Clinical Examination 7846 8 HEART INFARCTION 7 FX4FQ 9 DOB ( 3D) MYOCRD INFARCT AVID PLNR TOMOG Authorization Required Radiology - Nuclear Full Clinical Exam SPECT W/WO QUANTJ Medicine

78472 GATED HEART PLANAR SINGLE CARD BLOOD BLOOD GATED PLANAR 1 Authorization Required Radiology - Nuclear Full Clinical Review REST/STRESS STUDY Medical 78473 GATED HEART MULTIPLE CARD BL POOL GATED MLT STDY WAL Medical Authorization Required Full Radiology WAL Authorization 78472 81 HEART FIRST P DONKEY ONE CARD BL POOL PLANAR 1 STDY WAL Authorization Required Radiology - Nuclear Full Clinical Review MOTN EJECT FRACT Medicine 78483 HEART FIRST PASS MULTIPLE CARD BL POOL PLNR MLT STDY WAL Authorization Required Radiology - Nuclear Medicine EJYOTN Full Clinical 78483 PASS PASS MULTIPLE CARD BL POOL PLNR. 1STD RST/STRS MYOCRD IMG PET PRFUJ SINGLE STUDY Authorization Required Radiology - Nuclear Complete Clinical Medicine REST/STRESS Medicine 78492 MYOCRD IMG PET MLT RST&STRS MYOCRD IMG PET PRFUJ Multiple Authorization Required Radiology - Nuclear Medicine R4STHEST 8 Complete Clinical Medicine R7 & Review 9 E CT SHORT BL POOL GATED SPECT REST WAL Authorization Required Radiology - Nuclear Full Clinical Review MOTN EJCT FRCT Medicine 78496 HEART FIRST PASS ADD-ON CARD BL POOL GATED 1 STDY REST RT Authorization Required Radiology - Nuclear Full Clinical Review VENT EJCT 8OVCUNLAR FRCT Medicine 78499 HEART FIRST PASS ADD-ON CARD PX DX authorization required Radiology - Nuclear Full Clinical Examination NUCLEAR MEDICINE medicine 78599 RESPIRATORY NUCLEAR EXAMINATION NOT SET RESPIRATORY PX DX NUCLEAR authorization required Radiology - Nuclear Full Clinical Examination MEDICINE medicine 78608 BRAIN IMAGING - Author BRAIN IMAGING REQUIRED - Nuclear Clear Full Clinical Examination EVALUATION medicine 78609 BRAIN IMAGING GING (PET ) BRAIN IMAGING PET PERFUSION Approval Required Radiology - Nuclear Full Clinical Exam EVALUATION Medicine 78699 NUCLEAR EXAMINATION NERVOUS SYSTEM NERVOUS SYSTEM UNPLUGD PX DX Approval Required Radiology - Nuclear Complete Medicine - Nuclear 7NUCL Medicine - Nuclear 7NUCL Medicine - Nuclear RY NUCLEAR EXAMINATION UNINVITED GENITRONIC PX DX Authorization Required Radiology - Nuclear Full Clinical Review NUCLEAR MEDICINE medicine 78811 PET IMAGE LTD AREA PET IMAGING LIMITED AREA BREAST Authorization Required Radiology - Nuclear Full Clinical Review HEAD/NECK Medicine 78812 PET IMAGE CRANIO-THEMU By M. KRAVNE-LÅD Author. Nuclear Full Clinical Review Thigh Medicine 78813 WHOLE BODY PET IMAGING PET IMAGING WHOLE BODY PET IMAGING Approval Required Radiology - Nuclear Full Clinical Review Medicine 78814 PET-IMAGE W/CT LMTD PET IMAGING CT FOR ATTENUATION Clinic Approval Required 8A Full Radiology Approval 8A 8A 8A Radiology 1 . Beloved Image w/ct Skull-Fehar Image Access Beloved CT Attenuation Skull Authorization Required Radiology-Nuclear Complete Middle Meat Middle Medicine Clinical Review Database 78816 PET Image w/ Whole Body Images Access Beloved CT-Atenuation No Authorization Required W Radiology- NucleozJ0 HORP 7 8Z0 SPECT W/CT 1 RP LOCLZJ TUM SPECT W/CT 1 Area 1 Authorization Required Full Clinical Examination Required Date of Imaging 78831 RP LOCLZJ TUM SPECT 2 Areas RP LOCLZJ TUM SPECT 2 Area 1D IMG/1 AUTHORIZATION REQUIRED LOCLZJ TUM SPECT W/CT 2 RP LOCLZJ TUM SPECT CT 2AREA 1D Approval Required Full Clinical Review IMG/1 AR IMG>2+D 78835 RP QUAN SINGLE AREA MEASUREMENT RADIOPHARMACEUTICAL Approval Required 70 Full Approval Required 50 NUCLEAR RX ORAL ADMIN RP THERAPY ORAL ADMIN No Approval Required 79101 NUCLEAR RX IV ADMIN RP THERAPY INTRAVENOUS No approval required ADMINISTRATION 79200 NUCLEAR RX INTRACAV ADMIN RP THERAPY INRACAVITARIOUS No approval required 79 R3X00T APPLICATION RSTICIAL RADIOACTIVE No approval required COLLOID ADMN 79403 H EMATOPOIETIC N UCLEAR TX RP THER Radiolbld monoclonal antibody no approval required iv. infus 79440 nuclear RX intra-articular RP therapy intra-articular no approval required administration 79445 nuclear RX intra-arterial therapy Intra-arterial 9 Nearteight 9 Nuclear Medicine Therapy Therapy IONIZED CA BASIC METABOLIC PANEL CALCIUM No approval required IONIZED 80048 METABOLIC P ANEL TOTAL CA BASIC METABOLIC PANEL CALCIUM No approval required TOTAL 80050 GENERAL AUT 80050 GENERAL GENERAL 5 1 ELECTROLYTE PANEL ELECTROLYTE PANEL No approval required 80053 METABOLIC PANEL UNDERSTANDING COMPREHENSIVE METABOLIC PANEL No approval required 80055 OBSTETRICAL PANEL OBSTETRICAL PAN EL No approval required 80061 LIPID PANEL LIPID PANEL No approval required 80069 RENAL FUNCTIONAL PANEL RENAL FUNTE Auth HEPATITIS PANEL No approval required 80076 HEPATIC FUNCTION PANEL HEPATIC FUNCTION PANEL No. Approval Required 80081 General Panel Obstetric Panel No Approval Required 80145 Drug Analysis Analimumab Drug Test Adalimumab Approval Requires Full Clinical Review 80150 Amikacin Drug Screen Test Quant 5 AM Quant 5 AdRug Quant 5 Quant. FEINE DRUG ANALYSIS CAFFEINE No approval required 80156 CARBAMAZEPIN ANALYSIS TOTAL DRUG ANALYSIS CARBAMAZEPIN TOTAL No approval required 80157 CARBAMAZEPIN ANALYSIS NO DRUG ANALYSIS CARBAMAZEPIN NO Approval required 80158 DRUG ANALYSIS CYCLOSPORINE DRUG ANALYSIS CYCLOSPORINE No approval required 80159 DRUG C AS SAY CLOZAP 1 2 ANALYSIS OF DIGOXIN TOTAL QUANTITATIVE DIGOXIN DRUG SCREEN No Authorization Required TOTAL 80163 DIGOXIN FREE ANALYSIS QUANTITATIVE DIGOXIN DRUG SCREEN No Authorization Required FREE 80164 DIPROPYLACETIC ACD TOT ANALYSIS VALPROIC DRUG ANALYSIS No Authorization Required DIPROPYLACETIC ACID TOTAL 80165 DIPROPYLACETIC ACID Aquid. ACID FREE 80168 ETHOSUXIMIDE QUANTITATIVE DRUG SCREENING ANALYSIS No approval required ETHOSUXIMIDE 80169 DRUG ANALYSIS EVEROLIMUS DRUG ANALYSIS EVEROLIMUS No approval required 80170 GENTAMICIN COLLABORATION QUANTITATIVE SCREENING ANALYSIS No approval required GENTAMICIN 80171 DRUG SCREEN QUANT GABAPENTIN MEDICINE SCREEN QUANTITATIVE No approval required AMYCIN 80171 DRUG SCREEN AMOUNT OF GABAPENTINE QUANTITATIVE DRUG SCREENING GENTAMICIN 7 HALOPERIDOL QUANTITATIVE DRUG SCREENING No approval required HALOPRIDOL 80175 DRUG SCREENING QUAN LAMOTRIGINE QUANTITATIVE DRUG SCREENING No approval required LAMOTRIGINE 80176 LIDOCAIN ANALYSIS D RUG SCREEN QUANTITATIVE Approval not required LIDOCAIN

80177 Drug SCRN QUAN LEVETIRACETAM QUANTITATIVE DRUG SCREENING No Authorization Required LEVETIRACETAM 80178 LITHIUM ANALYSIS QUANTITATIVE DRUG SCREENING LITHIUM No Authorization Required 80180 DRUG SCRN SQUANT SCRN Auth Required MYCOPHENOLATE 80183 Drug SCRN QUANT OX CARBAZEPINE QUANTITATIVE SCREENING OXCARBAZE P INE 80184 ANALYSIS OF THE DETERMINATION OF PHENOBARBITAL ON DRUGS QUANTITATIVELY No Approval Required PHENOBARBITAL 80185 ANALYSIS PHENOBARBITAL TOTAL DRUG CHECK QUANTITATIVE No Approval Required PHENYTOIN TOTAL 80186 PHENOBARBITAL ANALYSIS 80185 PHENOBARBITAL ANALYSIS NO DRUG REQUIRED 80186 ANALYSIS PHENOBARBITAL NO DRUG REQUIRED 8 87 DRUG ANALYSIS POSACONAZOLE MEDIUM ASSAY POS ACONAZOLE Authorization Required Full Clinical Review 80188 QUANTITATIVE SCREENING ANALYSIS DRUG PRIMIDONE No authorization required PRIMIDONE 80190 PROCAINAMIDE QUANTITATIVE MEDICAL CHECK ANALYSIS No authorization required PROCAINAMIDE 80192 PROCAINAMIDE QUANTITATIVE MEDICAL CHECK ANALYSIS No approval required PROCAINAMIDE 80192 PROCA ANALYSIS QUANTITATIVE MEDICAL CHECK FOR INAMIDE No authorization required PROCAINAMIDE 80192 UG QUANTITATIVE PRO VIEW No approval required QUINIDIN 80195 ANALYSIS OF QUANTITATIVE DETERMINATION DRUG SIROLIMUS No approval required SIROLIMUS 80197 ANALYSIS OF QUANTITATIVE DETERMINATION DRUG TACROLIMUS No approval required TACROLIMUS 80198 ANALYSIS OF DRUG QUANTITATIVE DETERMINATION THEOPHYLLINE Not approved oval Required THEOPHYLLINE QUANTITATIVE CRUGDRIVT 80198 No approval required TIAGABINE 80200 TEST TOBRAMYCIN QUANTITATIVE PRO VIR DRUG RM QUANTITATIVE No approval required TOBRAMYCIN 80201 QUANTITATIVE SCREENING ANALYSIS DRUG TOPIRAMATE No approval required TOPIRAMATE 80202 QUANTITATIVE SCREENING ANALYSIS DRUG VANCOMYCIN No approval required VANCOMYCIN 80203 DRUG SCREENING QUANTUM ZONISAMIDE MEDICAL REVIEW REQUIRED00 ON QUANTITATIVE Z AFL 3 DRUG TRIAL IXIMAB Approval required INFLIXIMAB Full Clinical Review 80235 DRUG TRIAL LACOSA MID MEDICINE IDDELASSAY Authorization required LACOSAMID -a Full Clinical Review 80280 DRUG ANALYSIS VEDOLIZUMAB DRUG ANALYSIS VEDOLIZUMAB DRUG ANALYSIS Authorization Required Full Clinical Review 80285 DRUG ANALYSIS VORICONAZOLE DRUG ANALYSIS VORICONAZOLE DRUG ANALYSIS VORICONAZOLE DRUG ANALYSIS Approval Required Full Clinical Review Review 80285 QUANTITATION 8029 HERE No Approval Required SPECIFIED 80305 SECOND TEST PRSMV DIR OPT NOTE SECOND TEST PRSMV READ DIRECT No approval required OPTICAL NOTE PR -DATE 80306 DRUG TEST PRSMV INSTRMNT DRUG TST PRSMV READING INSTRMNT No approval required ASSTD DIR OPT OBS 80307 DRUG TEST PRSMV KEM ANLYZR DRUG INSTRM TEST SAMPLE 8 320 DRUGSC REEN QUANTALCOHOLS DRUGSCREEN QUANTITATIVE No approval required ALCOHOL 80321 ALCOHOL BIOMARKERS 1 OR 2 DRUG SCREEN QUANTUM ALCOHOLS Approval not required BIOMARKERS 1 OR 2 80322 ALCOHOLS BIOMARKERS 3/MORE DRUG SCARE QUANTUM ALCOHOL ALCOHOLS NOT REQUIRED 80322 ALCOHOLS BIOMARKERS S NO ALKALOIDS NOT OTHERWISE SPECIFIED Approval not required 80324 CHILD CHECK AMPHETAMINES 1/2 DRUG SCREEN QUANT AMPHETAMINES No approval required 1 OR 2 80325 AMPHETAMINES 3OR 4 OTHER SCREEN QUANT AMPHETAMINES No approval required 3 OR 4 80326 AMPHETORAMINES No. Red 5 or more 80327 Anabol Steroid 1 or 2 Screen Quant Anabolic No approval Steroid 1 or 2 80328 Anabol Quant Anabolic No approval Steroid 3 or more 80329 Analgesic Neopsic opioid without creaen 1 required or 2 80330 analgesics NON-OPIOID 3-5 ANALGESICS TO CHECK ANALGESICS NON - No approval required OPIOID 3-5 80331 NON-OPIOID ANALGESICS 6/MORE ANALGESICS TO CHECK ANALGESICS NON - No approval required OPIOID 6 OR MORE 80331 ANTIDEPRESSANT 2 SRESANT 2 SPRANT 2 OTONERGIC No CLASS 1 OR 2 ANTIDEPRESSANTS Required 80333 CLASS 3-5 SEROTONERGIC ANTIDEPRESSANTS No CLASS 3-5 ANTIDEPRESSANTS 80334 CLASS 6/MULTI SEROTONERGIC ANTIDEPRESSANTS No CLASS 3-5 ANTIDEPRESSANTS 80334 CLASS 6/MULTI SEROTONERGIC ANTIDEPRESSANTS No CLASS Approval Required 80334 CLASS 6/MORE ANTIDEPRESSANTS SEROTONERGIC No approval required CLASS 80334 ANTIDEPRESSANTS TRICYCLIC OTHER No approval required CYCLIC 1 OR 2 80336 ANTIDEPRESSANT TRICYCLIC 3-5 ANTIDEPRESSANT TRICYCLIC OTHER No approval required CYCLIC 3- 5 80337 TRICYCLIC AND CYCLIC 6/MORE ANTIDEPRESSANTS TRI CYCLIC OST . No approval required CYCLICALS 803 3 ANTI MORE NOTIFIC 803 6/3 MORE OTHERS No approval required SPECIFIED 80339 ANTIEPILEPTICS NOS 1-3 ANTIEPILEPTICS NOT OTHER No approval required SPECIFIED 1-3 80340 ANTIEPILEPTICS NO. 4-6 ANTIEPILEPTICS NOT OTHER No approval required SPECIFIED 4-6 80341 ANTIEPILEPTICS NO. 7/MORE ANTIPILEPTICS NO. ANTIPSYCHOTICS NO. 1-3 ANTIPSYCHOTICS NOT OTHER Approval not required SPECIFIED 1-3 80343 ANTIPSYCHOTICS NO. 4-6 ANTIPSYCHOTICS NO OTHER No approval required SPECIFIED 4-6 80344 ANTIPSYCHOTICS NO. ING BARBITURATES DRUG REVIEW BARBITURATES No Authorization Required 80346 BENZODIAZEPINES 1-12 DRUG SEARCH BENZODIAZEPINES 1- No Authorization Required 12

80347 BENZODIAZEPINES 13 OR MORE EMPLOYEE SCREENING BENZODIAZEPINES 13 No Clearance Required OR MORE 80348 EMPLOYEE SCREENING BUPRENORPHIN MEDICALSKREINING BUPRENORPHINE No Clearance Required 80349 SCANACRINNAAL NOID CANNACRINNAID NO. NATURAL 80350 CANNABINOIDS SYNTHETIC 1-3 CANNABINOID DRUG REVIEW No Approval Required SYNTHETIC 1-3 80351 CANNABINOID SYNTHETIC 4-6 CANNABINOID DRUG REVIEW No Approval Required SYNTHETIC 4-6 80352 CANNABINOID SYNTHETIC 7/MORE DRUG CHECK CANNABINOIDS No Approval Required 7/ 5 SYNTHETIC SYNTHETIC 7/5 COCAINE SCREENING No Approval Required 80354 FENTANYL DRUG SCREENING FENTANYL DRUG SCREENING No Approval Required 80355 GABAPENTINE BLOOD-FREE DRUG SCREENING GABAPENTIN NO- Approval No Required BLOOD 80356 HEROIN METABOLITH HEROIN METABOLIT DRUG SCREENING No Approval Required 80357 KETAMINE AND NORKETAMINE NORKETAMINE 803 57 KETAMINE AND NORKETAMINE NORKETAMINE 80357 358 REVIEW METHADONE APPROVAL REVIEW METHADONE No Approval Required 80359 METHYLENDIOXYAMPHETAMINES DRUG REVIEW No Approval Required METHYLENDIOXYAMPHETAMINES 80360 METHYLPHENIDATE REVIEW No Approval Required 80361 OPIATES 1 OR MORE Drug Check OPIATI 1 OR MORE OPIO 0362SLOG not required approval UG-PROVIR OPIOID AND OPIATES No approval required ANALOGUES 1 OR 2 80363 OPIOIDS AND OPIATES ANALOGUES 3/4 GENERAL OPIOIDS AND OPIATES No approval required ANALOGUES 3 OR 4 80364 OPIOIDS AND OPIATES ANALOGUES 5/MORE GENERAL OPIOIDS AND OPIATES No approval required ANA LOGOS 5/CCREENING 8036 MORE 80364 ANALOGUES 80364 OXYCOD ONE No approval required 80366 PREGABALIN DRUG SCREENING PREGABALIN DRUG SCREENING No approval required 80367 PROPOXYPHENE DRUG SCREENING PROPOXYPHENE DRUG SCREENING No approval required 80368 SEDATIVE HYPNOTICS DRUG SCREENING SEDATIVE HYPNOTICS/ REVENDING SKY MUSCLE 80 3689 REV 80368 SKELETAL MUSCLE DRUG SCREEN No approval required RELAXANTS 1 OR 2 80370 SKELETAL MUSK RELAXANTS 3 OR MORE SCAFFOLD MUSCLE DRUG SCREEN No approval required REJECTING AGENT 3 OR MORE 80371 STIMULANTS SYNTHETIC MEDICINE SCREENING No approval required SYNTHETIC 80372 DRUG SCREEN TAPENTADOL TAPENTADOL T RUGENT SCREINING 3 No 3 TRAMADOL DRUG SCREINING TRAMADOL No approval required 80374 STEREOISOMER ANALYSIS Drug SCREEN STEREOISOMER No Veterinary approval required ANALYSIS 1 DRUG CLASS 80375 DRUG / SUBSTANCE NO. 1-3 FRIEND/STUDENT DEFINITELY No approval required QUALITY/QUANTITY NO. 1-3 80376 DRUGS/STUDENT NO. 4-6 OTHER/STUDENT PRESENT QUANTITY/STUDENT NEEDED. 80377 SECONDARY/STUDENT NO. 7/MORE DRUGS/STOCKS DEFINITELY No approval required QUALITY/QUANTITY NO. 7/MORE 80400 ACTH STIMULATION PANEL ACTH STIMULATION PANEL ABRENAL COMPLAINT No authorization required INSUFFICIENCY ACCUMULATION ST1000 ST12002 required HYDROXYLAS DEFICITY 80406 ACTH STIMULATION PANEL ACTH STIMJ PANEL 3 BETA- No authorization required HYDROXYDEHYD DEFNCY 80408 ALDOSTERONE SUPPRESSION EVAL ALDOSTERONE SUPPRESSION No authorization required EVA LUATION PANEL 80410 CALCITONIN STIMULUS Stimulus Panel Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Panel Stimulus Stimulus Stimulus Stimulus Calculus Calculus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Stimulus Vrululus Vrulus Vr ula panel Stimula panel Stimulus Stimulus Kaldina panel stimuli stimulation panels calculus stimuli stimulation panels Us stimulus stimulus stimulus stimulus stimulus stimulus US stimulus stimulus stimulus STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS STIMULUS 8 PANEL CORTICOTROPIC RELEASING HORM No approval required STIMJ PANEL 80414 TESTOSTERON RESPONSE CHORNC GONAD STIMJ PANEL No approval required TSTO STERONE RESPONSE 80415 ESTRADIOL RESPONSE P ANEL CHORNC GONAD STIMJ PANEL No authorization required ESTRADIOL RESPONSE 80416 RENIN STIMULATION PANEL RENAL VEIN STIMULATION RENIN STIMULATION PANEL 804 PANEL 80416 PANEL RENIN STIMULATION RENAL VEIN STIMULATION PLATE 8 AL VEIN RENIN STIMULATION No authorization required PANEL 80418 HYPOFE COMB EVALUATION PANEL INIRANA FAST ANT PITUITARY No approval required EVALUATION PANEL 8042 0 DEXAMETHASONE PANEL DEXAMETHASONE SUPPRESSION PANEL No approval required 48 HR 80422 GLUCAGON TOLERANCE PANEL GLUCOSE TOLERANCE PANEL No approval required 8 INSULION GOL 48 HR 80422 GLUCOSE ILERATION PANEL No approval required PHEOCHROMOCYTOM 80426 PANEL FOR GONADOTROPIN HORMONES GONADOTROPIN RELEASE HORMONE Approval not required STIMJ PANEL 80428 GROWTH HORMONE PANEL GROWTH HORMONE STIMULATION Approval not required PANEL 80430 GROWTH HORMONE PANEL SUPRJ PANEL Approval not required GLUCOSE ADMN 80432 INSULIN PANEL REQUIRED No. SUPPRESSION PANEL 80434 INSULIN TOLERANCE PANEL INSULIN TOLERANCE PANEL ACTH no Authorization required INSUFFICIENCY 80435 INSULIN TOLERANCE PANEL GROWTH PANEL No approval required HORM DEFNCY 80436 METYRAPONE PANEL METYRAPONE PANEL No approval required 80438 TR H STIMULATION PANEL Auth EL 1 HR 80 439 TRH STIMULATION THYROTROPIN HORMONE RELEASE PANEL No approval required STMLJ PANEL 2 HR 80500 LABORATORY PATHOLOGY CONSULTANCY CLINICAL PATHOLOGY CONSULTANCY No approval required LIMITED 80502 LABORATORY PATHOLOGY CONSULTANCY CLINICAL PATHOLOGY CONSULTANCY No approval required COMPREHENSIVE 81000 NPEONAUTILS CONSULTANT 0 NPEONAUTILS MANAGER/ASSISTANT. AGNT NON- No approval required AUTO MICRSCPY

81001 URINALYSIS AUTO W/SCOPE-URNLER DIP-STICK/TABLET REAGENS No approval required AUTO MICROSCOPY 81002 URINALYSIS NONAUTO U/O SCOPE-URNLER DIP-STICK/TABLET RGNT NON- No approval required AUTO W/ORNICOLS IP STICK /TABLET RGNT AUTO No approval required U/O MICROSCOPY 81005 URINE ANALYSIS URINE QUALITATIVE/SEMIQUANTITATIVE EXCEPT Approval not required IMMUNOLOGY TESTER 81007 URINE TEST FOR BACTERIA URINALYSIS BACTERIURIA CULTI 5 REQUIRED M10PS ROSCOPIC EXAMINATION OF URINE URINALYSIS MICRO SCOPE ONLY No approval required 81020 URINE ANALYSIS GLASS TEST IN RIN ALIZA 2/ 3 GLASS TEST No. authorization required 81025 URINE PREGNANCY TEST URINE PREGNANCY VISUAL COLOR No authorization required CMPRSN METHS 81050 URINALYSIS VOLUME MEASUREMENT VOLUME MEASUREMENT VOLUME MEASUREMENT 8 EXPLANATION E10 CRYPT VOLUME MEASUREMENT E10 LICE PROCEDURE TESTING NOT LISTED URINO SIS PROCEDURE Required authorization Pathology and laboratory Full clinical examination 81105 HPA-1 GENOTYPING HPA-1 GENOTYPING REANALYSIS Authorization required Genetic testing and full clinical examination COMMON VARIANT consultation 81106 HPA-2 GENOTYPING HPA-2 GENOTYPING GENANALYSIS Full clinical examination and 1 VARIGEN authorization required 1 1. 07 HPA-3 GENOTYPING HPA-3 GENOTYPING GENANALYSIS IS Authorization required Genetic testing and full clinical examination COMMON VARIANT consultation 81108 HPA-4 GENOTYPING HPA-4 GENOTYPING GEN ANALYSIS Authorization required Genetic testing and full clinical examination 81108 HPA-4 GENOTYPING HPA-4 GENOTYPING GEN ANALYSIS Authorization required Genetic testing and full clinical examination 81108 HPA- 4 GENOTYPING HPA-4 5 GENE ANALYSIS GENOTYPING Authorization required Genetic testing and full clinical examination COMMON VARIANT consultation 81110 HPA-6 GENOTYPING HPA-6 GENOTYPING GENE ANALYSIS Authorization required Genetic testing and full clinical examination examination COMMON VARIANT consultation 8111111 GENOP GENE HP A-6 genetic testing and full clinical examination COMMON VARIANT consultation required 81112 HPA-15 GENOTIPIZATION HPA-15 GENOTIPING GENANALYSIS Authorization required Genetic testing and full clinical examination COMMON VARIANT consultation 81120 IDH1 COMMON VARIANT consultation IDH1 COMMON COMMON VARIANTS consultation and full clinical examination. 81121 IDH2 COMMON VARIANTS IDH2 COMMON VARIANTS Approval required Genetic testing and full clinical consultation 81161 DMD DUP/DELETE ANALYSIS DMD DUPLICATION/DELETION ANALYSIS Approval required Genetic testing and full clinical consultation 81162 BRCA1&2 GEN FULL BRCA SEQ 1 FULL SEQ 1 Genetic testing and full clinical examination DUP/DEL ALYS advice 81163 BRCA1&2 GEN FULL SEQ ALYS BRCA1 BRCA2 GENE ANALYSIS FULL authorization required Genetic test and full clinical examination SEQUENCE ANALYSIS advice 81164 BRCA1&2 BRCA1&2 DELCA ALquis FULL DUP/1 Gene required tic test and full clinical examination DUP/DEL ANALYSIS SIS advice 81165 BRCA1 GENE FULL SEQ ALYS BRCA1 GENE ANALYSIS FULL SEQUENCE Authorization required Genetic testing and full clinical examination ANALYSIS advice 81166 BRCA1 GENE FULL DUP/DEL DEL ANALYSIS REQUIRED DUP/DEL DEL ANALYSIS/ CDEL GENE TEST REQUIRED linear screening ANALYSIS advice 81 167 BRCA2 GENE FULL DUP /DEL ALYS BRCA2 GENE ANALYSIS FULL DUP/DEL Authorization required Genetic testing and full clinical examination ANALYSIS consultation 81170 ABL1 GENE ABL1 GENE ANALYSIS GENE ANALYSIS KINASEL EXAMINATION and full examination KINASEL DOMINICAN authorization Genetic examination required 81171 AFF2 GENE DETC ABNOR ALLELES A FF2 GENE ANALYSIS SCORE DETECT Authorization required Genetic test and full clinical examination ABNORMAL ALLELES Counseling 81172 AFF2 GENE CHARAC ALLELES AFF2 GENE ANALYSIS Authorization required Genetic testing and full clinical examination GENE CHARACTERIZATION 81 GENE ANALYSIS 3 GENE ANALYSIS Need FULL authorization GENE Genetic testing and full clinical examination SEQUENCE counseling 8 1174 AR GENE KNOWN FAMILY VARIANT AR GENE ANALYSIS KNOWN FAMILY Authorization required Gentest and full clinical examination VARIANT consultation 81175 ASXL1 COMPLETE GENE Sequence and GANA COMPLETE GENE Sequence. Full clinical examination SEQUENCE consultation 81176 ASXL1 GENE TARGET SEQ ALYS ASXL1 GENE ANALYSIS TARGET SEQ Authorization required Genetic test and full clinical examination ANALYSIS consultation 81177 ATN1 GENE DETC ABNOR ALLELE ATN1 GENE ANALYSIS EVAL DETECT Authorization required Genetic examination and cotx1N 811 77 ATN1 GENE ANALYSIS EVAL DETECT Authorization required. GENEDETC ABNOR ALLELE ATXN1 GENE ANALYSIS EVAL DETECT Authorization required Genetic testing and full clinical examination ABNORMAL ALLELES consultation 81179 ATXN2 GENE DETC ABNOR ALLELE ATXN2 GENE ANALYSIS EVAL DETECT Authorization required Genetic testing and full clinical examination ABNORMAL ALLETC ATX81180N counseling ABNORMAL ALLETC GENANALYSIS EVAL DETECT Authorization required Genetic testing and full clinical examination ABNORMAL ALLELES consultation 81181 ATXN7 GENE DETC ABNOR ALLELE ATXN7 GENE ANALYSIS EVAL DETECT Authorization required Genetic testing and full clinical examination ABNORMAL ALLELES consultation 81182 ATXN8OS GEN DETC ABNET 81182 ATXN8OS GEN DETC EVALISEN Author required genetic testing and full clinical examination ABNOR ALLELES counseling 81183 ATXN10 GENE DETC ABNOR ALLEL ATXN10 GEN ANALYSIS EVAL DETC Authorization required Genetic testing and full clinical examination ABNORMAL ALLELES counseling 81184 CACNA1A GEN DETC ABNOR ALLEL CACNALYS authorization Genetics required CACNALYS authorization EVAL DANALYS authorization Examination ABNORM ALL ELES counseling 81185 CACNA1A GEN FULL GENE SEQ CACNA1A GENE ANALYSIS Required FULL GENE Authorization Genetic testing and full clinical examination SEQUENCE consultation 81186 CACNA1A GENE KNOWN FAMILY VRNT CACNA1A GENE ANALYSIS KNOWN Authorization required genetic testing and full clinical DE1CNI 8 FUL clinical DE1 CN 8 TC ABNOR ALLELE CNBP GENE ANALYSIS EVAL DETE CT Approval required genetic testing and full clinical examination ABNORMAL ALLELES consultation 81188 CSTB GENE DETC ABNOR ALLELE CSTB GENE ANALYSIS EVAL DETECT Authorization Required genetic testing and full clinical examination ABNORMAL ALLELES consultation 81189 CSTB GENE ANALYSIS GENEFULL Author requires genetic testing and full clinical examination SEQUENCE consultation 81190 CSTB GENE KNOWN FAMILY VRNT CSTB GENE ANALYSIS KNOWN FAMILY Authorization required Genetic testing and full clinical examination VARIANT consultation 81200 ASPA GENE ANALYSIS GENE ASPA Full genetic examination 81 01 APC GEN FULL SEQUENCE APC GENE ANALYSIS FULL Gene authorization required Genetic test and full clinical examination SEQUENCE consultation 81202 APC GEN FULL SEQUENCE FAM VARIANTS APC GENE ANALYSIS KNOWN FAMILY Authorization Genetic testing and full clinical examination VARIANT consultation required 81203 APC GEN authorization GENE Tick testing and full clinical examination required DUPLICATION/DELETION VARIANT consultation 81204 AR GENE CHARACTER ALLELES AR GENE ANALYSIS CHARACTERIZATION Authorization required Genetic testing and full clinical examination review ALLELS counseling center

81205 BCKDHB GENE BCKDHB GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANT consultation 81206 BCR/ABL1 GENE MAJOR BP BCR/ABL1 MAJOR BREAKPNT Authorization required Genetic testing and full clinical testing QUANTITIVE/BCRATIVE/70 ABL1 GENE MINOR BP BCR/ ABL1 MIN OR BREAKPNT - authorization required Genetic testing and full clinical examination QUALITATIVE/QUANTITATIVE counseling 81208 BCR/ABL1 GENE OTHER BP BCR/ABL1 OTHER BREAKPNT authorization required Genetic testing and full clinical examination QUALITATIVE/QUANTITATIVE GENE COLVITATIVE/QUANTITATIVE BLM81 QUANTITATIVE 2281DEL6IN S7 Approval required Genetic testing and full clinical review VARIANT consultation 81210 BRAF GENE BRAF GENE ANALYSIS V600 VARIANT(S) Authorization required Genetic testing and full clinical review consultation 81212 BRCA1&2 185&5385&6174 VRNT required genetic testing 128 BRCA1 BRCA1 authorization Full clinical review Review 5385INSC 6 174DELT consultation 81215 BRCA1 GENE KNOWN FAMILY VRNT BRCA1 GENE ANALYSIS KNOWN Authorization required Genetic test and full clinical examination FAMILY VARIANT Counseling 81216 BRCA2 GEN FULL SEQ ALYS BRCA2 GENE ANALYSIS FULL SEQUENCE Authorization required C18 BRClinical examination and 17 Full BRCANIS testing and 17 NOW FAMILY VRNT BRCA2 GENE ANALYSIS KNOWN Authorization Re required genetic testing and full clinical examination FAMILY VARIANT consultation 81218 GEN CEBPA GENE ANALYSIS CEBPA FULL SEQUENCE GENE ANALYSIS CEBPA FULL GENE Authorization Genetic testing and full clinical examination required SEQUENCE counseling 81219 GEN CALR COMPLETE GENE ANALYSIS SEQUENCE CEBPA FULL GENE Authorization required Genetic testing and full clinical examination SEQUENCE no. seling 81219 CALR GENE COM VARIANA authorization CALR GENE COM VARIANA is required. linical Review VARIANTS IN EXON 9 consultation 81220 CFTR GENE COM VARIANTS CFTR GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANTS consultation 81221 CFTR GENE KNOWN FAM VARIANTS CFTR GENE ANALYSIS REQUIRED Genetic Fully known Fully CFTR GENE KN OWN ANALYSIS OF CFTR GENE REQUIRED Genetic KNOW sales 81222 CFTR GENE DUP/SPLIT VARIANT CFTR GENE ANALYSIS Authorization required Genetic testing and full clinical examination DUPLICATION/DELETION VARIANT consulting 81223 CFTR GENE ANALYSIS CFTR GENE FULL SEQUENCE CFTR GENE ANALYSIS FULL GENE Authorization required Genetic testing and full clinical examination GENE ANALYSIS SEQUENCES 8 GENE ANALYSIS SERVICES 81224 GEN ANALYSIS Guidelines 81223 ER INTRON 8 POLY-T Approval required Genetic testing and full clinical examination ANALYSIS consultation 81225 CYP2C19 GENE COM VARIANTS CYP2C19 GENE ANALYSIS COMMON Approval required Genetic testing and full clinical examination VARIANT consultation 81226 GENE CYPCOMCY P6D Authorization required Genetic testing and full clinical examination VARIANT consultation 81227 CYP2C9 GENE COM VARIANT CYP2C9 GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANT consultation 81228 CYTOGEN MICRARRAY COPY NMBR CYTOGENOM CONST MICROARRAY Authorization required Genetic testing and full clinical examination COPYTOGEN MICRARRAY COPYTO 22 COPY NUMBER12 9 PY NO&SNP CYTOGENOM CONST MICROARRAY Y Authorization required Genetic testing and full clinical examination COPY NUMBER&SNP VAR consultation 81230 CYP3A4 GENE COMMON VARIANTS CYP3A4 GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANTS consultation 81231 CYP3A5 RECOMMENDATION JOINT Author 5 row genetic testing and full clinical examination VARIANT ko unseling 81232 DPYD GEN COMMON VARIANT DYPD GENANA LIGHT COMMON authorization required Genetic testing and full clinical examination VARIANT consultation 81233 BTK GEN COMMON VARIANT BTK GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANT GENE ANALYSIS 81233 GENE COMMON VARIANT BTK GENE ANALYSIS COMMON authorization required Gene testing and full clinical examination VARIANT GENE ANALYSIS 84 EVAL DETECT- authorization required Genetic testing and full clinical examination consultation ABNORMAL ALLELES 81235 EGFR GENE COM VARIANTS EGFR GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANT consultation 81236 EZH2 GENE FULL GENE SEQUENCE GENE SEQU ENCE GENE QUESTION OVERVIEW GENE EXAMINATION GENE SEQUENCE i GENE GEN. SEQUENCE consultation 81237 EZH2 GENE COMMON VARIANTS EZH2 GENE ANALYSIS COMMON authorization required Genetic test and full clinical examination VARIANT consultation 81238 F9 FULL GENE SEQUENCE F9 FULL GENE SEQUENCE Approval required Genetic test and full clinical examination consultation 81239 GEN GENE SEQUENCE approval 81 239 PAK GENE SEQUENCE OF GENE and Gene Gene Sequence Gene Gene Test Full Clinical Screening Allele Characterization Advice 81240 F2 GENE F2 Gene Analysis 20210G> Variant requires Authorization Genetic Testing and Full Clinical Screening Advice 81241 F5 Gene F5 Coagulation Factor V Anal Authorization REPORT F4CCAN 81241 GENE F5 COAGULATION FACTOR V ANAL Required permission. ENE-ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANT counseling 81243 FMR1 GENE DETECTION FMR1 ANALYSIS DETECTION SCORE Authorization required Genetic testing and full clinical examination ABNORMAL ALLELES counseling 81244 ALLELES FMR1 GENE KARK GENE ANALYSIS FMR1 Full clinical test CHANNELS Full clinical test LELES ADVICE CHANNELS 81245 FLT3 GENE FLT3 GEN ANALYSIS Internal authorization required genetic test and full clinical examination of tandem variants DUP Counseling 81246 FLT3 gene analysis flt3 genes tyrosine kinarization requires genetic test and complete clinical genes variant 82 genes 82 genes VARIANTS counseling 81248 G6PD KNOWN FAMILY VARIANT G6PD GENE ANALYSIS KNOWN FAMILY Authorization required Genetic testing and full clinical examination VARIANTS consultation 81249 G6PD FULL GENE SEQUENCE Author GENE SEQUENCE Full GENE SEQUENCE GLY6PD Clinical examination SEQUENCE consultation 8 1250 GENE G6PC GENE ANALYSIS G6PC COMMON authorization required Genetic testing and full clinical examination VARIANTS consultation 81251 GBA GENE GBA GLUCOSIDASE/BETA/ACID ANAL Approval required genetic testing and full clinical examination COMM VARIANT consultation 81252 GENE GENE GENE GENE GENE GENE GENE GENE GENE GENE GENE GENE GENE GENE Approval required Genetic testing and full clinical examination SEQUENCE consultation 81253 G JB2 GENE KNOWN FAM VARIANTS GJB2 GENE ANALYSIS KNOWN FAMILY Authorization required Genetic testing and full clinical examination VARIANTS consultation 81254 GJB6 GEN GEN COM VARIANTS Complete gene test COM VARIANTS 6 Clinical examination VARIANTS consultation 81255 HEXA GENE HEXA GENE ANALYSIS OFTEN authorization required Genetic testing and full clinical examination VARIANTS consultation 81256 HFE GENE HFE HEMOCHROMATOSIS GENE ANAL Authorization required Genetic testing and full clinical examination COMMON VARIANTS consultation 81257 HBA1/HBAHBALY GEN ANAL authorization Full authorization Genetic testing and full clinical examination 81257 HBA1/HBAHBALY GEN ANAL authorization 81257 HBA 1/ HBAHBALY GEN ANAL authorization Genetic testing and full clinical examination linear view DELETION/ VARIANT consultation 81258 HBA1/HBA2 GEN FAM VRNT HBA1/HBA2 GENE ANALYSIS KNOWN Authorization required Genetic testing and full clinical examination FAMILY VARIANT consultation 81259 HBA1/HBA2 FULL GENE sequence GEN sequence GEN sequence HFU ing and full Clinical examination SEQUENCE advice

81260 GENE IKBKAP GENE ANALYSIS IKBKAP COMMON authorization required Genetic testing and full clinical examination VARIANT consultation 81261 IGH GENE REARRANGE AMP METH[email protected]RARANGE ABNORMAL CLONAL Authorization required Genetic testing and full clinical examination POP AMPLIFIED consultation 81262 IGH GENE REARRANG DIR PROBE[email protected]RARANGE ABNORMAL CLONAL Approval required Genetic testing and full clinical examination POP DIRECT PROBE consultation 81263 IGH VARI REGIONAL MUTATION[email protected]VARIABLE REGION SOMATIC authorization required Genetic testing and full clinical examination MUTATION ANALYSIS consultation 81264 IGK REARRANGEABN CLONAL POP[email protected]GENE ARRANGEMENT DETECT Authorization required Genetic testing and full clinical examination ABNORMAL CLONAL POP consultation 81265 STR MARKERS ANAL SAMPLE COMPARISON ANAL STR MARKERS Authorization required Genetic testing and full clinical examination PATIENT&COMP SPECTRAN Guidelines S8126 SPECTRAN SPECTRAN S8 MARKERS EA authorization required Genetic testing and full clinical examination ADDL SAMPLE consultation 81267 CHIMERISM ANAL WITHOUT CELL CHOICE CHIMERISM W/COMP TO BASELINE authorization required Genetic testing and full clinical examination W/O CELL CHOICE consultation 81268 CHIMERISM ANAL CHIMERISM W/CELL CHOICE/CELL CHOICE authorization TOCHIMERISM CHOICE/CELL WCOMRED and full clinical examination W /SELECT CELL EA consultation 81269 HBA1/HBA2 GENE DUP/DEL VRNTS HBA1/HBA2 GENE ANALYSIS DUP/DEL Authorization required Genetic testing and full clinical examination VARIANTS consultation 81270 JAK2 GENE JAKHENE Author P. Genetic test P. 617IS Author Gentest. i Complete clinical examination VARIANT consultation 81271 HTT GENE DETC ABNOR ALLELES HTT GENE ANALYSE DETECT Authorization required Genetic testing and complete clinical examination ABNORMAL ALLELES consultation 81272 KIT GENE TARGET SEQ ANALYSIS KIT Complete examination SEQ ANALYSIS KIT GENE ANALYSIS Complete examination KIT GENE ANALYSIS ANALYSIS consultation 81273 KIT GENE ANALYSIS D816 VARIANT KIT GENE ANALYSIS D816 VARIANT(S) Approval required Genetic testing and full clinical examination consultation 81274 HTT GENE CHARAC ALLELES HTT GENE ANALYSIS Approval required Genetic testing and full clinical examination CHARACTER 81274 HTT GENE CHARAC ALLELES EXON 2 GENE ANALYSIS KRAS VARIANT IN Authorization required Genetic testing and full clinical examination EXON 2 consultation 81276 KRAS GENE ADDL VARIANTS KRAS GENE ANALYSIS ADDITIONAL Authorization required Genetic testing and full clinical examination VARIANT(ER) consultation 81277 CYTOGENOMIC NEO CYTOGENOMIC NEO authorization Genetic testing NEOPL ing and Full Clinical l View MICROARRAY ANALYSIS consultation 81283 IFNL3 GENE IFNL3 GENE ANALYSIS RS12979860 Authorization required Genetic testing and full clinical examination VARIANT consultation 81284 FXN GENE DETC ABNOR ALLELE FXN GENE ANALYSIS authorization ABNOR ALLELE Full GENE ANALYSIS authorization ABNOR ALL ELES Full ANALYSIS ANALYSIS EVAL DÖVEL and unseling 81285 FXN GENE CHARAC ALLELES FXN GENE ANALYSIS Authorization Required Genetic testing and full clinical examination ALLELE CHARACTERIZATION consultation 81286 FXN GENE FULL GENE SEQUENCE ANALYSIS FXN GENE Full authorization required GENE Genetic test and full clinical examination SEQUENCE consultation 81287 ALLMMGMT GENERAL Prerequisites and full clinical examination METHYLATION ANALYSIS consultation 81288 MLH1 GENE MLH1 GEN ANALYSIS PROMOTER Authorization required Genetic testing and full clinical examination METHYLATION ANALYSIS consultation 81289 FXN GENE KNOWN FAMILY VARIANT FXN GENE ANALYSIS Genetic Knowledge Study Full Knowledge Study Full Knowledge Study Full Knowledge Study FAMILY. ing 81290 MCOLN1 GEN MCOLN1 MUCOLIPIN1 GENE ANALYSIS Requires authorization Genetic testing and full clinical examination COMMON VARIANTS consultation 81291 MTHFR GEN MTHFR GENE ANALYSIS COMMON authorization required Genetic testing and full clinical examination VARIANTS consultation 81292 MLH1 GEN FULL SEQ MLH1 GEN ANALYSIS Authorization required Urgent consultation 81293 MLH 1 GENE KNOWN VARIANTS MLH1 GENE ANALYSIS KNOWN Authorization required Retesting and full clinical examination FAMILY VARIANTS consultation 81294 MLH1 GENE DUP/DELETE VARIANT MLH1 GENE ANALYSIS Authorization required Genetic testing and full clinical examination MFU 9 VARIANT DUPLICATION 9 LL SEQ MSH2 GENE ANALYSIS FULL SEQUENCE Required is authorization Genetic testing and full clinical examination ANALYSIS advice 81296 KNOWN MSH2 GENE VARIANTS ANALYSIS MSH2 GENE KNOWN Authorization required Genetic testing and full clinical examination advice VARIANT FAMILY 81297 MSH2 GENE DUP/DELETION Author Genetic testing and full clinical examination Full clinical examination DUPLICATION/DELETION VARIANT advice 81298 MSH6 GENE FULL SEQ MSH6 GENE ANALYSIS FULL SEQUENCE Authorization required Genetic testing and full clinical examination ANALYSIS consultation 81299 MSH6 GENE KNOWN VARIANTS MSH6 GENE ANALYSIS requires full CNOWIN authorization Full CNOWIN authorization and full CNOWIN authorization 81300 MSH6 GENE DUP/DELETE VA RIANT MSH6 GENE ANALYSIS Authorization required Gentest and full clinical examination DUPLICATION/DELETION VARIA consultation 81301 MICROSATELITE INSTABILITY MICROSATELIT INSTAB ANAL Authorization required Retesting and full clinical examination MISMATCH REPARATION DEF MELL SEQUENCE approval required Genetic testing and full clinical examination counseling 81303 MECP2 GENE KNOWN VARIANT MECP2 GENE ANALYSIS KNOWN Authorization required Genetic testing and full clinical examination FAMILY VARIANT consultation 81304 MECP2 GENE DUP/DELETE MECP2 VARIANT RE-ANALYSIS Authorization required/ RE-ANALYSIS PL RE-ANALYSIS OR OR Counseling 81305 MYD88 GENE P.LEU265PRO VRNT MYD88 RE-ANALYSIS P.LEU265 Authorization required ed. Genetic Testing and Full Clinical Screening (L265P) VARIANT Counseling 81306 NUDT15 GENE COMMON VARIANTS NUDT15 GENE ANALYSIS COMMON Approval Required 81306 Full Gene Testing 8B20 Review 81306 GENES GENE FULL GEN SEQ PALB2 GENE ANALYSIS FULL GENE Approval Required Genetic Testing and Full Clinical Screening SEQ UENCE Counseling 81308 PALB2 GENE KNOWN FAMILY VRNT PALB2 GENE ANALYSIS KNOWN Authorization required Genetic testing and full clinical examination FAMILY VARIANT consultation 81309 TRGET PIK3 TEGNE GENE PIK3SENE Authorization Required genetic testing and full clinical examination SEQUENCE ANALYSIS consultation 81310 NPM1 GENE NPM1 ANAL NUCLEOPHOSMIN GENE Authorization required Genetic testing and full clinical examination EXON 12 VARIANT consultation 81311 NRAS GENE VARIANT EXON 2&3 NRAS GENE ANALYSIS FULL GENE ANALYSIS ON NRAS GENE ANALYSIS On. 2&3 81312 PABPN1 GENDETC ABNOR ALLEL PABPN1 GENE ANALYSIS EVAL DETC Approval required Genetic test and full clinical examination ABNORMAL ALLELES consultation 81313 PCA3/KLK3 ANTIGEN PCA3/KLK3 PROSTATE SPECIFIC approval required Genetic test and full clinical examination ANTIGEN RATIO consultation 813 GANAGENE GANA PDRAFRAGETNE GANALY red Pathology and Lab Full clinical review SEQUENCE ANALYSIS 81315 PML/RARALPHA COME BREAD POINT PML/RARALPHA COMMON authorization required Genetic testing and full clinical review BREAKPOINT QUAL/QUANT counseling 81316 PML/RARALPHA 1 BREAKPOINT PML/RARALPHA REQUEST PML/RABREAKPOINT authorization/RARALPHA authorization / RABREAKPOINT authorization and reassessment/ RABREAKPHA SINGLE consultation

81317 PMS2 GENE FULL SEQ ANALYSIS PMS2 GENE FULL SEQUENCE ANALYSIS Authorization required Genetic testing and full clinical examination consultation 81318 PMS2 KNOWN FAMILY VARIANTS PMS2 GENE ANALYSIS KNOWN GENE ANALYSIS REQUIRED KNOWN GENE ANALYSIS and FULL CLINICAL EXAMINATION 8 1319 PMS2 GENE DUP/DELETE VARIANTS PMS2 GENE ANALYSIS Authorization required genetic testing and full clinical examination counseling DUPLICATION/DELETION VARIANTS 81320 PLCG2 GENE COMMON VARIANT PLCG2 GENE ANALYSIS COMMON Authorization required Genetic testing and full clinical examination VARIANT counseling PTEN GANA 81321 GENE 81321 NCE approval required genetic testing and full clinical examination ANALYSIS ko unseling 81322 PTEN GENE KNOWN FAM VARIANT GENE ANALYSIS PTEN KNOWN FAMILY Authorization required Genetic testing and full clinical examination VARIANT consultation 81323 PTEN GENE DUP/DELETED VARIANT GENE ANALYSIS PTEN REVISION ANALYSIS full GENE ANALYSIS AND VARIANT ANALYSIS consultation 81324 PMP22 GENE D UP /DELETE PMP22 GENE ANAL Required authorization Genetic testing and full clinical examination DUPLICATION/DELETION ANALYSIS consultation 81325 PMP22 GENE FULL SEQUENCE ANALYSIS PMP22 GENE FULL SEQUENCE Authorization required Genetic screening and full clinical examination ANA 23 GENE ANALYSIS and full clinical sequence PMP22 GENE ANALYSIS FULL SEQUENCE FAM VARIANT PMP22 GENE ANALYSIS SIS KNOWN Authorization required Genetic testing and full clinical examination FAMILY VARIANT consultation 81327 SEPT9 GENE PRMTR MTHYLTN ALYS SEPT9 GENE PROMOTOR METHYLATION Authorization required Genetic testing and full clinical examination ANALYSIS consultation 81328 SLCO1B1 GENE PROMOTOR COMCO 1BANT COM 1 GANALYSIS COMM. Genetic Testing and Full Clinical Screening VARIANT Consultation 81329 SMN1 GENE DOS/DELETION ALYS SMN1 GENE ANALYSIS DOSAGE/DELETE Authorization Required Genetic Testing and Full Clinical Screening ALYS W/SMN2 ALYS Consultation 81330 SMPD1 GENE COMMON VARIANTS SMPD1 GENE ANALYSIS TOGETHER Authorization Required S PN1 Genetic Screening and Full Clin8NR -study 1 /UBE3A GENE SNRPN /UBE3A METHYLATION ANALYSIS Approval required Genetic testing and full clinical review consultation 81332 SERPINA1 GENE SERPINA1 GENE ANALYSIS COMMON Approval required Genetic testing and full clinical review VARIANT consultation 81333 TGFBI GENE RECOMMENDATION Authorization TGFBI G ENECOM tic testing and Full Clinical review VARIANT consultation 81334 RUNX1 GENE TARGET SEQ ALYS RUNX1 GENE ANALYSIS TARGET Approval required Genetic testing and full clinical review SEQUENCE ANALYSIS consultation 81335 TPMT GENE COM VARIANTS TPMT GENE ANALYSIS COMMON authorization required 81335 TPMT GENE COM VA RIANTS TPMT ANALYSIS GENE COMMON authorization required 86 Full CANTI 36 Genetic test 1 GENE FULL GEN SEQUENCE SMN1 GENE ANALYSIS FULL GENE Authorization required Genetic testing and full clinical examination SEQUENCE consultation 81337 SMN1 GENE KNOWN FAMILY SEQ VRNT SMN1 GENE ANALYSIS KNOWN Authorization Required Genetic testing and full clinical examination FAMILY SEQ VARIANT consultation 81340[email protected]THE WORK OF THE GENOME IS STRENGTHENED[email protected]REQUEST ANAL Authorization required Genetic testing and full clinical examination Counseling AMPLIFICATION METHODS 81341[email protected]REPROCESS DIRPROBE[email protected]ANAL MODIFICATION DIRECT Permission required Genetic testing and full clinical examination TRIAL METHODOLOGY consultation 81342 TRG GENE MODIFICATION ANAL[email protected]GENOME SEQUENCE Authorization required Genetic testing and full clinical examination ANALYSIS consultation 81343 PPP2R2B GEN DETC ABNOR ALLEL PPP2R2B GEN ANALYSIS EVAL DETC authorization required Genetic testing and full clinical examination ABNORMAL ALLELES ABNORMAL ALLELES DETCANAL GENE ANALYSIS ABNOR 1344 T-ANALYSIS SIS ABNORMAL ALLELES DETC ER EVAL DETECT - authorization required Genetic testing and full clinical examination consultation ABNORMAL ALLELES 81345 TERT GENE TARGET SEQ ALYST TERT GENE ANALYSIS TARGET Authorization required genetic testing and full clinical examination SEQUENCE ANALYSIS consultation 81346 TYMS GENE COM ANALYSIS COM VARIANTE TYMS Complete clinical examination TYMS Genetic examination GCOM VARI ANALYSIS MRAVA TYMS VARIANT REQUEST consultation 81350 UGT1A1 GENE COMMON VARIANTS UGT1A1 GENE ANALYSIS COMMON Approval required Genetic testing and full clinical examination VARIANT consultation 81355 VKORC1 GENE VKORC1 GENE ANALYSIS COMMON Approval required Genetic testing and full clinical examination VARIANT(S) G813KOMAND HV ARMON 3COMMANT HVARMONI S Approval genetic testing required and advice on full clinical examination 81362 HBB GENE FAMILY VARIANT KNOWN HBB FAMILY VARIANT KNOWN Authorization required Genetic testing and full clinical examination advice 81363 HBB DUP/DEL VARIANT HBB DUPLICATION/DELETION VARIANT Full genetic examination and coquilin BB 81363 FULL GENE SEQUENCE HBB FULL GENE SEQUENCE Authorization required Genetic testing and full clinical examination consultation 81370 HLA I & II TYPING LR HLA CLASS I&II LOW HLA-A -B -C - Authorization required Genetic testing and full clinical examination DRB1/3/4/5&DQB consultation 81371 HLA I & II TYPE VERIFY LR HLA I&LI LOW RESOLUTION HLA-A -B&- Authorization required Genetic testing and full clinical DRB1 consultation 81372 HLA AND TYPING COMPLETED LR HLA CLASS I LOW RESOLUTION TYPING Authorization required Genetic testing and full clinical I13P 8 LOCUS LR HLA CLASSES AND TYPING LOW SOLUTION Approval required Genetic screening and full clinical exam ONE LOCUS EACH CONSULTATION 81374 HLA AND TYPING 1 ANTIGEN LR HLA AND LOW SOLUTION SINGLE ANTIGEN Approval required Genetic screening and full HLA IN DEVELOPMENT II18 EKW. AG EQUIV LR HLA II LOW RESOLUTION HLA- Approval required Genetic testing and full clinical examination DRB1/3/4/5 I -DQB1 consultation 81376 HLA II TYPING 1 LOCUS LR HLA CLASS II TYPING LOW RESOLUTION Approval required LOClinical examination and full consultation 81377 HLA II TYPE 1 AG EQUIV LR HLA II LOW SOLUTION ET ANTIGEN Authorization required Genetic testing and full clinical examination EQUIVALENT EA consultation 81378 HLA I & II TYPING HR HLA I&II HIGH CONTAMINATION HLAC Authorization Request - Gene Authorization Request - Genetic Authorization Request - Clinical review I - DRB1 Counseling 81379 HLA AND TYPING FULL HR HLA CLASS AND HIGH RESOLUTION TYPING Approval required Genetic testing and full clinical examination COMPLETE instruction 81380 HLA AND TYPING 1 LOCUS HRSO CLASS Complete HR CLASS Authorization and resubmission CLASS. Report ONE LOCUS EA Advisory 81381 HLA I TYPING 1 ALLELE HR HLA I HIGH RESOLUTION TYPING 1 Approval required genetic testing and full clinical examination ALLELE/ALLELE GRP advisory 81382 HLA II TYPING 1 LOC HRSOPPING CLASS Full HRSO CLASS Full KR HLA CLASS Author on View ONE LOCUS EA consultation 81383 HLA II TYPING 1 ALLELE HR HLA II HIGH RESOLUTION 1 Authorization required Genetic testing and full clinical examination Consultation ALLELES/ALLELE GROUPS 81400 MOPATH PROCEDURE LEVEL 1 MOLECULAR GENE PATHOLOGY Full GENE PATHOLOGY LECULAR PATHOLOGY authorization and co-audit. supplier 81401 MOPATH PROCEDURE LEVEL 2 MOLECULAR PATHOLOGY PROCEDURE Authorization required Genetic testing and full clinical examination LEVEL 2 consultation 81402 MOPATH PROCEDURES LEVEL 3 MOLECULAR PATHOLOGY PROCEDURE Authorization required Genetic testing and full clinical examination LEVEL 81 PROCUEL 3 MOLECULAR PATHOLOGY L LEVEL 3 MO04 LAR-PATHOLOGY PROCEDURE Authorization required Genetic testing and full clinical examination LEVEL 4 counseling

See Also

Clarification of CPT code 99153

81404 MOPATH PROCEDURE LEVEL 5 MOLECULAR PATHOLOGY PROCEDURE Approval required genetic testing and full clinical examination LEVEL 5 Counseling 81405 MOPATH PROCEDURE LEVEL 6 MOLECULAR PATHOLOGY PROCEDURE Approval required MOPATH clinical examination and full examination 4 RE LEVEL 7 MOLECULAR PATHOLOGY PROCEDURE Genetic testing approval and full examination required clinical review LEVEL 7 Consultation 81407 MOPATH LEVEL 8 MOLECULAR PATHOLOGY PROCEDURE Approval required Genetic testing and full clinical review LEVEL 8 Consultation 81408 MOPATH LEVEL 9 MOLECULAR PATHOLOGY PROCEDURE Approval and full clinical review Full clinical review Opening LEVEL 8 81410 AORTIC DYSFUNCTION/DILATION AORTIC DYSFUNCTION KTION/DILATION Authorization required Genetic testing and full clinical examination GENOME SEQ ANALYSIS consultation 81411 AORTIC DYSFUNCTION/DILATION AORTIC DYSFUNCTION/DILATION Authorization required Genetic testing and full clinical examination DUP/DEL ANALYSIS 814 DEL ANALYSIS 814AZ1 ANALYSIS 814AZ1 ANALYSIS KENAZI JEWI SH ASSOC DSRDRS GEN authorization required Genetic testing and full clinical examination SEQ ANAL 9 GEN consultation 81413 CAR ION CHNNLPATH INC 10 GNS CAR ION CHNNLPATH GENOMIC SEQ authorization required Genetic testing and full clinical examination ALYS INC 10 GNS consultation 81414 CAR ION CHNNLPATH CHNDELPATH CAR ION CHNDEL authorization required ALYS Genetic testing and full clinical review PANEL 2 GENER consultation 81415 EXOME SEQUENCE ANALYSIS EXOME SEQUENCE ANALYSIS Authorization required Genetic testing and full clinical review consultation 81416 EXOME SEQUENCE ANALYSIS EXOME SEQUENCE ANALYSIS EXOME Genetic testing and full clinical review consultation ical Review COMPARATOR EX OME consultation 81417 EXOME REVIEW EXOME ASSESSMENT REASSESSMENT PREVIOIDY Approval required genetic testing and full clinical examination EXOME SEQ CONSULTATION OBTAINED 81420 FETAL CHRMMOML ANEUPLOIDIA FETAL CHROMOSOMAL ANEUPLOIDY Approval required genetic testing and full clinical examination 81420 FETAL CHRMOML ANEUPLOIDIA FETAL CHROMOSOMAL ANEUPLOIDIA L MICRO DELTJ FETAL CHROMOSOMAL ANEUPLOIDIA Approval required Genetic testing and full clinical review GENOMIC SEQ ANALYSIS consultation 81425 GENOME SEQUENCE ANALYSIS GENOME SEQUENCE ANALYSIS Authorization required Genetic testing and full clinical review consultation 81426 GENOME SEQUENCE ANALYSIS GENOME COMPENSATION ANALYSIS GENOME COMPENSATION REVIEW GENOMIC COMPENSATION REVIEW POSSIBLE GENOME ME consultation 81427 GENOM REASSESSMENT GENOM REASSESSMENT PREC approval required Genetic Testing and Full Clinical Screening OBTAINED GENOME SEQ Counseling 81430 HEARING LOSS ANALYSIS Sequences GENOME SEQUENCE HEARING LOSS Authorization Required Genetic Testing and Full Clinical Screening ANALYSIS ANALYSIS 34 HEARING LOSS 60 HEARING LOSS 60 EAR LOSS DUP/DEL ANALYSIS Authorization Required Genetic Testing and Full Clinical Screening Counseling 81432 HRDTRY BRST CA-RLATD DSordrs Hereditary Ca-Related Gene Authorization Genetic Testing and Complete Clinical Review SEQ Analysis 10 gene Counseling 81433 BrST 81433333333333333331 Required Authorization Genetic Testing and Complete Clinical Review DUP/ RY Net Performance hereditary net HAND DSRDRS GEN SEQ Authorization required Genetic testing and full clinical examination ANALYZE 15 GEN counseling 81435 CADITARY COLDIRS REQUEST HERE COLDITARY COLDITARY Genetic testing and full clinical examination SEQ ANALYSIS 10 GEN counseling 81436 HEREDITARY COLION CA DSORDRS HEREDITARY COLDIRS CA DSRDRS Authorization required Genetic testing and full clinical examination clinical examination DUP/DEL ANALYSIS 5 GEN consultation 81437 HEREDITY NURONDCRN TUM DSRDRS Authorization TUM NUDSRDRN HERDET Full DSKRIDTRY COLON and full clinical examination GEN SEQ ANAL 6 GEN consultation 81438 HEREDITY NURONDCRN TUM DSRDRS HEREDITY NURONDCRN TUM DSRDRS Authorization Re required genetic testing and full clinical examination DUP/DEL ANALYSIS consultation 81439 HRDTRY CARDMYPY GENPANEL HEREDITARY CARDIOMYOPALY HEREDITARY CHARDIOMYOPALY RECORDING 5 GEN consultation 81440 MITOCHONDRIAL GENE NUCLEAR MITOCHONDRIAL 100 GEN authorization required Genetic testing and full clinical examination GENOMIC SEQ consultation 81442 NOONAN SPECTRUM DISORDERS NOONAN SPECTRUM DISORDERS GENE authorization required Genetic testing and full clinical review SEQ ANALYSIS 12 GEN -Council geevnetic inner 8144 Gene-counsel geevnetic144 Tegers 8144 Mandatory genetic testing and full clinical examination succeeded state council 81445 Targeted genomic SEQ analyzes gene seq analyzes Solid organ approval required Genetic testing and full clinical examination Neoplasm 5-50 Gen Advisory DIVERSION HERE Genetic testing and full clinical examination GEN SEQ PNL consultation 81450 TARGETED GENOMIC SEQ ANALYZER GEN SEQ ANALYZER HEMATOLYMPHOID Permission required Genetic testing and full clinical examination NEO 5-50 GENE consultation 81455 TARGETED GENOMIC SEQ ANALYZER GEN SEQ ANALYZER SOL Permission required NEO 5 -5 0 GENE ANALYSIS 81455 TARGETED GENOME SEQ ANALYZES GENE SEQ ANALYZES SOL Approval required NEO 5-50 CLINICAL EXAMINATION and COORGEL GEN SEQ ANALYSIS 5 supplier 81460 WHOLE MITOCHONDRIAL GENOME WHOLE MITOCHONDRIAL GENOME Approval required Genetic testing and full clinical review consultation 81465 WHOLE MITOCHONDRIAL GENOME OM Authorization required Genetic testing and full clinical examination ANALYSIS PANEL ANALYSIS PANEL 81465 INTERNET VIA X-LINK1470 UAL DBLT GENOMIC authorization required Genetic testing and full clinical examination SEQ ANALYSIS consultation 81471 X-LINKED INTELLECTUAL DBLT X-LINKED INTELLECTUAL DBLT DUP/DEL Authorization required Genetic testing and full clinical examination G ENE ANALYSIS consultation 81479 UNINVITED MOLECULAR PATHOLOGY UNINVITED MOLECULAR PATHOLOGY NOT REQUIRED Full MOLECULAR authorization required and required. DURE consultation 81490 AUTOIMMUNE RHEUMATOID ARTHRITIS AUTOIMMUNE RHEUMATOID ARTHRITIS Authorization required Genetic testing and full clinical examination ANALYSIS 12 BIOMRKRS consultation 81493 ARTERY DISEASE CARBON MRNA MRNA GENE BRAIN ARTERIA Authorization required Genetic testing and full clinical examination EXPRESS 000 EXPRESS 2 GEON8O 000 PROTEIN ONCO (OVARY) BIOCHEMICAL TESTING - authorization required Genetic testing and full clinical examination Consultation with TWO PROTEINS 81503 ONCO (OVAR) BIOCHEMICAL TEST FIVE PROTEINS ONCO (OVARY) Permission required Genetic testing and full clinical examination Consultation with FIVE PROTEINS 81504 TINORIGISSUE ONCOLOGIN TINNOIG ISSUE ONCOLOGIN ILAR approval required Genetic test ing and full clinical examination SCOR-ALGORITHM consultation 81506 ENDO ANALYSIS SEVEN ANAL ENDOCRINOLOGY BIOCHEMICAL TEST Authorization required Genetic testing and full clinical examination SEVEN ANAL consultation 81507 FETAL ANEUPLOIDIA TRISOM 18 FETAL ANEUPLOIDIA TRISOM AKVIVLO18 18 Genetic RISK 3 test ing and full clinical examination ANALYSIS TRISOM RISK consulting 8150 8 FTL CGEN ABNOR TWO PROTEINS FETAL ASSOCIATED ABNOR ANALYSIS TWO Approval required Genetic testing and full clinical examination PROTEIN consulting 81509 FTL CGEN ABNOR 3 PROTEINS FETAL ASSOCIATED ABNOR ANALYSIS 3 Approval required genetic testing and full clinical examination FTL CGEN ABNOR 3 protein AL FOSTER TESTING RELATED ABNORS Authorization required Genetic testing and full clinical examination TRE ANAL consultation 81511 FTL CGEN ABNOR FIRE ANAL FOSTER CONFLICT ABNOR ASSAY Authorization required Genetic testing and full clinical examination FIRE ANAL consultation 81512 FTL ANAL consultation 81512 FTLIV CONGENITAL ABNOR FFETAL ANAL INSTRUCTIONS ABNOR FFETAL FTALIZATION CONGENITAL ABNOR FFE tic test and full clinical examination ANAL advice

81518 ONC BRST MRNA 11 GENES ONCOLOGY MRNA BREAST GEN Authorization required Genetic testing and full clinical examination EXPRESSION 11 GENES consultation 81519 ONCOLOGY MRNA BREAST ONCOLOGY MRNA BREAST GEN Authorization required CESION 20 GENES 8 Complete examination and 52 GENES 8 NC MRNA BREAST 58 GENES ON MRNA BREAST GENE XPRSN PRFL Authorization Genetic testing and full clinical examination required HYBRD 58 GENES Counseling 81521 ONC BREAST MRNA 70 GENER ONC BREAST MRNA MICRORA GENE Authorization Genetic testing and full clinical examination required XPRSN PRFL 70 GENES BRENES2 MRNA Counseling 8152 BRENES2 AST MRNA GEN XPRS N Authorization required Genetic Testing and complete clinical examination PRFL 12 GENES consultation 81525 ONCOLOGY MRNA COLON ONCOLOGY MRNA GENES COLON Permission required for genetic testing and complete clinical examination EXPRESSION 12 GENES consultation 81528 ONCOLOGY COLON NO. Genetic testing and QUAN 10 DNA MARKERS consultation 81535 ONCOLOGY GYNECOLOGIC ONCOLOGY GINE LIVE TUM CELL Authorization required Genetic testing and full clinical examination CLTR&CHEMO RESP 1st consultation 81536 ONCOLOGY GYNECOLOGIC ONCOLOGY GINE LIVE TUM CELLIN authorization Rough and full GEN CELLIN authorization Revision ing 81538 ONCOLOGY LUNG ONCOLOGY LUNG MS 8-PROTEIN Permission required Genetic test and full clinical examination SIGNATURE consultation 81539 ONCOLOGY PROSTATE PROB SCORE ONCOLOGY PROSTATE BIOCHEMICAL Permission required Genetic test and full clinical examination ANALYSIS 4 PROTEIN consultation 81540 UONCOLOGON ONCOLOGON TINKOLOGY Approval required genetic testing and full clinical examination MRNA 92 GENI consultation 81541 ONC PROSTATE MRNA 46 GENES ONC PRST8 MRNA GENE XPRSN PRFL RT- Authorization required Genetic test and full clinical examination PCR 46 GENES consultation 81542 ONC PROSTATE MRNA 22 CNT GENE ONC PRST8 MRNA test MICRORA Complete CFLlin examination and PR2 GENES consultation 81545 THYROID ONCOLOGY ONCOLOGY thyroid roid gene expression Authorization required Genetic testing and full clinical examination 142 GENES consultation 81551 ONC PROSTATE 3 GENE ONC PRST8 PRMTR METHYLATION PRÄV GENES PC authorization and RFL PC authorization RFL 81552 ONC UVEAL MLNMA MRNA 15 GENE ONC UVEAL MLNMA MRNA GENE authorization required Genetic testing and full clinical examination XPRSN PRFL 15 GENES consultation 81595 CARDIOLOGY HRT TRNSPL MRNA CARDIOLOGY HRT TRNSPL MRNA GENE authorization required Genetic testing and full clinical examination EXPRESS 6NC HRCT 6NC HRCT 20 SIGER NFCT DS CHRNC HCV 6 BIOCHEMICAL ANALYSIS Authorization required Genetic testing and full clinical examination SRM ALG LVR consultation 81599 NON-INVITATION MAAA UNPLUGD MULTIANALYT ASSAY Authorization required Pathology and laboratory Full clinical examination ALGORITHMIC ANALYSIS 82000ONE TESTONES QUATIVETONE BOXETON 82009 ANALYSIS 82009 ANALYSIS 82009 ANALYSIS Required QUATIVETON ANALYSIS 82010 ANALYSIS ACETONE KETONE LEMPERS SERUM QUANTITATIVE No authorization required 82013 AN ACETYLCHOLINESTERASE ANALYSIS ACETYLCHOLINESTERASE ANALYSIS No approval required 82016 ACYLCARNITINES QUAL ACYLCARNITINES QUALITATIVE EACH No Auth Required SPECIMENT 82016 ACYLCARNITINES QUAL ACYLCARNITINES QUALITATIVE EACH No Auth Required SPECIMENT CARNICYL TINES ACH No Auth Required SPECIMENT CARNICYL TINES ACH No Auth Required SPECIMENT 82024 ACTH ADRENOCORTICOTROP IC HORMONE TEST No Auth Required ACTH 82030 ADP & AMP ADENOSINE 5-MONOPHOSPHATE ANALYSIS No Auth Required approval CYCLIC 82040 ANALYSIS OF SERUM ALBUMIN ALBUMIN SERUM PLASMA/WHOLE No authorization required BLOOD 82042 OTHER SOURCE ALBUMIN QUAN EA OTHER SOURCE ALBUMIN ALBUMIN No Authorization required E20 AUT 3 ALBUMIN AUT 4 ITATIVE URINE QUANTITATIVE ALBUMIN No authorization required 82044 UR ALBUMIN SEMIQQUANTITATIVE URINE ALBUMIN SEMIQQUANTITATIVE No authorization required 82045 ALBUMIN ISCHEMIA MODIFIED ALBUMIN ISCHEMIA MODIFIED No authorization required 82075 BREATH ANALYSIS ETHANOL ALCOHOL BREATH ANALYSIS No authorization required A85 ANALYSIS 820 ANALYSIS Authorization required 82088 ALDOSTERONE ANALYSIS ALDOSTERONE ANALYSIS No authorization required 821 03 ALPHA-1-ANTITRYPSIN ALPHA TOTAL -1- ANTITRYPSIN TOTAL No authorization required 82104 ALPHA-1-ANTITRYPSIN PHENOTYPE ALPHA-1-ANTITRYPSIN No approval required 82105 ALPHA-FETOPROTEIN SERUM ALPHA-0FENO ALPHA-6 PROTEIN SERUM ALPHA-0FENO required PROTEIN AMNIOTIC ALPHA-FETOPROTEIN AMNOTIC FLUID No approval required 8 2107 ALPHA-FETOPROTEIN L3 AFP-L3 FRACTION ISOFORM & TOTAL No Approval Required AFP W/RATIO 82108 ALUMINA ANALYSIS ALUMINA ANALYSIS No Approval Required 82120 AMINAL AMINES VQUANALINES LITATIVE No Approval Required 82127 AMINO ACID SINGLE QUALITATIVE AMINO ACID 1 QUALITATIVE EACH No Approval Required SAMPLE 82128 AMINOSY RER HIGHER QUALITY AMINO ACIDS QUALITATIVE No Approval Required. 82135 AMINOLEVULUNIC ACID ANALYSIS AMINOLEVULUNIC ACID DELTA No Approval Required 82136 AMINO ACIDS QUANTITY 2-5 AMINO ACIDS 2-5 AMINO ACIDS No Approval Required QUANTITATIVE EA SPEC 82139 AMINO ACIDS QUANTITY 6 OR MORE AMINO ACIDS 6/> AMINO ACIDS NO. authorization required QUANTITY EA 4 AM 1 AMON 80 .uth required 82143 SKIN AMNINIC FLUID SKIN AMNITIC FLUID No authorization required 82150 AMYLASE ANALYSIS AMYLASE ANALYSIS No authorization required 82154 ANDROSTANEDIOL GLUCURONIDE ANDROSTANEDIOL GLUCURONIDE No authorization required ASSAYNEDIONE 7 Auth Re requested 8215 8216 0 ANDROSTERONE DETERMINATION ANDROSTERONE Not required approval 82163 ANGIOTENSIN II ANALYSIS ANGIOTENSIN II No approval required 82164 ENZYME TEST ANGIOTENSIN AND ANGIOTENSIN CONVERTING ENZYME No approval required 82172 APOLYPOPROTEIN ANALYSIS APOLYPOPROTEIN ANY approval required Pathology and laboratory Complete clinical examination 82175 SENICAY OF ASSICAY Br. SENICAY OF ASSIC 82175 180 ASCORBIC ACID DETERMINATION BLOOD ASCORBIC ACID ANALYSIS No approval required 82190 ATOMIC ABSORPTION ATOMIC ABSRPJ SPECTROSCOPY EA No approval required ANALYTE 82232 BETA-2 PROTEIN ANALYSIS BETA-2 MICROGLOBULIN No approval required 82239 BILE ACIDS TOTAL 0 2 ACID ACIDS LINE 0BI LE HOLYLBLYCINE BILE ACIDS CHOLYLGLYCINE No authorization required 82247 BILIRUBIN TOTAL BILIRUBIN TOTAL No authorization required 82248 BILI RUBIN DIRECT BILIRUBIN DIRECT No authorization required 82252 FAECAL BILIRUBIN TEST BILIRUBIN FECES QUALITATIVE No authorization required 82261 BIOTINIDASE ANALYSIS Auth Squipeachinidase EBIOTINIDASE No.

82270 OCCULT BLOOD REDUCES BLOOD OCCULT PEROXIDASE ACTV No Auth Required QUAL FECES 1 DETER 82271 OCCULT BLOOD OTHER SOURCES BLOOD OCCULT PEROXIDASE ACTV No Auth Required QUAL OTHER SOURCES 82272 CCULT BLD OCCEST FECES 82272 ACTV No Auth Requir ed QUAL FECES 1-3 SPEC 822 74 EXAMINATION FOR BLOOD FAECAL BLOOD OCCULT FAECAL HGB DETER IA No authorization required QUAL FECES 1-3 82286 ANALYSIS OF BRADYKININ BRADIKININ No authorization required 82300 ANALYSIS OF CADMIUM Auth. Y 25 HYDROXY INCLUDES FRACTIONS IF No approval required DONE 82308 CALCITONIN ANALYSIS CALCITONIN No approval required 82310 CALCIUM ANALYSIS CALCIUM TOTAL No approval required 82330 CALCIUM ANALYSIS CALCIUM IONIZED No approval required 82331 CALCIUM REQUIRED CALCITONIN REQUIRED RED TEST 82340 URINE CALCIUM DETERMINATION CALCIMUURIN QUANTITATIVE NO DEFINITE Not required approval SAMPLE 82355 STONE ANALYSIS QUALITATIVE ANALYSIS CALCULATION QUALITATIVE ANALYSIS CALCULATION No authorization required 82360 STONE ANALYSIS QUANTUM STONE QUANTITATIVE CHEMICAL No authorization required 82365 CALCULATION CAuth SPECTRO SPECTRO 2370 X-RAY CALCULATION X-RAY DIFFRACTION CALCULATION No authorization required 82373 ANALYSIS C -D CARBOHYDRATE DEFICIENCY MEASUREMENT TRANSFER No approval required TRANSFERRIN 82374 ANALYSIS IN BLOOD CARBON DIOXIDE CARBON DIOXIDE BICARBONATE No approval required 82375 ANALYSIS OF CARBOXYHB QUANTITATIVE AMOUNT OF CARBOXHEMOGLOBIN No approval required 82375 ANALYSIS OF CARBOXYHB QUANTITATIVE . ACTIV No approval required 82378 CARCINOEMBRYON ANTIGEN CARCINOEMBRYON ANTIGEN CEA No approval required 82379 ANALYSIS OF CARNITINE CARNITIN QUANTITATIVE EACH No approval required SAMPLE 82380 ANALYSIS OF CAROTENE CAROTENE No approval required 82382 ANALYSIS OF URINE CATECHOLAMINES TOTAL URINE No approval required 82 383 ANALYSIS OF BLOOD CATECHOLAMINES THECOLAMINE CATECHOLAMINE 8 AuthHR 8 BLOOD TECHOLAMINES FRACTIONATED No authorization required 82387 ANALYSIS CATHEPSIN-D CATHEPSIN-D No authorization required 82390 ANALYSIS CERULOPLASMIN CERULOPLASMIN No authorization required 82397 CHEMILUMINESCENT ANALYSIS CHEMILUMINESCENT AS. AY No approval required 82415 CHLORAMPHENICOL TEST CL OODPHENICOL 82397 CHEMILUMINESCENT TEST CHEMILUMINESCENT TEST no. authorization required 82415 CHLORAMPHENICOL TEST CHLORAMPHENICOL CLOODPHENICOL 82397 CHEMILUMINESCENCE TEST CHEMILUMINESCENCE TEST No authorization required 82415 CHLORAMPHENICOL TEST CHLORAMPHENICOL CLOODPHENICOL 82397 CHEMILUMINESCENCE TEST CHEMILUMINESC ORL ANALYSIS No authorization required 82415 CLAIMS ANALYSIS ORAMPHENICOL CHLOODPHENICOL RAMPHENICOL 82397 LD No approval required 82436 URINE ANALYSIS CHLORIDE CHLORIDE URINE No approval required 82438 ANALYSIS OTHER LIQUID CHLORIDES CHLORIDE OTHER SOURCE No approval required 82441 CHLORINATED HYDROCARBON TEST HYDROCARBON CHLORINE TEST No approval required 82465 ANALYSIS BLD/SERUM CHOLESTEROL SERUM CHOLESTEROL/TOTAL CARBONS REQUIRED SELECT LINE 4 LINESTERASE SERUM No approval required 82482 ANALYSIS RBC CHOLINESTERASE RBC CHOLINESTERASE RBC No approval required 82485 ANALYSIS CHONDROITIN SULFATE CHONDROITIN B SULFATE No approval required QUANTITATIVE 82495 CHROMIUM ANALYSIS CHROMIUM ANALYSIS No approval required 82507 CITRATE ANALYSIS CITRATE ANALYSIS C25 required CLAGEN C2SS No. LINKS ANY METHOD No approval required 82525 COPPER ANALYSIS COPPER ANALYSIS No approval required 82528 CORTICOSTERONE ANALYSIS CORTICOSTERONE ANALYSIS No approval required 82530 NO CORTISOL NO CORTISOL No approval required 82533 TOTAL CORTISOL CORTISOL TOTAL No approval required 82540 ANALYSIS NO A2 CREAT CREAT CREAT 8 AUTOGRAPHS QUAL/QUAN COL-CHR/MS ANALYTE DRUG FREE NES No approval required QUAL/QUAN EA SPEC 82550 CK (CPK) CREATINE KINASE TEST TOTAL No approval required 82552 BLOOD CREATINE KINASE ISOZYME CPK TEST No approval required 82553 CREATINE KINASE AFR 82553 CREATINE KINASE AFRACLY 2554 CREATINE ISOFORMS CREATINE KINAS ISOFORMS No approval required 82565 CREATININE ANALYSIS BLOOD CREATININE No approval required 82570 URINE ANALYSIS CREATININE CREATININE OTHER SOURCE No approval required 82575 CREATININE CLEARANCE TEST REQUIRED NO NO CRYOFIBRN ANALYSIS No approval required 82595 CRYOGLOBULIN ANALYSIS CRYOGLOBULIN QUALITATIVE /POLU- Not required approval QUANTITATIVE 82600 CYANIDE ANALYSIS CYANIDE ANALYSIS No approval required 82607 VITAMIN B-12 CYANOCOBALAMIN VITAMIN B-12 No approval required 82608 B-12 B SUBSEQUENT CAPACITY Auth. CAPACITY 82610 CYSTATIN C CYSTATIN C No approval required 82615 URINE TEST FOR CISTINE CSTINE&HOMOCSTINE URINE No approval required QUALITATIVE 82626 DEHYDROEPIANDROSTERONE DEHYDROEPIANDROSTERONE No approval required 82627 DEHYDROEPIANDROSTERONE No . ESOXYCORTICOSTERONE DESOXYCORTICOSTERONE 11- No approval required 82634 DEOXYCORTISOL DEOXYCORTISOL 11- No approval required 82638 DIBUCAINE NUMBER ANALYSIS DIBUCAINE NUMBER ANALYSIS No approval required 82642 DIHYDROTESTOSTERONE DIHYDROTESTOSTERONE ( DHT) No approval required 82652 VIT D 1 25-DIHYDROXY 1 2 5 DIHYDROXY INCLUDES AUTOTESTOSTERONE 6 PARCELATE 6 REQUIRED 6 FRACTION ASE FAECAL ELASTASIS PANTRY FACES No approval required QUAL/SEMI-QUAN 82657 ENZYME ACTIVITY OF CELLS NZYM ACTIV BLD CELLS/TISS No approval required NONRADACT SUBSTRATE EA 82658 ENZYME ACTIVITY OF RA CELLS NZYM ACTV BLOOD CELLS/TISS RADA CT No approval required SUBSTRATE EA 8266 4 ELECTROPHERE ELECTROPH. LISTED HERE 82668 ANALYSIS OF ERYTHROPOETIN ANALYSIS OF ERYTHROPOETIN no. Approval required 82670 ESTRADIOL ANALYSIS ESTRADIOL ANALYSIS No approval required 82671 ESTROGEN ANALYSIS FRACTIONATED ESTROGEN ANALYSIS No approval required 82672 ESTROGEN ANALYSIS ESTROGEN ANALYSIS ANALYSIS NO. DETERMINATION OF ESTRIOL Approval not required 82679 DETERMINATION OF ESTRANES ESTRANES Approval not required

82693 ANALYSIS OF ETHYLENE GLYCOL ANALYSIS OF ETHYLENE GLYCOL No approval required 82696 ANALYSIS OF ETHIOCHOLANOLON ANALYSIS OF ETHIOCHOLANOLON No approval required 82705 FATS/LIPIDS FECES/LIPIDS FECES AQUAD1 FECIVES QUAUT0 FAT/LIPIDS F ECES QUANTITY OF FATS/LIPIDS QUANTITATIVE FECES No approval required 82715 ANALYSIS E FAECAL FATS DIFFICULAR FATS FECES QUANTITATIVE No approval required 82725 BLOOD FATTY ACID ANALYSIS UNSTERIFIED FATTY ACID No approval required 82726 LONG CHAIN FATTY ACIDS AUT LONG CHAIN 8 VERY LONG CHAIN 8 TIN FERRITIN ANALYSIS No approval required 82731 FETAL FIBRONECTIN ANALYSIS FTL FIBRONECTIN CERVICAL No approval required SEMI-QUAN SECRETION 82 735 ANALYSIS FLUORIDE FLUORIDE ANALYSIS No approval required 82746 SERUM FOLIC ACID ANALYSIS FOLIC ACID ANALYSIS NO. BC FOLIC ACID ANALYSIS RBC No approval required 82757 SEED FRUCTOSE ANALYSIS SEED FRUCTOSE ANALYSIS No approval required 82759 RBC GALACTOKINASE ANALYSIS GALACTOKINASE ANALYSIS RBC No approval required 82760 GALACTOSE ANALYSIS GAL ACTOSE ANALYSIS required NO. FERASE GALACTOSE-1-PHOSPHATE URIDYL No approval required TRANSFERASE QUAN 82776 GALACTOSE TRANSFERASE TEST GALACTOSE-1-PHOSPHATE URIDYL No approval required TRANSFERASE SCREEN 82777 GALECTIN-3 GALECTIN-3 No approval required 82784 ANALYSIS IGA/IGD/IG G/IGM EACH TEST OF GAMMAGLOBACHA IGGULIN Required IGM2 ANALYSIS IGE GAMAGLOBULIN ANALYSIS IGE No approval required 82787 IGG 1 2 3 OR 4 EACH GAMAGLOBULIN IMMUNOGLOBULIN No approval required SUBCLASS 82800 PH BLOOD GAS ONLY PH BLOOD No approval required FIGHT IN GOSNYS 828 0 PH No approval required PCO2 PO2 CO2 H CO3 82805 BLOOD GASES W/O2 SATURATION GASES DIRECT MEASUREMENT OF BLOOD PH XCPT No approval required PULSE OXIMETRY 82810 BLOOD GASES O2 ONLY SAT GASES ONLY BLOOD O2 SATURATION No approval required DIRECT MEASUREMENT 82820 HEMOGLOBIN AFFINITY-0% HEMOGLOBINITY-5% SATURATION SILT 82930 STOMACH ANALYSIS M/PH EA SPEC GASTRIC ACID ANALYSIS W/PH EACH No approval required SAMPLE 82938 GASTRIN TEST GASTRIN AFTER SECRETIN STIMULATION Approval not required 82941 GASTRIN ANALYSIS GASTRIN ANALYSIS 829OF GLAYON Required No approval required 82 945 GLUCOSE OTHER GLUCOSE BODY FLUIDS OTHER THAN No approval required BLOOD 8 2946 GLUCAGON TOLERANCE TEST GLUCOSE TOLERANCE TEST No approval required 82947 GLUCOSE ANALYSIS QUANTITATIVE GLUCOSE QUANTITATIVE BLOOD XCPTAGENT No approval required S48 SLU 8 S4 SE GLUCOSE REAGENT STRIP No approval required 82950 GLUCOSE TEST POST-DOSING GLUCOSE GLUCOSE No approval required 82951 GLUCOSE TOLERANCE TEST (GTT) GLUCOSE TOLERANCE TEST GTT 3 No approval required SAMPLE 82952 GTT ADDED GLUCOSE TOLERANCE SAMPLE EA ADDL ADDITIONAL No SAMPLE 8 E9ME 5ASSY 8 E2952 GTT 5 required UC-6-PHOSPHATE DEHYDROGENASE Not required approval QUANTITATIVE 82960 G6PD GLUC-6-PHOSPHATE DEHYDROGENASE ENZYME TEST No approval required SCREEN 82962 GLUCOSE BLOOD TEST GLUC BLD GLUC MNTR DEV SPECIFIC No approval required FDA SPECOF HOME 8296 3 3 GLUCOSIDASE BETA No approval required 82965 GDHAMATE ENZYME ANALYSIS GLUT No application roval DEHYDROGENASE required 82977 GGT DETERMINATION GLUTAMYLTRASE GAMMA ANALYSIS No approval required 82978 GLUTATHIONE ANALYSIS GLUTATHY ANALYSIS 82978 GLUTATHY ION ANALYSIS 82978 GLUTATHY 82 RET ANALYSIS GLUTATHY 99 HIONE REDUCTASE required No approval required RBC 8298 5 GLYCALATE PROTEIN ANALYSIS GLYCALATE PROTEIN ANALYSIS Not required approval 83001 GONADOTROPIN ANALYSIS ( FSH) FOLLICLE GONADOTROPIN No approval required HORMONE STIMULATION 83002 GONADOTROPIN (LH) ANALYSIS LUTEINIZATION GONADOTROPIN (LH) GONADOTROPIN (LH) ANALYSIS HUMAN GROWTH HORMONE No application required roval 83006 GROWTH PROMOTION GENE 2 EXPRESSED GROWTH PROMOTION No approval required GENE 2 8300 9 H PYLORI (C-13) BLOOD HPYLORI BLOOD ANAL UREASE ACT NON- No authorization required RADACT ISOTOPE 83010 ANALYSIS QUANTOGLOBIN HAPTOGLOBIN QUANTUM ANALYSIS 8 AQUANT ANALYSIS 3 ANALYSIS HAPTOGLOBIN ANALYSIS HAPTOGLOBIN PHE NOTYPES No authorization required 83013 H PYLORI ( C-13) BREATH HPYLORI BREATH ANAL UREASE ACT No approval required NON-RADACT ISTOPE 83014 H PYLORI DRUG ADMIN HPYLORI DRUG ADMINISTRATION No approval required 83015 NEW No approval required ANALYZE 83018 HEAVY METAL QUANTITY EACH NES HEAVY METAL QUAN TIATIVE ACH NES No approval required 83020 HEMOGLOBIN ELECTROPHORESIS HEMOGLOBIN FRACTJ/QUANTJ No approval required ELECTROPHORESIS 83021 HEMOGLOBIN CHROMOGLOBIN KHOMOGLOBIN USED no. GRAPHY 83026 HEMOGLOBIN KO BBERSULFATE HEMOGLOBIN COPPER SULFATE No approval required METHOD NO. -AUTOMATIC 83030 FETAL HEMOGLOBIN CHEMICAL HEMOGLOBIN F FETAL CHEMICAL No approval required 83033 FETAL HEMOGLOBIN ANALYSIS QUAL HEMOGLOBIN F FETAL QUALITATIVE No approval required 83036 GLYCOSYLATE HEMOGLOBIN TEST A1703. GLYCOSYLATE HB HOME DEVICE HGB GLYCOSYLATE DEVICE PURIFIED No FDA approval required HOME USE 83045 BLOOD METHEMOGLOBIN TEST HEMOGLOBIN METHEMOGLOBIN No approval required QUALITATIVE 83050 BLOOD METHEMOGLOBIN ANALYSIS HEMOGLOBIN METHEMOGLOBIN No approval required QUANTITATIVE 83051 PLASMA HEMOGLOBIN ANALYSIS HE ANALYSIS required POSSIBLE BIN without authorization

83060 DETERMINATION OF SULFHEMOGLOBIN IN BLOOD HEMOGLOBIN SULFHEMOGLOBIN No approval required QUANTITATIVE 83065 DETERMINATION OF HEMOGLOBIN HEAT HEMOGLOBIN THERMOLABIL No approval required 83068 CHECK FOR HEMOGLOBIN STEENSTABIN STquin red 83069 URINE ANALYSIS OF HEMOGLOBIN IN URINE FOR HEMOGLOBIN No approval required 83070 ANA LYSE OF HEMOSIDERIN QUAL ANALYSIS OF HEMOSIDERIN QUALITATIVE No approval required 83080 ANALYSIS B HEXOSAMINIDASE ANALYSIS B-HEXOSAMINIDASE ANALYSIS EACH No authorization required ANALYSIS 83088 ANALYSIS HISTAMINE ANALYSIS HISTAMINE ANALYSIS No authorization required 83090 ANALYSIS required 83090 ANALYSIS 8 Auth 3150 ANALYSIS HOM ANALYSIS OVANILIC ACID HOMOVANILLIC ACID ANALYSIS No authorization required 83491 HYDROCOSTEROID ANALYSIS 17 SICORTICOSTEROID 17 No approval required 83497 5-HIAA ANALYSIS OF HYDROXYINDOLEDIC ACID No authorization required 5-HIAA ANALYSIS 1 PRO8Y GESTRON 17- No authorization required D 83500 ANALYSIS WITHOUT HYDROXYPROLINE ANALYSIS WITHOUT HYDROXYPROLINE No authorization required 83505 ANALYSIS OF TOTAL HYDROXYPROLINE ANALYSIS OF HYDROXYPROLINE No authorization required 83516 IMMUNOSAY NON-ANTECROPIC IMMUNOASSAY ANALYTE No necessary approval QUALITATIVE/SEMI-QUALITATIVE MULTIPLE ANALYSIS 5 STEP 83516 Approval required QUALITATIVE/SEMI-QUALITY ONE STEP 83519 RIA IMMUNOASSAY WITHOUT ANTIBODY Q UANT Approval not required RADIOIMMUNOASSAY 83520 IMMUNOASSAY QUANTITY NO. NONAB IMMUNOASSAY OF ANALYTES No approval required QUANTITATIVE NO. 83525 INSULIN ANALYSIS TOTAL INSULIN DETERMINATION No approval required 83527 REQUIRED 83527 INSULIN 8 ANALYSIS INTRINSIC FACTOR ANALYSIS INTRINSIC FACTOR ANALYSIS No approval required 83540 IRON ANALYSIS IRON ANALYSIS No approval required 83550 IRON BINDING IRON BINDING ABILITY TEST Not approval required 83 570 ISOCITRIC DEHYDROGENASE IDH ENZYME ANALYSIS No approval required 83582 KETOGENIC GENESTERIC STEROID ANALYSIS ANALYSIS. Analysis 83586 17- ketosteroid analysis of ketosteroid 17- total approval 83593 Cathosteroid fractionation No approval 83605 Lacta acid Lanctata No approval (LDHACE ENZY) NOT required 83605 ANALYSIS OF LDH ENZYME LACTATE DEHYDROGENASE No approval required ISOENZYMES SEP&QUAN 83630 LACTOFERRIN FECES (QUAL) LACTOFERRIN FACES QUALITATIVE No approval required 83631 LACTOFERRIN FACES (QUANTITY) LACTOFERRIN FAECA QUANTITY No approval required 83631 LAC TOFERRIN FACES (QUANTITY) LACTOFERRIN RIN FAECAL QUANTITATIVE No approval required 83631 FAECAL LACTOFERRIN (QUANTITY) Required SOMATOMAMMOTROPIN 83633 URINE LACTOSE TEST LACTOSE QUALITATIVE URINE No authorization required 83655 ANALYSIS LEAD ANALYSIS No authorization required 83661 L/S RATIO FETAL LUNG FETAL LUNG MATURITY LECITHIN UNIT No authorization required SPHINGOMYELIN RATIO 83662 FOAM STABILITY FETAL NO LUNG FETAL LUNG UNIT MATURITY NO. POLARIZE FETAL LUNG FETAL LUNG MATURE FLUORESCENCE No approval required POLARIZE 83664 LAMELE BDY FETAL LUNG FETAL LUNG MATURE LAMELLE No approval required BODY WISE 83670 LAP ENZYME LEUCINE AMINOPEPTIDASE ANALYSIS LAP No approval required 83690 L ASE ANALYSIS 3 AOF 5 ANALYSIS 3 AOF 5 LIPOPROTEIN ANALYSIS (A ) LIPOPROTEIN (A) No authorization required 83698 ANALYSIS LIPOPROTEIN PLA2 LIPOPROTEIN ASSOCIATED authorization required Pathology and laboratory Complete clinical examination PHOSPHOLIPASE A2 83700 LIPOPRO BLD ELECTROPHORETIC LIPOPROTEIN BLOOD authorization required Pathology and laboratory Complete clinical examination and laboratory ELEKTROPHOLIPOR 83 700 I BLD HR FRACTION OF LIPOPROTEIN IN BLOOD High Required Authorization Complete Clinical Review of Pathology and Laboratory Resolty & QUANTJ Lipoprotein Blood Quan Number Needs Need Authorizations Full Clinical Review Lipoprotein Direction High Density 8 Required Cho 1Pro19 And Direct Lipoprotein Measurement No. CHOLESTEROL 83721 BLOOD LIPOPROTEIN ANALYSIS LIPOPROTEIN DIRECT MEASUREMENT No approval required LDL CHOLESTEROL 83722 LIPOPRTN DIR MEAS SD LDL CHL DIR MEASURES LIPOPROTEIN LIPOPROTEIN SMALL DENSE No approval required. 35 MAGNESIUM ANALYSIS MAGNESIUM ANALYSIS No authorization required 83775 MALATE DEHYDROGENASE ANALYSIS MALATE DEHYDROGENASE ANALYSIS No authorization required 83785 MANGUS ANALYSIS MANGO ANALYSIS No authorization required 83789 MASS SPECTROMETRY QUAL/QUAN MASS SPECTRUM&TAND EM MASS SPECTRUM MANGA 8 NCU TEST 8 QUANTITATIVE MERCURY ANALYSIS Required No authorization required 838 35 METANEPHRINE ANALYSIS METANEPHRINE No Authorization Required 83857 METHEMALBUMIN METHEMALBUMIN ANALYSIS No Authorization Required 83861 TEAR MICROFLUID ANALYSIS MICROFLUIDIC TEAR ANALYSIS No Authorization Required OSMOLARITY 838 64 MUCOPOLYSARUCOPHARIDS No Auth 83872 SYNOVIC FLUID ANALYSIS MUCIN SYNOVIC FLUID ROES TEST No Authorization Required 83873 CSF PROTEIN ANALYSIS MYELIN BASIC PROTEIN CEREBROSPINAL No approval required LIQUID 83874 MYOGLOBIN ANALYSIS MYOGLOBIN No approval required 83876 MYELOPEROXIDASE ANALYSIS MYELOPEROXIDASE MPO No approval required 83880 PEPTIDETRIETICURATRIUD A8 PTIDIC ANALYSIS REQUIRED 3 NEPHELOMETRY ANALYZES NON-SPEC NEPHELOMETRY ANALYSIS EACH No approval required ANALYTICS NES 83885 NICKEL ANALYSIS NICKEL ANALYSIS No approval required 83915 NUCLEOTIDASE ANALYSIS NUCLEOTIDASE ANALYSIS 5'- No Approval Required 83916 OLIGOCLONAL BANDS OLIGOCLONAL IMMUNE No Approval Required 83918 AQUANTORGANIC TOTALANCIDES AQ UANTORGANIC Approval Required EACH SAMPLE 83919 ORGANIC ACIDS QUAL. EACH ORGANIC ACID QUALITATIVE EACH No approval required SAMPLE 83921 ORGANIC ACID SINGLE QUANTITY ORGANIC ACID 1 QUANTITATIVE No approval required 83930 BLOOD OSMOLALITY ANALYSIS BLOOD OSMOLALITY TEST No approval required

83935 URINE OSMOLITY ANALYSIS URINE OSMOLITY TEST No approval required 83937 OSTEOCALCIN DETERMINATION OSTEOCALCIN DETERMINATION No approval required 83945 OXALATE DETERMINATION OXALATE DETERMINATION OXALATE DETERMINATION-3 PRO OXALAT NO. COPROTEIN HER-2/NEU Approval required Genetic testing and full clinical examination Consultation 83951 ONCOPROTEIN DCP ONCOPROTEIN DES-GAMMA-CARBOXY- No approval required PROTHROMBIN DCP 83970 PARATHORMONE ANALYSIS PARATHORMONE ANALYSIS No approval required 83986 BOSPHERE NON-FLUID PHOS ANALYSIS Approval required STATED 83987 EXHAUST CONDENSATE PH EXHAUSTED CODE ANALYSIS authorization required Pathology and laboratory Complete clinical examination 83992 PHENCYCLIDINE ANALYSIS PHENCYCLIDINE ANALYSIS Approval not required 83993 CALPROTECTIN FAECAL ANALYSIS CALPROTECTIN FAECAL 8 OF ANALYSIS 30 CUB BLOOD ON 8 ANALYSIS ANALYSIS 30 INE BLOOD No approval required 84035 PHENYL KETONE ANALYSIS PHENYL KETONE ANALYSIS No authorization required QUALITATIVE 84060 ACID PHOSPHATASE ANALYSIS ACID PHOSPHATASE ANALYSIS TOTAL No authorization required 84066 PROSTATE PHOSPHATASE ANALYSIS ACID PHOSPHATASE ANALYSIS No authorization required Test 8 PROSTATE 5 ALKALINE PHOSPHATASE No authorization required 8407 8 ALKALINE PHOSPHATASE ANALYSIS ALKALINE PHOSPHATASE ANALYSIS No authorization required HEAT STABLE 84 080 ANALYSIS OF ALKALINE PHOSPHATES ANALYSIS OF ALKALINE PHOSPHATASE No authorization required ISOENZYMES 84081 ANALYSIS OF PHOSPHATIDYLGLYCEROL PHOSPHATIDYLGLYCEROL No authorization required 84081 ANALYSIS OF PHOSPHATIDYLGLYCEROL PHOSPHATIDYLGLYCEROL No authorization required 84 081 ANALYSIS OF PHOSPHATIDYLGLYCEROL 6-DEHYDE RBC No authorization required 84087 ANALYSIS OF PHOSPHOHEXOSE ENZYME ANALYSIS OF FOSF OHEXOSES No approval required ISOMERAS 84100 ANALYSIS OF PHOSPHORUS ANALYSIS OF INORGANIC PHOSPHORUS No approval required 84105 URINE PHOSPHORUS ANALYSIS INORGANIC PHOSPHORUS ANALYSIS No approval required URINE 84106 PORPHOBILINOGEN TEST PORPHOBILINOGEN PORPHOBILINOGEN PORPHOBILINOGEN PORPHOBILINOGEN 1 INORGANIC PHOSPHORUS 1 HOBILINOGEN PORPHOBIL ANALYSIS INGENIC URINE No approval required QUANTITATIVE 84112 EVAL Amniotic fluid PROTEIN EVAL C /V AMNION PROTEIN IN Not required approval QUALITY EA SAMPLE 84119 URINE TEST FOR PORPHYRIN PORPHYRIN URINE QUALITATIVE No approval required 84120 URINE ANALYSIS PORPHYRIN P ORPHIRIN PORPHYRIN URINE TYPING & no. A12AC FECES PORPHYRINS PORPHYRINS QUANTITATIVE FECES No authorization required 84132 ANALYSIS SERUM POTASSIUM POTASSIUM SERUM PLASMA/WHO No authorization required BLOOD 84133 URINE ANALYSIS POTASSIUM URINE POTASSIUM No authorization required 84134 ANALYSIS PREALBUMIN PREALBUMIN No authorization required 84137 PR 4EGNA 84133 138 ANALYSIS PREGNANETRIOL PREGNANETRIOL None approval 84140 required PREGNENOLON ANALYSIS PREGNENOLON No approval required 84143 ANALYSIS 17- HYDROXYPREGNENO 17-HYDROXYPREGNENOLON No approval required 84144 PROGESTERONE ANALYSIS PROGESTERONE ANALYSIS No approval required 84145 PROCALCITONIN (PCT) no. PROLACTIN ANALYSIS PROLACTIN No authorization required 84150 PROSTAGLANDIN ANALYSIS PROSTAGLANDIN EACH No authorization required 84152 DOG ANALYSIS COMPLEX PROSTATE-SPECIFIC ANTIGEN ANALYSIS No authorization required COMPLEX 84153 DOG TOTAL PROSTATE-SPECIFIC ANALYSIS TOTAL PROSTAGLANDS ANALYSIS required 84153 Auth. TE SPECIFIC ANTIGEN No approval required FREE 84155 SERUM PROTEIN ANALYSIS PROTEIN XCPT REFRACTOMETRY SERUM No approval required PLASMA/WHL BLD 84156 URINE PROTEIN ANALYSIS PROTEIN TOTAL XCPT REFRACTOMETRY No approval required URINE 84157 REFRACTIN ANALYSIS FOR PROTEIN OTHER REV. 84160 PROTEIN ANALYSIS ANY SOURCE TOTAL PROTEIN REFRACTOMETRY ANY No SRC approval required 84163 DADDY SERUM PREGNANCY LINKED PLASMA No PROTEIN approval required 84165 PROTEIN E-PHORESIS SERUM PROTEIN ELECTROPHORETIC No approval required FRACTINE SERUM PROQU ANTJ & 8165 PROTEIN 84165 TEIN ELECTROP FXJ &QUAN OTH no. approval required FLUS CONCENTRATI 84181 WESTERN BLOT TEST PROTEIN WESTRN BLOT I&R No approval required BLOOD/OTHER FLUID 84182 PROTEIN WESTERN BLOT TEST PROTEIN WESTRN BLOT BLOOD/OTHER No approval required FLU IMMUNOLOGICAL 84202 PROB. ATIVE No approval required 84203 RBC TEST PROTOPORPHYRIN PROTOPORPHYRIN RBC SCREEN No approval required 84206 PROINSULIN ANALYSIS PROINSULIN ANALYSIS No approval required 84207 VITAMIN B-6 ANALYSIS PYRIDOXAL PHOSPHATE ANALYSIS No approval required 84210 PYRUVATE ANALYSIS OF 4 ANALYSIS PY20V INA required SEE PYRUVATE KINASE ANALYSIS Not required authorization 84228 QUININE ANALYSIS QUININE ANALYSIS No authorization required 84233 ESTROGEN ANALYSIS ESTROGEN RECEPTOR ANALYSIS No authorization required 84234 PROGESTERONE ANALYSIS PROGESTER RECEPTOR ANALYSIS No authorization required ONE ASSAY 842 OCRINE OTH/THN No authorization required ESTRGN /PROGST 84238 NON-DOCRYNAL RECEPTOR RECEPTOR ANALYSIS NON-ENDOCRINE ANALYSIS No authorization required SPECIFY RECEPTOR 84244 RENIN ANALYSIS RENIN ANALYSIS No authorization required 84252 VITAMIN B-2 ANALYSIS RIBOMIN BASSAY-VITA 5 ANALYSIS Required SELENIUM ANALYSIS No authorization required 84260 SEROTONIN ANALYSIS SEROTONIN TEST No authorization required 84270 SEX HORMONE TEST GLOBUL SEX HORMONE BINDING TEST GLOBULIN 8 required 4275 SIALIC ACID TEST REQUEST 8 SIALIC ACID TEST Authentic TEST8 SILICA ANALYSIS No authorization required 8429 5 SERUM ANALYSIS SODIUM SODIUM SERUM PLASMA OR WHOLE No authorization required BLOOD 84300 URINE ANALYSIS SODIUM URINE ANALYSIS SODIUM No authorization required

84302 SODIUM SWEAT ANALYSIS SODIUM ANALYSIS OTHER SOURCE No authorization required 84305 SOMATOMEDIN ANALYSIS SOMATOMEDIN ANALYSIS No authorization required 84307 SOMATOMEDIN ANALYSIS SOMATOMEDIN ANALYSIS SPUTROUT1 SPUTROUT13 REQUIVITY1 SPUTROUT13 TE ANALYSIS Not required No authorization required ELSEWHERE STATED 8431 5 SPECIFIC BODY GRAVITY HOUSEHOLD SPECIFIC GRAVITY EXCEPT URINE No Approval Required 84375 SUGAR CHROMATOGRAM ANALYSIS SUGAR CHROMATOGRAPHY No Approval Required TLC/PAPER CHROMATOGRAPHY 84376 SUGARS SINGLE QUAL SUGARS MONO DI&OLIGOS 1ACH No Approval EQUALIGARIVE EQUALIGAR 4S 7 REQUIRED QUALITY SUGARS MONO DI &OLIGOS MLT No Approval Required QUALITATIVE EACH SPE 84378 SUGARS SINGLE QUANTITY OF SUGAR MONO DI&OLIGOS 1 No approval required QUANTITATIVE EACH SPEC 84379 SUGARS MULTIPLE SUGARS MONO DI&OLIGOS MLT No approval required QUANTITATIVE EA SPEC 84392 URINE SULFATE ANALYSIS 84392 URINE SULFATE ANALYSIS 4 ANALYSIS 4 LF0AY SULF ATE no. FREE TESTOSTERONE TESTOSTERONE ANALYSIS FREE No authorization required 84403 TOTAL TESTOSTERONE ANALYSIS TOTAL TESTOSTERONE ANALYSIS No authorization required 84410 BIOLOGICALLY AVAILABLE TESTOSTERONE ANALYSIS BIOVLBL TESTOSTERONE DIRECT No authorization required MEASUREMENT 84425 VITAMIN B-1 AY VITAMIN B-1 ANALYSIS VITAMIN B0 -4 required. THIOCYANATIZATION TO THIOCYANATE No approval required 84431 THROMBOXANURIN THROMBOXANMETABOLIT W/WO No approval required THROMBOXANURIN 84432 THYROGLOBULIN ANALYSIS THYROGLOBULIN ANALYSIS No approval required 84436 TOTAL THYROGLOBULIN ANALYSIS FOR 4 TOTAL THYROXINE DETERMINATION 4 Required 7 AS NEONATAL THYROXINE ASSAY REQUIRED THYROXINE INJECTION None approval ELUTION 84439 ANALYSIS OF FREE THYROXINE ANALYSIS OF FREE THYROXINE No authorization required 84442 ANALYSIS OF THYROXINE ACTIVITY ANALYSIS OF THYROXINE BINDING No authorization required GLOBULIN 84443 ANALYSIS OF THYROID STIMULATION HORMONE STANDARD 4 445 ANALYSIS OF TSI GLOBULIN thyroid stimulation immune No authorization required GLOBULIN TSI 84446 ANALYSIS OF VITAMIN E ANALYSIS OF TOCOPHEROL ALPHA No authorization required VITAMIN E 84449 TRANSCORTIN ANALYSIS TRANSCORTIN CORTISOL ANALYSIS No authorization required BINDING GLOBULIN 84450 TRANSFERASE (AST) (SGOTPARTAT) No AuthLAN A 8 TRANSFERO AS0red INE AMINO (ALT) (SGPT ) TRANSFER A LANIN AMINO ALT No authorization required SGPT 84466 TRANSFERINA ANALYSIS L7383 TRANSFERINA ANALYSIS No authorization required 84478 Triglyceride analysis Triglyceride No approval 4THRO 9T Needs Graft Hormone Hormone Ratio 84480 Trijodionon T3 Analysis No Authorization Total TT3 84481 Free analysis (FT-3) TRIJODTORININA analysis T3 FREE No authorization required 84482 T3 REVERSE TRIIODOTHYRONIN REQUIRED 8 OPONIN QUANTUM ANALYSIS TROPONIN QUANTITATIVE No authorization required 844 85 DUODENAL FLUID ANALYSIS DUODENAL FLUID TRYPSIN DETERMINATION No required 8 4488 FAECAL TEST FOR TRYPSIN ANALYSIS OF TRYPSIN FACES QUALITATIVE No authorization required 84 490 FECINEC ANALYSIS FOR TRYPSIN ANALYSIS - HR No authorization required COLLECTION 84510 TYROSINE ANALYSIS TYROSINE ANALYSIS No authorization required 84512 ANAL. TROPONIN QUALITY SIS TROPONIN QUALITY TEST No authorization required 84520 UREA NITROGEN ANALYSIS UREA NITROGEN ANALYSIS No authorization required QUANTITATIVE 84525 AUTROGEN QUANTITATIVE QUANTITATIVE red SEMIQUANTITATIVE 84540 URINE/URINE-N ANALYSIS UREA NITROGEN URINE ANALYSIS No authorization required 84545 UREA-N PURIFICATION TEST UREA NITROGEN PURIFICATION No authorization required 84550 BLOOD/URINE ACID ANALYSIS BLOOD/URIC ACID ANALYSIS No authorization required ASSAYURICUR ASSAYUR50 SECOND SOURCE No Authorization required 84577 FECES/UROBILINOGEN ANALYSIS UROBILINOGEN FECES No Authorization required QUANTITATIVE 84578 URINE TEST UROBILINOGEN UROBILINOGEN ANALYSIS No Authorization required U4ROBILINOGEN 0 8 QUANTITATIVE DETERMINATION OF URINE No authorization required fox SPECIMEN 84583 URINALYSIS UROBILINOGEN ANALYSIS UROBILINOGEN URINE No authorization required SEQQUANTITATIVE 84585 URINALYSIS VMA VANILIBANDELIC ACID ANALYSIS No authorization required URINE 84586 ANALYSIS VIP ANALYSIS VA SOACTIVE BOWEL No approval required PEPTIDES 84588 TEST TEST TEST TEST TEST VASOACTIVE BOWEL IC No approval required HORMONE 8 4590 VITAMIN A ANALYSIS VITAMIN A ANALYSIS No approval required 84591 NO VITAMIN ANALYSIS VITAMIN ANALYSIS NONE OTHER No approval required SPECIFIED 84597 VITAMIN K ANALYSIS VITAMIN K ANALYSIS No approval required 84600 VOLATILE ANALYSIS ANALYSIS NO. 60SE required LERANCE TEST XYLOSE ABSORPTION TEST BLOOD No approval required &/URINE 84630 ZINC ANALYSIS ZINC ANALYSIS No approval required 84681 C-PEPTIDE ANALYSIS C-PEPTIDE ANALYSIS No approval required 84702 CHORIONIC GONADOTROPIN TEST GONADOTROPIN TEST GONADOTROPIN NO. GONADOTROPIN ANALYSIS CHORIONIC GONADOTROPIN No approval required QUALITATIVE 84704 HCG FREE BETALANC TEST CHORIONIC GONADOTROPIN HCG FREE No approval required BETA CHAIN 84830 OVULATION TESTS EGG GLASS TEST VISUAL COLOR No approval required COMPARISON HLH 8499 9 CLINICAL CHEMISTRY TEST NO CHEMISTRY LAB REQUIRED 50 K EMIAR. 2 Bleeding time test Bleeding time test No authorization required 85004 AUTOMATED DIFFERENTIAL WBC COUNT BLOOD COUNT AUTOMATED No authorization required DIFFERENTIAL WBC COUNT

85007 BL SMEAR W/DIFF WBC COUNT BLOOD COUNT SMEAR MCRSCP W/MNL No approval required DIFRNTL WBC COUNT 85008 BL SMEAR U/O DIFF WBC COUNT BLD COUNT SMEAR MCRSCP U/O MNL No approval required DIFRNTL WBC COUNT -COAT BLOOD COUNT MANUAL DIFRNTL WBC No Authorization Required COUNT BUFFY COAT 85013 SPUNTED MICROHEMATOCRIT BLOOD BLOOD COUNT SPUNTED No Authorization Required MICROHEMATOCRIT 85014 HEMATOCRIT BLOOD BLOOD HEMATOCRIT No Authorization Required 85014 BLOODCOUNTHEGL 85014 Auth Required 85025 COMPLETE CBC M/AUTO DIFF WBC BLOOD BLOOD COMPLETE AUTO&AUTO No Vet Authorization Required DIFRN TL WBC 85027 COMPLETE CBC AUTOMATED BLOOD COUNT COMPLETE AUTOMATED No authorization required 85032 MANUAL CELL COUNT EACH BLOOD COUNT MANUAL CELL COUNT No authorization required EACH 85041 AUTO COUNT RBC AUT. 4 MANUAL COUNT OF RETICULOCITE BLOOD COUNT RETICULOCYTE No approval required AUTOMATED 85045 AUTOMATIC COUNT OF RETICULOCITE BLOOD COUNT RETICULOCYTE No approval required AUTOMATED 85046 RETICYTE/HGB CONCENTRATE BLOOD COUNT RETICULOCYTE AUTO No approval required 1/> COUNT L0KOBLOODCYTE L0KOBLADCY TE WBC No vet approval required a AUTOMATED 85049 AUTOMATIC COUNTING DRUM BLOOD AUTOMATIC DRUM BOARD COUNT No approval required 85055 RETICULATED TROMBROMED BOARD ASAY RETICULATED BROMED BOARD ASAY No approval required 85060 BLOODSMEAR INTERPRETATION BLOODSMEAR PERIPHERAL INTERP No approval required PHYSIONS W/5ROWRIT BRO W/5ROWIT RES WEAR No approval required INTERPRETATION 85130 CHROMOGENIC TEST SUBSTRATE TEST CHROMOGENIC SUBSTRATE No approval required 85170 BLOOD CLOT REMOVAL BLOOD CLOT REMOVAL No approval required 85175 BLOOD PROPOLIZATION TIME PHOTOGLYCYZATION TIME WHOLE BLOOD No approval required DILUTION 85210 LOFTFACTOR II PROTHROM SPECTOR F8 5220 BLOOC KOGEL FACTOR V TEST KO GEL FACTOR V No approval required ACG/PROACCELERIN LABILE FACTOR 85230 KOGEL FACTOR VII PROCONVERTIN COAGULATION FACTOR VII PROCONVERTIN No authorization required STABLE FACTOR 85240 KOGEL FACTOR VIII AHG 1 STAGE COAGULATION FACTOR VII Authenticator STABLE FACTOR 14III No F5 III RELTD ANTGN NOISE FACTOR VIII RELATED No authorization required ANTIGEN 85245 KOGEL FACTOR VIII VW RISTOCTN COAGULATION FACTOR VIII VW FACTOR No authorization required RISTOCETIN COFACT 85246 KOGEL FACTOR VIII VW ANTIGEN COAGULATION FACTOR VIII VW FACTOR No authorization required CL52ANTICING M824TRICK CLOTIGEN CLOTIC FACTOR VIII MULTIMETRIC NO Analysis required 85250 Cooking Factor IX PTC/CHRISTMAS Clotting factor IX PTC/Christmas No authorization required 85260 Cooking Factor x Stuart-Power Cookold Factor x Stuart-Prower TAKE KOHEL FACTOR XI Required PTAII 8 PTA II COAGULATION no. A5 FACTOR XII HAGEMAN No approval required 85290 KOGEL FACTOR XIII FIBRIN STAB STABILIZING FACTOR XIII FIBRIN No approval required STABILIZING 85291 KOGEL FACTOR XIII FIBRIN SCRN STAB ILIZING FACTOR XIII FIBRIN STABILIZING No approval required PRODUCT FACTOR CLOUBREK FACTOR 85291 ALICREIN ANALYSIS No approval required FLETCHER FACT ANALYSIS 85293 KOGEL FACTOR WEIGHT SIZE KININOGEN HIGH MOLECULAR WEIGHT No approval required KININOGEN ANALYSIS 85300 ANTITHROMBIN III ACTIVITY ANTITHROMBIN III ACTIVITY NOISE INHIBITORS ANTITHROMBIN No approval required III ACTIVITY 85301 ANTITHROMBIN III ANTITROMBIN III ACTIVITY COAGULATION H SLOWING INHIBITORS ANTITHROMBIN No approval required III ACTIVITY 85301 ANTI THROMBIN III ANTITHROMBIN III ANTITHROMBIN III ANTIGEN SIZE INHIBITORS ANTITHROMBIN No approval required III ACTIVITY 85301 ANTITHROMBIN III ANTITHROMBIN III ANTIGEN COAGULATION INHIBITORS III 85302 PROTEIN INHIBITOR PROT C ANTIGEN COAGULATION INHIBITOR PROTEIN C No approval required ANTIGEN 85303 PROTEIN C INHIBITOR ACTIVITY Coagulation inhibitors PROTEIN C No approval required ACTIVITY 85305 Coagulants PROT S TOTAL Coagulants PROTEIN S TOTAL No approval required 85306 COAGULATION INHIBITORS PROT INHIBITER PROT S TOTAL INHIBITORS PROTEIN S TOTAL No approval required 85306 COAGULATION INHIBITORS PROT INHIBITOR PROT 7 FREE CLOTT 7 ANALYSIS ACTIVATED PROTEIN C ACTIVATED PROTEIN C APC RESISTANCE No approval required ANALYSIS 85335 TEST FACTOR INHIBITOR TEST FACTOR INHIBITOR TEST No approval required 85337 THROMBOMODULIN THROMBOMODULIN No approval required 85345 COAGULATION TIME LEE & WHITE COAGULATION AND WHITE COAGULATION TIME 4 TIME L8 IVATED COAGULATION TIME ACTIVATED No approval required 85348 COAGULATION TIME OTR METHOD COAGULATION TIME OTHER METHODS No approval required 8 5360 EUG LOBULIN LYSIS EUGLOBULIN LYSIS No approval required 85362 FIBRIN DEGRADATION PRODUCTS FIBRIN DGRADJ SPLT PRODUXS AGGLUJ No approval required SLIDE SEMIQUAN FIBRINO 85 362 FIBRIN DEGRADATION PRODUCTS uth PARACOAGJ required 85370 FIBRINOGEN TEST FIBRIN DGRADJ SPLT PRODUCTS No approval required QUANTITATIVE 85378 FIBRIN DEGRADATION SEMIQUA NT FIBRIN DGRADJ PRODUCES D-DIMER No approval required QUAL/SEMIQUAN 85 379 FIBRIN DEGRADATION QUANTUM FIBRIN DGRADJ PRODUCTS D -DIMER No approval required QUAL/SEMIQUAN 85379 FIBR IN DEGRADATION QUANTUM FIBRIN DGRADJ PRODUCTS D-DIMER No approval required QUAL/SEMIQUAN 85379 DEGRADATION OF FIBRIN QUANT FIBRIN DGRADJ PRODUCTS D-DIMER No approval required QUAL/SEMIQUAN 85379 DEGRADATION OF FIBRIN QUANT FIBRIN DGRADJ PRODUCTS D-DI NO MORE Approval required QUAL/SEMIQUAN 85379 DEGRADATION OF FIBRIN QU ANT FIBRIN DGRADJ PRODUCTS D-DIMER No approval required PRODUCTS D-DIMER No approval required ULTRA SENSITIVE 85384 FIBRINOGEN ACTIVITY FIBRINOGEN ACTIVITY No approval required 85385 FIBRINOGEN ANTIGEN FIBRINOGEN ANTIGEN No approval required 85390 FIBRINOLYSIS INS SCREEN I&R FIBRINOLYSINS/COAGULOPATHY No approval oval required SCREEN INTERPOR & REPOR

85396 NOISE ANALYSIS WHOLE BLOOD TEST COAGJ/FBRNLYS WHOLE BLOOD ANALYSIS No approval required APPENDIX PO. DAG 85397 COLORKNING FUNCTION ACTIVITY COAGJ&FIBRINOLYSIS FUNCTIONAL Approval not required ACTV NOS 85397 FMIN NO. ACTORS & INHIBITORS No approval required PLASMIN 85410 FIBRINOLYTIC ANTIPLASMIN FBRNLYC AGENTS & INHIBITORS ALPHA- No approval required 2 ANTIPLASMIN 85415 FIBRINOLYTIC PLASMINOGEN FBRNLYC AGENTS & INHIBITORS No approval required PLSMNG ACTIVATOR 85420 F IBRINOLYTIC AGENTS & INHIBITORS PLASMINOGEN FBRNLYC Auth 4 PLSM IC FACTORS AND PLASMINOGEN INHIBITORS FBRNLYC No Authorization Required PLSMNG AGIC ASAY 85441 HEINZ BODIES DIRECT HEINZ BODIES DIRECT No Authorization Required 85445 HEINZ BODIES INDUCED HEINZ BODIES INDUCED ACETYL No Authorization Required PHENYLHYDRAZINE 85460 HEMOGLOBIN FETAL HGB/RBCS FETOMATERNAL No Authorization Required HE MRRG DIFRNTL LYSIS 85461 HEMOGLOBIN FETAL HGB/ETR BO Need MATE 4. 75 HEMOLYSIS ACID HEMOLYSIS ACID No approval required 85520 HEPARIN ANALYSIS HEPARIN ANALYSIS No approval required 85525 HEPARIN NEUTRALIZATION HEPARIN NEUTRALIZATION No approval required 85530 HEPARIN-PROTAMIN TOLERANCE TST No approval required 85536 I RON PANEL PERIPHERAL BLOOD IRON PANEL 4 Autherin-Protamin Tolerant. TION 4 OSPHATASE WBC ALKALINE PHOSPHATASE NUMBER No authorization required 85547 RBC MECHANICAL FRAGILITY MECHANICAL FRAGILITY RBC no authorization required 85549 MURAMIDASE MURAMIDASE no authorization required 85555 RBC OSMOTIC FRAGILITY OSMOTIC FRAGILITY RBC UNCOVERED No authorization required 85557 RBC OSMOTIC FRAGILITY OSMOTIC 5 Auth THROMBLADE AGREGATION IN VITRO No authorization required EACH AGENT 85597 PHOSPHOLIPID PLTLT NEUTRALIZATION PHOSPHOLIPID NEUTRALIZATION No Authorization Required PLATE BLADES 85598 HEXAGNAL PHOSPH PLTLT NEUTRL PHOSPHOLIPID NEUTRALIZATION No Authorization Required HEXAGONAL 85610 PROTHROMBIN TIME No Authorization Required PLASMA FRCT J EACH 856 12 VIPER VENOM PROTHROMBIN TIME RUSSELL VIPER VENON TIME No approval required UNDILUTED 85613 RUSSELL VIPER VENOM DILUTE RUSSELL VIPER VENOM TIME DILUTE No approval required 85635 REPTILASE TEST REPTILASE TEST No approval required 85651 RBC SED SPEED NON-AUTO SEDIMENTATION RBC SEDIMENTATION RBC RBC SEDIMENTATION 85635 REPTILASE TEST ATE RBC No approval required AUTOMATED 85660 RBC SICKLE DECREASE RBC TEST No approval required 85670 PLASMA THROMBIN TIME PLASMA THROMBIN TIME No approval required 85675 THROMBIN TIME TITER THROMBIN TIME TITER No approval required 85705 IN THROMBIN TIME PLASMA MA No red required 85730 THROMBOPLAST TIME PARTIAL THROMBOPLAST IN TIME PARTIAL No PLASMA authorization required /WHOLE BLOOD 85732 THROMBOPLASTIN TIME PARIAL THROMBOPLASTIN TIME PRTL SUBSTIT No authorization required PLASMA FRCTJ EA 85810 VISCOSITY TEST BLOOD VISCOSITY No authorization required 85999 HEMATOLOGY Authorization required Laboratory & COQUILIZATION Complete HEMATOLOGY PROCEDURE and COVINA INCORPORATION. ULATION PROCEDURE 86000 AGGLUTININ FEBRILE ANTIGEN AGGLUTININ FEBRILE EACH ANTIGEN No approval required 86001 ALLERGEN SPECIFIC IGG ALLERGEN IGG SPECIFIC No approval required QUAN/SEMIQUAN EA ALLERGEN 86003 ALLG SPEC IGE RAW XTRC EA ALLERGEN SPECIAL IGE RAW ALLERGEN No approval required EXTRA EACH 860EC05 ALLERGEN 860EC05 EXTRACT 860EC05 wanted MULTIALERGEN SCREEN 86008 ALLG SPEC IGE RECOMB EA ALLERGEN SPEC IGE No approval required RECOMBINANT/PURIFIED COMPNT EA 86021 WBC ANTIBODIST IDENTIFICATION ANTIBODIST IDENTIFICATION LEUKOCYTE No approval required ANTIBODIES 86022 SUBSTANCES LIST ANTIBODIFICATION REQUIRED ANTIBODIF06 23 IMMUNOGLOBULIN ANALYSIS IDENTIFICATION BROBOLET ANTIBODIES No approval required IMMUNOGL ANALYSIS 86038 ANTI-NUCLEAR ANTIBODIES ANTI-NUCLEAR ANTIBODIES ANA No approval required 86039 ANTI-NUCLEAR ANTIBODIES (ANA) ANTI-NUCLEAR ANTIBODIES ANA TITER No approval required 86060 ANTISTREPTOLISIN O TITER ANTISTREPTOLISIN O TITER No approval oval required 86060 ANTISTREPTOLYSIN O TITER Approval required 86077 PHYS BLOOD BANK SERV XMATCH BLD BANK PHYS SV CS DIFFC CROSS No approval required MATCH& /EVAL REP 86078 PHYS BLOOD BANK SERV REACTJ BLD BANK PHYS SVCS INVSTGJ TFUJ RXN No approval required REPRT 86079 PHYS BLOOD BANK SERV AUTHRJ BLD BANK PHYS DEquirt SVREVIJ STAUTH-1 REPRT 86079 ACTIVE PROTEIN C-REACTIVE PROTEIN No approval required 86141 C-REACTIVE PROTEIN HS C-REACTIVE PROTEIN HIGH SENSITIVITY No approval required 86146 BETA-2 GLYCOPROTEIN ANTIBODY BETA 2 GLYCOPROTEIN AND ANTIBODY No approval required EACH 86147 CARIBODIBODY CARANTIG CARANTIG ACH IG CLASS No app roval required 86148 ANTIPHOSPHOLIPID ANTIBODIES ANT -PHOSPHATIDYLSERINE ANTIBODY No approval required know 86152 CELL NUMBER & ID CELL NUMBER IMMUNE SELECTJ No approval required & ID FLUID SPEC. IS TEST KEMOTAXIS TEST SPECIFY METHOD No approval required

86156 COLD AGGLUTININ SCREEN COLD AGGLUTININ SCREEN No approval required 86157 COLD AGGLUTININ TITER COLD AGGLUTININ TITER No approval required 86160 COMPLEMENT ANTIGEN COMPLEMENT ANTIGEN EACH No approval required FUNCTION6 COMPONENT 8 COMPONENT 8 COMPONENT 8616 0 IVITY COMPONENT No approval required EACH COMPONENT 86162 COMPLEMENT TOTAL (CH50) COMPLEMENT TOTAL HEMOLYTIC No approval required 86171 COMPLEMENT FIXATION EACH COMPLEMENT FIXATION TEST EACH No approval required ANTIGEN 86200 CCP ANTIBODY CYCLIC CITRULLINATED PEPTIDE No approval required ANTIBODY 86215 DEOXYANTIBODY ANTIBODY ANTIBODY Approval required 86225 DNA ANTIBODY NATIVE DNA ANTIBODY NATIVE/ DOUBLE No approval required LANAC 86226 DNA ANTIBODY SINGLE CHAIN DNA ANTIGEN SINGLE CHAIN No authorization required 86235 NUCLEAR ANTIGEN ISOLATEABLE ANTIBODY NUCLEAR ANTIGEN No authorization required ANTIBODY ANY METHOD 86255 FLUORESCENT ANTIGEN ANTIBODY ANY METHOD 862 55 FLUORESCENT ANTIGEN ANTIBODY Auth EA ANTIBODY 86256 FLUORESCENT ANTIBODY GEN ANTIBODY CENT ANTIBODY TITER FLUORESCENT NONNFCT AGT ANTB No approval required TITER EA ANTIBODY 86277 GROWTH HORMONE ANTIBODY HUMAN GROWTH HORMONE ANTIKOF No approval required ANTIKOF 86280 HEMAGLUTINATION INHIBITION HEMAGLUTINATION INHIBITOR TEST No approval required HAI 86294 IMMUNOQUAASSAY TUMORIGEN No /SEMIQUANT ITATIVE 86300 TUMOR IMMUNOASSAY CA 15-3 IMMUNOASSAY IVANJE TUMOR ANTIGEN No approval required QUANTITATIVE CA no. S PROTEIN 4 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) No authorization required 86308 HETEROPHILIC ANTIBODIES TEST HETEROPHILIC ANTIBODIES TEST No authorization required 86309 HETEROPHILIC ANTICOPHITE HETEROPHILIC ANTIBODIES TITER No authorization required 86310 HETEROPHILIC ANTIBODIES ANTIBODIES No Auth red ABSORPTION 86316 IMMUNOASSAY TUMOR OTHER IMMUNOASSAY TUMOR ANTIGEN No authorization required QUANTITATIVE 86317 IMMUNOISP INFECTIOUS AGENT IMMUNOASAY INFECTIONUS AGENT No approval required ANTIBODY QUAN NOS 86318 IMMUNOASAY INFECTIONUS AGENT IMMUNOASAY NFCT AGT ANTB No approval required QUAL/SEMIQUAN 1 STEP 86320 SERUM IMMUNOELECTROPHORESIS IMMUNOELECTROPHORESIS IMUNOELECTROPHORESIS 8 OTHER 5 REQUIRED 8C IMMUNOELECTROPHORESIS PREDICTION OTHER No approval required LIQUID CONCENTRATION 86327 IMMUNOELECTROPHORESIS CROSSED No approval required 86329 IMMUNODIFFUSION NES IMMUNODIFFUSION NOT ELSEWHERE No approval required SPECIFIED 86331 IMMUNODIFFUSION OUCHTERLONY IMMUNODIFFUSION GEL DIFFUSION No app required roval QUAL EA AG/ANTBDY 86332 EXAMINATION DEVELOPMENT OF THE IMMUNE COMPLEX TESTING OF IMMUNOLOGICAL 86332 IMMUNODIFFUSION IMMUNODIFFUSION I3MM TESTING 4-6 PHORESIS SERUM IMMUNOFIXJ ELECTROPHORESIS No approval required SERUM 86335 IMMUNFIX E -FORSIS/ URINE/CSF IMMUNOFIXJ ELECTROPHORESIS OTHER No approval required LIQUID 86336 INHIBIN A INHIBIN A No approval required 86337 INSULIN ANTIBODIES INSULIN ANTIBODIES No approval required 86340 INDRISIBODIC INTRINSIC FACTOR 8 6341 ANTIBODY TO CELLS WILL NOT ISLAND CELL ISLET ANTIBODY No authorization required 86343 LE UKOCYTE HISTAMINE RELEASE LEUKOCYTE HISTAMINE RELEASE TEST No authorization required LHR 86344 LEUKOCYTE PHAGOCYTOSIS LEUCOCYTE PHAGOCYTOSIS No authorization required 86352 CELL FUNCTION ANALYSIS W/STIM CELL FUNCTION ANALYSIS STIMULUS No authorization required 5 LYMPHOCYTE TR MIT OGEN/AG Not required approval INDUCED BLASTOGENESIS 86355 B TOTAL CELL COUNT B TOTAL CELL NUMBER Approval not required 86356 MONONUCLEAR CELL ANTIGEN MONONUCLEAR CELL ANTIGEN No approval required QUANTITATIVE NUMBER EA 86357 NK CELLS TOTAL CELL COUNT NATURAL KILLER TOTAL NUMBER No approval required NUMBER 8635 CELL TOTAL TNO. 6360 ABSOLUTE T-CELL COUNT/ RATIO ABSOLUTE T-CELL COUNT CD4&CD8 No authorization required RATIO 86361 ABSOLUTE T-CELL COUNT ABSOLUTE CD4 T-CELL COUNT No authorization required 86367 TOTAL STEM CELL NUMBER TOTAL STEM CELL NUMBER No authorization required 86376 MICRODYOMAL ACHANT A MICROS u th Required 86382 VIRUS NEUTRALIZATION TEST VIRUS NEUTRALIZATION TEST VIRAL No authorization required 86384 NITROBLUE TETRAZOLIUM DYE NITROBLUE TETRAZOLIUM DYE TEST No authorization required NTD 86386 NUCLEAR MATRIX PROTEIN 22 NUCLEAR MATRIX PROTEIN 22 NMP22 No authorization SCRN PARTICLE AGGLUTINATION EXAMINATION No authorization required EACH ANTI BODY 86406 AGGLUT PARTICLE ANTBDY TITR AGGLUTINATION TITER PARTICLES EACH No Auth Required ANTIBODIES 86430 RHEUMATOID FACTOR TEST QUAL RHEUMATOID FACTOR QUALITATIVE No Auth Required 86431 REUMATOID FACTOR QUANTITATIVE RHEUMATOID FACTOR 8 M4 REQUIRED No TSUMM AUT. CELL MEDIATED ANTIGEN RESPONSE No approval required GAMMA INTERFERON 86481 TB AG RESPONSE T-CELL SUSP TB ANTIGEN RESPONSE GAMMA No approval required INTERFERON T-CELL SUSP 86485 CANDIDA SKIN TEST CANDIDA SKIN TEST No approval required 86486 SKIN TEST NO ANTIGEN SKIN T TEST UNINVITED ANTIGEN COCC no Authen SKIOS90 Kvi 8 SKIOS90 SKIN 8 SKIOS90 EST COCCIDIOIDOMYCOSIS No approval required 86510 HISTOPLASMOSIS SKIN TEST HISTOPLASMOSIS SKIN TEST No approval required 86580 TB INTRADERMAL TEST SKIN TEST TUBERCULOSIS No approval required INTRADERMAL 86590 STREPTOKINASE ANTICOF STREPTOKINASE ANTICOF No approval required 865 59 PTRES TQUANTIL TQUALTON TQUAL-TIL TQUALIN PONEMAL No QUAL ANTIBODY approval required

86593 SYPHILIS TEST NON-TREP QUANTITATIVE SYPHILIS TEST QUANTITATIVE No approval required 86602 ANTINOMYCES ANTIBODY ANTIBODY ACTINOMYCES No approval required 86603 ADENOVIRUS ANTIBODY AuthenOVIRUS A6 6 CLAIM ODY ANTIBODY ASPERGILLUS No approval required 86609 BACTERIUM ANTICODY ANTICODY BACTERIUM NO No approval required OTHER S TED SPECIFIC IRANI 86611 BARTONELLA ANTIBODY ANTICODY BARTONELLA No approval required 86612 BLASTOMYCES ANTIBODY ANTICODY BLASTOMYCES No approval required 86615 BORDETELLA ANTIKOF ANTICOF BORDETELLA No approval required 86617 I No approval required TST CONFIRMATION 86618 LYME DISEASE ANTIBODY BORRELIA BURGDORFERI No approval required LYME DISEASE 86619 BORRELIA ANTIBODY ANTITI JELO BORRELIA RELAPSING FEVER No approval required 86622 BRUCELLA ANTIBODY BRUCELLA ANTIBODY No authorization required 86625 CAMPYLOBACTER ANTIBODY ANTICODY CAMPYLOBACTER No authorization required 86628 CANDIDA Auth 86628 CANDIDA ANTITIO 8 MYDIA ANTICODY CHLAMYDIA ANTIBODY No authorization required 86632 CHLAMYDIA IGM ANTICODY CHLAMYDIA IGM ANTIBODIES 8666 35 COCCIDIOIDES ANTIKOF ANTIKOF COCCIDIOIDES No approval required 86638 Q FEVER ANTICOPH ANTICOF COXIELLA BURNETII Q FEVER No approval required 86641 CRYPTOCOCCUS ANTISTOF ANTISTOF CRYPTOCOCCUS No 6IBODCY4 IRUS CMV No approval required 86645 CMV ANTIBODY IGM ANTIBODY CYTOMEGALOVIRUS CMV No approval required IGM 86648 DIPHTHERIA ANTICODY ANTICODY DIPHTHERIA No approval required 8665 1 ENCEPHALITIS CAL IFORN ANTBDY ANTIBODIES ENCEPHALITIS CALIFORNIA No approval required LA CROSSE 86652 ENCEPHALITIS EAST EQNE ANBDY ANTIBODY ENCEPHALITIS ENCEPHALITIS EAST 6 TØST 6 STOUCH 6 ANTIBODY ANTIBODY ENCEPHALITIS ST. LOUIS No approval required 86654 ENCEPHALTIS WEST EQNE ANTBDY ANTBDY ENCEPHALITIS WESTRN No approval required EQUINE 86658 ENTEROVIRUS ANTIBODY ENTEROVIRUS ANTBDY No approval required 86663 IBODIBODI- EBRR EPANTIBODY-No. Approval required EARLY ANTIGEN EA 86664 EPSTEIN-BARR NUCLEAR ANTIGEN ANTICODY EPSTEIN-BARR EB VIRUS No approval required NUCLEAR AG EBNA 86665 EPSTEIN-BARR CAPSID VCA ANTIBODY EPSTEIN-BARR EB VIRUS No approval required VIRAL CAPSID VCA 86666 EHRLI CHIA ANTIBODY EHRLICHIA 86666 REQUIRED D FRANCISELLA TULARENSIS No approval required 86671 FUNGUS NES ANTIBODY ANTICODE FUNGUS NOT ELSEWHERE No approval required SPECIFIED 86674 GIARDIA LAMBLIA ANTIBODY ANTIBODY GIARDIA LAMBLIA No approval required 86677 HELICOBACTER PYLORI ANTIBODY ANTIBODY H ELICOBACTER PYLORIRIBODY approval i 86677 HELICOBACTER PYLORI ANTIBODY O ANTICODY HELICOBACTER PYLORIRIGORIATION needed C6thlinical Review and 86677 HELICOBACTER PYLORI IBODY HELMINTH NO OTHERS No approval required STATED 86684 ANTIBODY TO HEMOPHILUS INFLUENZA ANTIBODY TO HEMOPHILUS INFLUENZA No approval required 86687 HTLV-I ANTIBODY ANTIBODY HTLV-I No approval required 86688 HTLV-II ANTIBODY HT LV-II No approval required 86689 HTLV/ HIV CONFIRM ANTIBODY ANTIBODY Auth. Auth 6692 HEPATITIS DELTA AGENT ANTBDY ANTIBODY HEP DELTA AGENT No authorization required 86694 HERPES SIMPLEX NES ANTBDY ANTICOF HERPES SMPLX NON- No authorization required SPECIFIC TYPE TEST 86695 HERPES SIMPLEX TYPE 1 TEST ANTICOF HERPES SMPLX TYPE 1 No no SIMPLEX TYPE 6 TEST 6692 Required 6 TEST HERPES SMPLX TYPE 2 No approval required 86698 HYTOPLASMA Antibodies antibodies histoplasma No author Required 86704 HEP B CORE ANTICOF TOTAL HEPATITIS B CORE ANTICOF HBCAB No approval required TOTAL 86705 HEP B CORE ANTICOF IGM HEPATITIS B CORE ANTICOF HBCAB No approval required ANTISTOF 86705 HEP B CORE ANTICOF IGM HEPATITIS B CORE ANTICOF HBCAB No approval required IGM ANTISTOF 86705 ODY HBSAB No approval required 86707 HEPATITIS BE ANTIBODY HEPATITIS BE ANTIBODY HBEAB No approval required 86708 HEPATITIS A ANTIBODY HEPATITIS A ANTISTOF HAAB No approval required 86709 HEPATITIS A IGM ANTISTO F FLUENZA VIRUS None authorization required 86711 JOHN CUNNINGHAM ANTIBODY ANTIBODY JOHN CUNNINGHAM VIRUS No authorization required 86713 LEGIONELLA ANTIBODY LEGIONELLA ANTIBODY No authorization required 86717 LEISHMANIA ANTICODY ANTICODY LEISHMANIA No authorization required 86720 LEPTOSPIRA ANT IBODY ANTICODY LEPTOSPIGEN MOUTHNOLISTER 3 LISTERIACYTOGEN MONOTOGEN No authorization required approval 86727 LYMPH CHORIOMENINGITIS AB ANTISTOF LYMPHOCYTIC No approval required CHORIOMENINGITIS 86732 MUCORMICOSIS ANTIBODY ANTICODY MUCORMICOSIS No approval required 86735 MUMPS ANTICOF ANTICOF ANTITIOF MUMPS No approval required 86738 MYCOPLSMA ANTICOF ANTICOF MYKOPLSM No approval required 86741 NEISSERIA MENINGITIDIS ANTIBODY NEISSERIA AuthentiODY 8 Y NO CARDIA No approval required 86747 ANTIBODY ABOUT PARVOVIRUS ANTIBODY PARVOVIRUS Not required authorization 86750 MALARIA ANTIBODY ANTIBODY PLASMODIUM MALARIA No authorization required 86753 PROTOZOA ANTIBODY NOSE ANTIBODY PROTOZOA NES No authorization required 86756 RESPIRATORY VIRUS ANTIBODY ANTICODY RESPIRATORY SYNCTIAL No authorization required VIRUS 86757 RICKETSIA 5 Auth 9 ROTAVIRUS ANTIBODY ANTIBODY ROTAVIRUS No authorization required 867 62 RUBELEA ANTIBODIES BODY RUBELLA ANTIBODIES It is not approval required 86765 RUBEOLA ANTIBODY RUBEOLA ANTIBODY No approval required 86768 SALMONELA ANTIBODY SALMONELA ANTIBODY No approval required 86771 SHIGELLA ANTIBODY ANTICODY SHIGELLA No approval required 86774 TETANUS ANTIBODY ANTICODY TODIBODY ANT 7S ANTIBODY ANTICOD Y TOXOPLASMA ANTIBODY No approval required 86778 TOXOPLASMA ANTISTOF IGM ANTIBODY TOXOPLAM SMA IGM No approval required 86780 TREPONEMA PALLIDUM ANTIBODY TREPONEMA PALLIDUM No approval required

86784 TRICHINELLA ANTIBODY TRICHINELLA ANTIBODY No approval required 86787 VARICELLA-ZOSTER ANTIBODY VARICELLA-ZOSTER ANTIBODY No approval required 86788 WEST NILE VIRUS AB IGM ANTNIBODIR W8 ANTIBODY W8 I 8 LE VIRUS ANTIBODY ANTICOD Y WEST NILE VIRUS No approval required 86790 VIRUS ANTIBODY NOSE ANTIBODY O VIRUS NO OTHER TEST No approval required SPECIFIED 86793 ANTIBODY TO YERSINIA VIRUS YERSINIA No approval required 86794 ANTIBODY TO ZIKA VIRUS IGM ANTICOF ANTIBODY TO ZIKA VIRUS No approval required 86794 ANTIBODY TO ZIKA VIRUS IGM ANTIBODY TO ZIKA VIRUS IGM No approval required 86794 IBODY No application required roval 86803 HEPATITIS C AB HEPATITIS C ANTIBODY TEST No approval required 86804 HEP C AB TEST CONFIRM HEPATITIS C ANTIBODY CONFIRM No approval required TEST 86805 LYMPHOCYTOTOXICITY ANALYSIS LYMPHOCYTOTOXICITY TEST SHOW No approval required CROSSMATCH TITRATE 86806 LOCITOTOXICITY IMFAUT. SSMTCH U/O TITRATE 86807 CYTOTOXIC ANTIBODIES SERUM CHECK CHECK % REACTIVE No approval required ANTIBODIES STANDARD METH 86808 CYTOTOXIC ANTIBODIES SERUM CHECK CHECK % REACTIVE No approval required ANTIBODIES QUICK METH 86812 HLA TYP ING A B OR C HLA TYPING A/B/C SINGLE ANTIGEN None approvals Required 86813 A B OR C HLA ANTIGEN TYPING Approval not required 86816 HLA TYPING DR/DQ HLA TYPING DR/DQ SINGLE ANTIGEN No approval required 86817 HLA TYPING DR/DQ HLA TYPING DR/DQ MULTIPLE No approval required ANTIGENS 86821 LYMPHO CYTE HOLE CULTURE required MIXED 86825 HLA X-MATH NON -CYTOTOXIC HLA CROSSMATCH NON-CYTOTOXIC 1ST No approval required SERUM/DILUTION 86826 HLA X-MATCH NONCYTOTOXC ADDL HLA CROSSMATCH NON-CYTOTOXIC No approval required. ASS II No approval required ANTIGENS QUAL 86829 HLA CLASS I/II ANTISTOF QUAL ANTISTOF HLA CLASS I OR CLASS II No approval required ANTIGENS QUAL 86830 HLA CLASS I PHENOTYPE QUAL ANTISTOF HLA CLASS I PHENOTYPE No approval required PANEL QUALITATIVE 86830 H LA CLASS I PHENOTYPE II PHENOTYPE No approval required PANEL QUAL 86832 HLA CLASS I HIGH DEFIN QUAL ANTIBODY HLA CLASS I HIGH No approval required DEFINITION PANEL QUAL 86833 HLA CLASS II HIGH DEFIN QUAL ANTISTOF HLA CLASS II HIGH No approval required DEFINITION PANEL QUAL QUAL HMICLAN HMI 6 P ANEL QUAL QUAL 8 ASS I No approval required SEMI-QUANTITATIVE PANEL 86835 HLA CLASS II SEMI-QUANTITATIVE PANEL ANTICOF HLA CLASS II No approval required SEMI-QUANTITATIVE PANEL 86849 IMMUNOLOGICAL PROCEDURE UNSETTLED IMMUNOLOGY Approval required Pathology and laboratory Complete clinical examination 86850 RBC SERIES RBC 8685 0 SCREEN RBC SERIES RBC TECHNIQUE required 86860 RBC ANTISTOF ELUTION ANTISTOF ELU TION RBC EACH ELUTION No approval required 86870 RBC ANTIBODIST IDENTIFICATION ANTITIOD ID RBC ANTIBODIES EA No approval required PANEL EA SERUM TQ 86880 COOMBS TEST DIRECT ANTIHUMAN GLOBULIN DIRECT EACH No approval required ANTISERUM TQUAL6 ANTISERUM 5 I IND IR QUAL EA No approval required REAGENS CELL 86886 COOMBS TEST INDIRECT TITER ANTIHUMAN GLOBULIN INDIRECT EACH No authorization required ANTIBODISTIC TITER 86890 AUTOLOG BLOOD PROCESS AUTOL BLD/COMPONENT COLLJ No authorization required STORAGE PREDEPOSITED 86891 AUTOLOGOUS BLOOD OP CALCULATION 86 0 BLOOD GROUP SEROLOGIC ABO BLOOD TYPING SEROLOGIC ABO No authorization required 86901 BLOOD YPNING SEROLOGICAL RH(D) BLOOD GROUP SEROLOŠKI RH (D) No approval required 86902 BLOOD GROUP ANTIGEN DONOR EA BLOOD GROUP ANTIGEN DONOR REAGENT No approval required SERUM 86902 BLOOD GROUP ANTIGEN DONOR EA BLOOD GROUP ANTIGEN DONOR REAGENT No approval required SERUM 6TYPE 4 ANTIGEN CHECK No approval required PATIENT SERUM/ UNIT 86905 BLOOD GROUP RBC ANTIGENS BLOOD GROUP RBC ANTIGEN p No approval required OTH/THN ABO/RH D EACH 86906 BLD TYPING SEROLOGY RH PHNT BLOOD GROUP SEROLOGY RH No approval required PHENOTYP 869 COMPTENOTYP 869 B CLICK TYPING PATERNITY PR INDIV No approval required ABO RH&MN 86911 BLOOD GROUP ANTIGEN SYSTEM BLOOD GROUP PATERNITY INDIV ADDL No approval required ANTIGEN SYS 86920 COMPATIBILITY TEST SPIN COMPATIBILITY EACH UNIT CURRENT No approval required SPIN TECH 86920 COMPATIBILITY COMPATIBILITY 8 6920 Approval required 86922 COMPATIBILITY TEST ANTIGLOBE COMPATIBILITY EACH J UNITS Not required approval ANTIGLOBULIN 86923 COMPATIBILITY TEST ELECTRICAL COMPATIBILITY OF EACH UNIT ELECTRO LOW No approval required 86927 PLASMA FRESH FROZEN FRESH FROZEN PLASMA THAW No approval required. 86931 FROZEN BLOOD THAWING FROZEN BLOOD EACH UNIT THAWING No approval required 86932 FROZEN BLOOD FREEZING/OPTINING FROZEN BLOOD EACH UNIT FREZING & No approval required OPTINING 86940 HEMOLYSINS/AGGLUTININ AUTO HEMOLYSINS&AGGLUTININ AUTO No approval required SC REEN EACH 86941 HEMOLYSINS/AGGLUTININS GGLUTINS No. 45 BLOOD PRODUCT/RADIATION RADIATION BLOOD PRODUCT EACH No approval required UNIT 86950 LEUCOCYTE TRANSFUSION LEUCOCYTE TRANSFUSION No approval required 86960 VOL. BY TROMBLES AT POOLING PLATES Auth.

86970 RBC PRETX INCUBATJ W/CHEMICL PRETX RBC ANTIBODIES INCUBAT Approval not required W/KEM AGNTS/DRUGS EA 86971 RBC PRETX INCUBATJ W/ENZYMES PRETX RBC ANTITIO INCUBAT Approval not required W/ENZJSTX W/ENZJS PRETX RBC ANTITOBY INC UBAT None approvals required M/DENSITY GRADE SEP 86975 RBC SERUM PRETX INCUBJ MEDICINES PRETX SERUM RBC ANTIBODY No authorization required INCUBATION MEDICALS EACH 86976 RBC SERUM PRETX ID DILUTION PRETX SERUM RBC ANTIBODY ID Required 7C ANTIBODY No AuthRE 7C TX INCUBJ/INHIB PRETX S ERUM RBC ANTB ID no. Approval required INCUBATION INHIBITORS EA 86978 RBC PRETX SERUM PRETX SERUM RBC ANTIBODIES ID DIFFIAL Approval not required. EACH ABSRPJ 86985 BROKEN BLOOD OR BLOOD BROKEN PRODUCTS/BLOOD PRODUCTS E8 TRUTTRANCE U99. TRANSFUSION MEDICINE Approval Required General Medicine - Other Full Clinical Review PROCEDURE Services & Procedures 87003 SMALL ANIMAL INOCULATION ANIMAL INOCULATION SMALL ANIMAL Approval not required W/OBS&DSJ 87015 SAMPLE INFECT AGNT CONCENTRATION INFECTIOUS AGENTS CONCENTRATION Approval not required 8 7015 SAMPLE INFECT AGNT CONCNTJ CONCENTRATION INFECTIOUS AGENCIES None approvals Required for 87015 BLOOD AEROBIC No approval required W/ID ISOLATES 87045 FACES CULTURE AEROBIC BACT CUL BACT SCALE AEROBIC ISOL No approval required SALMONELLA&SHIGELL 87046 Stool CULTR AEROBIC BACT EA CUL BACT Stool AEROBIC ADDL No approval required PATHOGEN&ID EA 87070 CULTURE SECOND SPECIMEN FOR AEROBIC . AEROBISOL 87071 CULTURE AEROBIC QUANT OTHER CUL BACT QUAN AEROBIC ISOL XCPT UR No BLOOD/FEKT approval required 87073 BACTERIA CULTURE ANAEROBIC CUL BACT QUAN ANAERC ISOL XCPT UR No BLOOD/FEKT approval required 87075 BACTERIA CULTURE OTHER ISO BACTER AUT. & ID 87076 Culture anaerobic Ident Each Cul Bact Anaerobic Addl Meths No Claim Definite EA ISOL 87077 Culture Aerobic Identify Cul Bact Aerobic Addl Meths No Culture Screen Oly Cul Pthg L psmptv PTHGNC ORGANISMS No approval required SCR DNS FORM 87086 URINE CULTURE/BACTERIA COLONY COUNT QUANTITATIVE No approval required COLON COUNT URINE 87088 URINE BACTERIA CULTURE CULTURE BCT ISOL&PRSMPTV ID no. GI-FORM/YEAR PRSMPTV ID no. Approval required SKN HAIR/NAILS 87102 ISOLATION OF FUNGI CULTURE FNGI SOUL CULTURE/YEAST PRSMPTV No approval required OTHER XCPT BLOOD 87103 BLOOD CULTURE FUNGUS CULTURE FNGI SOUL/YEAST ISOL No approval required 87100 FUNC. UTH required 87107 Form for identification Fungus Culture Fungus definite ID of each no need to approval the form of the organism 87109 Mycoplasma Culture of Mycoplasma any Source No 87110 Culture Klmidija Culture of any Source does not need the approval of CCOUROT CULTE- CULTYBERE CULTY-16 FAST ISOL 87118 IDENTIFICATION OF MYCOBACTERIA CULTURE MYCOBACTERIAL DEFINITIVE No Authorization required 87140 CULTURE TYPE IMMUNOFLUORESC CULTURE TYPING No Authorization required 87143 CULTURE TYPING GLC/HPLC CULTURE TYPING GAS/HIGH PRESSURE LIQUID No authorization required 87147 CULTURE TYPING NO CULTURE TYPE PE Auth 87 149 DNA/RNA DIRECT CULTURE TEST TYPING NUCLEIC ACID PROBE None Auth Required 87150 DNA/RNA AMPLIFIED PROBE CULT TYPE NUC ACID AMP PRB No authorization required 87152 TYPE CULTURE PULSE FIELD GEL CULTURE TYPING IDENTIFJ PULSE FIELD No authorization required 87153 DNA/RNA SEQUENCE AKULTY 8 REQUIRED 87153 DNA/RNA TYPING ADDED SEQUENCES KULTY5 URE METHOD CARB TOUR TYPING OTHER METHODS No approval required 87164 DARK POLE EXAMINATION ANY SOURCE No approval required W/SAMPLE COLLECTION 87166 DARK POLE EXAMINATION ANY SOURCE IN/U No approval required SPECIMEN COLLECTION M8SCOP 6 EXAMINATION No approval required ARTHROPODA 8716 9 MACROSCOPIC EXAMINATION OF PARASITES MACROSCOPIC EXAMINATION OF PARASITES No approval required 87172 SHIRT INSPECTION SHIRT INSPECTION No approval required 87176 TISSUE HOMOGENIZATION CULTURE TISSUE CULTURE HOMOGENIZATION No approval required 87177 OPARSEARASITES AND MASSUT Re required CONCENTRATION & ID 87181 MICROBES AFTER DIF STDY ANTIMICROBIAL SENSITIVITIES No approval required AG NT AGAR DILUTJ 87184 MICROBE FOLLOWING DISC MODERATE ANTIMICROBIAL STUDY No approval required DISC METHOD 87185 MICROBIAL SATISFACTION STUDY ANTIMICROBIAL No approval required 67185 MICROBIAL ENZYME STUDY ANTIMICROBIAL No approval required 67185 MICRO BIAL ENZYME SATISFACTION STUDY ANTIMICROBIAL No approval required 671 85 STUDY OF SATISFACTION WITH MICROBIAL ENZYMES ANTIMICROBIAL DELIGHEDSTUDIE ANTIMICROBIEL No approval required 6 TIBLTY STDY ANTIMICRBIAL No approval required MICRO/AGAR DILUTJ 87187 MICROBE SUSCEPTIBLE MLC SUSCEPTIBLTY STDY ANTMCRB No approval required MICRO /AGAR DILUTJ EA 87188 MICROBE SUSCEPT MACROBROTH SC STD ANTMCRB AGT MACROBROTH No approval required DIL METH EA AGT 87190 SUSCEPTIBILITY TO MYCOBACTERIAL SUSCEPTIBILITY ON MICROBES STDY ANTMCRB AGT MACROBROTH No approval required B87190 MICROBE SUSCEPT MYCOBACTERI SUSCEPTIBLTY STDY ANTMCRBOR MJCOMTID 7 SERUM LEVEL REQUIRED SERUM BACTERICIDAL TITERS No approval required 87205 GRAM STAIN SMR PRIM SRC GRAM/GIEMSA-FLET No approval required BCT FUNGI/CELLS 8 7206 BRAZIS FLUORESCENT /ACID STAI SMR PRIM SRC FLUORESCENT&/AFS BCT No authorization required FNGI PARASIT 87207 SMEAR SPECIAL- FLEVE SMR PRIM SRC SPEC SPEC BOD Auth

87209 SMEAR COMPLEX STAIN SMR PRIM SRC CPLX SPEC STAIN No approval required OVA&PARASITS 87210 SMEAR WET MOUNT SALINE/INK SMR PRIM SRC WET MOUNT NFCT AGT No approval required 87220 TISSUE EXAMINATION KOH FUNGI SVO/FN FUNGI Auth/Fungi / ECTOPARASIT 87230 POISON OR ANTITOXIN TEST TOXIN/ANTITOXIN ANALYSIS TISSUE No approval required CULTURE 87250 VIRUS INOCULATION EGG/ANIMAL VIRUS INOCULATION EGG/SM ANIMAL No approval required OBSIR2SULDSJ T87202SJUDSJ ATION No approval required CYTOPATHIC EFFECT 87253 VIRUS INOCULATION TISSUE ADDL VIRUS TISSUE CULTURE ADDL STDY/ID no. approval required EACH ISOLATE 87254 VIRUS INOCULATION SHELL VIA VIRUS CENTRIFUGE ENHNCD ID no. approval required IMFLUOR STAIN EA 87255 GENETIC VIRUS ISOLATE HSV VIRUS ID NO. DENOVIRUS AG IF IAADI ADENOVIRUS No authorization required 87265 PERTUSSIS AG IF IAADI BORDETELLA No authorization required PRTUSSIS/PARAPRTUSSIS 87267 ENTEROVIRUS ANTIBODY DFA IAADI ENTEROVIRUS DIRECT No authorization required FLUORESCENT ANTIBODY 8726IF Not required CH7 Auth LAMYDIA TRACHOMATIS AG IF IAADI CHLAMYDIA TRACHOMATIS No veterinary authorization required 87271 CYTOMEGALO VIRUS DFA IAADI CYTOMEGALOVIRUS DIR No authorization required FLUORESCENT ANTIBODY 87272 CRYPTOSPORIDIUM AG IF IAADI CRYPTOSPORIDIUM No authorization required 87273 HERPES SIMPLEX 2 AG IF IAADI HERPES SMPLX VIRUS TYPE 2 HERPES AG 7 7 Auth 2 No. HERPES SMPLX VIRUS TYPE 1 No approval required 87275 INFLUENZA B AG IF IAADI INFLUENZA B VIRUS No approval required 87276 INFLUENZA A AG IF IAADI INFLUENZA A VIRUS No approval required 87278 LEGION PNEUMOPHILIA AG IF IAADI LEGIONELLA PNEUMOPHILA No approval required 87278 LEGION PNEUMOPHILIA AG ACH No approval required TYPE 87280 RESPIRATORY SYNCYTIAL AG IF IAADI RESPIRATORY SYNCYTIAL VIRUS No approval required 87281 PNEUMOCYSTIS CARINII AG IF IAADI PNEUMOCUSTIS CARINII No approval required 87283 RUBEOLA AG IF IAADI RUBEOLA No approval required 87285 TREPONEMA PALLIDUM AG No IF IAADI ZOSTER AG IF IAADI VARICELLA ZO STAR VIRUS No authorization required 87299 DETECTION OF ANTIBODIES NOSE IF IAADI NOT OTHERWISE SPECIFIED EACH No authorization required ORGANISM 87300 AG DETECTION POLYVAL IF IAADI POLYV MLT ORGANISMS EA No authorization required POLYV ANTISERUM 87301 ADENOVIRUS AG IADENOVIRUSIA Auth IA 4 A UTICIA 10 Auth. 7305 ASPERGILLUS AG IA IAAD IA QUAL/ SEMIQUAN MULTIPLE No authorization required TRIN ASPERGILLUS 87320 CHYLMD TRACH AG IA IAAD IA CHLAMYDIA TRACHOMATIS No authorization required 87324 CLOSTRIDIUM AG IAAD IA CLOSTRIDIUM DIFFICILE TOXIN no. Auth CRYPTOCOCCUS NEOFORMANS No authorization required 87328 CRYPTOSPORIDIUM AG IA IAAD IA CRYPTOSPORIDIUM No authorization required 87329 GIARDIA AG IA IAAD IA GIARDIA No authorization required 87332 CYTOMEGALOVIRUS AG IA IAAD IA CYTOMEGALOVIRUS No authorization required 87335 E COLI 0157 AG IA IAAD IA 87332 CYTOMEGALOVIRUS AG IA IAAD IA COLICHE 0157 AG IA IAAD IA DK 3 EB HIST DISPR AG IA IAAD IA ENTAMOEBA HISTOLYTICA No authorization required DISPAR GRP 87337 ENTAMOEB HIST GROUP AG IA IAAD IA ENTAMOEBA HISTOLYTICA GRP No authorization required 87338 HPYLORI CHAIR IA IAAD IA HPYLORI CHAIR No authorization required 87339 H PYLORI AG IA IAAD IA HPYAT 8 B00 Required authorization IA IAAD IA HEPATITIS B SURFACE ANTIGEN No authorization required 87341 HEPATITIS B SURFACE AG IAAD IA HEPATITIS B SURFACE AG No authorization required. GEN No approval required 87385 HITOPLASMA CAPSUL AG IA IAAD IA HISTOPLASM CAPSULATUM No approval required 87389 HIV-1 AG W/HIV-1 & HIV-2 AB IAAD IA HIV-1 AG W/HIV-1 & HIV-2 No approval required ANTBDY SINGLE 87390 HIV-1 AG IA IAAD IA HIV-1 No approval required 87391 HIV-2 AG IA IAAD IA HIV-2 No approval required 87400 INFLUENZA A/B AG IA IAAD IA INFLUENZA A/B EACH No approval required 87420 RESP SYNCYTIAL AG IA IA IA REQUIRAD IA RESPICT 87425 ROTAVIRUS AG IA IAAD IA ROTAVIRUS No authorization required 87427 SHIGA-LIKE TOXIN AG IA IAAD IA SHIGA-LIKE TOXIN No authorization required 87428 SARSCOV & INF VIR A&B AG IA IAAD IAAD IA Auth & SAREN 7430 STREP A AG IA IAAD IA STREPTOCOCCUS GROUP A No approval required 87449 AG DETECT NOS IA MULT IAAD IA MULTI-STEP METHOD NO. EACH No approval required ORGANISM 87451 AG DETECT POLYVAL IA MULT IAAD IA POLYV MLT POLYVAL ORGANISM required 7 B DNA AMP PROBE IADNA BARTONELLA AMPLIFIED HEALTH No approval required TECH 87472 BARTONELLA DNA QUANT IADNA BARTONELLA No approval required HENSELAE&Q UINTANA QUANTJ 87475 LYME DIS DNA DIR PROBE IADNA BORRELIA BURGDORFERI DIRECT No approval required 8RR7 PROBE TAMPEL DNA AND URGDORFERI No approval required AMPLIFIED PROBE TQ 87480 CANDIDA DNA DIR PROBE IADNA CANDIDA ART DIRECT PROBE No approval required TQ 87481 CANDIDA DNA AMP PROBE IADNA CANDIDA SPECIES AMPLIFIED No approval required PROBE TQ 87482 CANDIDA DNA QUANT IADNA CANDIDA ART No approval required CBE QUANTIFIC QUANTIFIC QUANTIFIC QUANTIFIC QUANTIFIC QUANTIFIC QUANTIFIC 87482 CNS DNA/RNA AMP PROBE MORE

87486 CHYLMD PNEUM DNA CLAMYDIA PNEUMONIAE No approval of the Amplified Pneum DNA Quantity Idna Chlamydia Pneumoniae No approval Quarterification 87486 No approval Direct probe TQ 87491 CHY LMD CALL DNA Chomatis No Authorization Veterinarian Amplified Probe TQ 87492 CHYLMD TRACH DNA QUANT IADNA CHLAMYDIA TRACHOMATIS No Authorization Required QUANTIFICATION 87493 C DIFF AMPLIFIED PROBE INF AGENT NUCLEIC ACID No Authorization Required 7AMP5 PROBERIUM 8749G ADNA CYTOMEGALOVIRUS DIRECT No Authorization Required 87496 CYTOMEG DNA AMP PRO BE IADNA CYTOMEGALOVIRUS AMPLIFIED No Authorization Required 97 CYTOMEG DNA QUANT IADNA CYTOMEGALOVIRUS No approval required 87498 ENTEROVIRUS PROBE&REVRS TRNS IADNA ENTEROVIRUS AMPLIF PROBE & No Auth DNA0AMPY 87498 No approval required 87501 INFLUENZA DNA AMP PROB 1+ INFECTIONUS AGENT DNA/RNA No approval required 87502 INFLUENZA DNA AMP PROBE INFE CAUSE DNA/RNA No approval required 87503 INFLUENZA DNA AMP PRO B ADDL NFCT AGENS DNA/RNA INFLUENZA >2 No authorization required 87505 NFCT AGENT DETECTION Auth PATHOGEN 87506 IADNA-DNA/RNA PROBE TQ 6-11 IADNA-DNA/RNA GI PTHGN MULTIPLEX No authorization required PROBE TQ 6-11 11 87507 IADNA-DNA/RNA PROBE TQ 6-11 RNA PROBE TQ 12-25 IADNA-DNA/RNA required AUT GI PTH PROBE TQ 12-25 87510 GARDNER VAG DNA DIR PROBE IADNA GARDNERELLA VAGINALIS No approval required DIRECT PROBE TQ 87511 GARDNER VAG DNA AMP PROBE IADNA GARDNERELLA VAGINALIS No approval required AMPLIFIED VAGINALIS GQUANTAAGNER TQ G8NTAAGNER TQ 87511 S No approval required QUANTIFICATION 87516 HEPATITIS B DNA AMP PROBE IADNA HEPATITIS B VIRUS AMPLIFIED No approval required PROBE TQ 87517 HEPATITIS B DNA QUANTITY IADNA HEPATITIS B VIRUS No approval required QUANTIFICATION 87520 HEPATITIS C RNA DIR PROBE IADNA DIRECT PROBE 7 ITIS C PROBE&RVRS TRNSC IADNA HEPATITIS C AMPLIFIED No Authorization Required PROBE&REVRSE TRANSCR 87522 HEPATITIS C REVRS TRNSCRPJ IADNA HEPATITIS C QUANT & REVERSE No Authorization Required TRANSCRIPTION 87525 HEPATITIS G DNA DIR PROBE IADNA HEPATITIS G DIRECT PROBE No Auth NA HEPATITIS G AMPLIFIED PROBE No Authorization Required TECH 8752 7 HEPATITIS G DNA QUANT IADNA HEPATITIS G QUANTIFICATION No Authorization Required 87528 HSV DNA DIR PROBE IADNA HERPES SIMPLX VIRUS DIRECT No Authorization Required PROBE TQ 87529 HSV DNA AMP PROBE IADNA PROBE IADNA PROBE IADNA HERPES SIMPLX VIRUS DIRECT No Authorization Required. No A7 SV DNA QUANT IADNA HERPES SOMPLX VIRUS No authorization required QUANTIFICATION 87531 HHV-6 DNA DIR PROBE IADNA HERPES VIRUS-6 DIRECT PROBE No authorization required TQ 87532 HHV-6 DNA AMP PROBE IADNA HERPES VIRUS-6 AMPLIFIED No authorization required PROBE TQ VHVIRUS IQUANT 8753 6 No authorization required QUANTIFICATION 87534 HIV-1 DNA DIR PROBE IADNA HIV-1 DIRECT PROBE TECHNIQUE No authorization required 87535 HIV-1 PROBE&REVERSE TRNSCRPJ IADNA HIV-1 AMPLIFIED PROBE & no authorization required REVERSE TRANSCRPJ HIV-1 HIV-1 TRANSCRPJ HIV-1 -17 TRANSCRP6 1 QUANT & REVERSE No authorization required TRANSCRIPTION 87537 HIV- - 2 QUANT & REVERSE No authorization required TRANSCRIPTION 87540 LEGION PNEUMO DNA DIR PROB IADNA LEGIONELLA PNEUMOPHILA No authorization required DIRECT PROBE TQ 87541 LEGION PNEUMO DNA AMP PROB IADNA LEGIONELLA PNEUMOPHILA 8 EUMO DNA quanta Legionella Pneumophila No approval Quantification 87550 MYCOBACT ERIA DNA DIR SPECIES DIRECT No approval Индана Антике инте табарам Антифиица 87555 M.TUBERCULO DNA DIR PROBE IADNA MYCOBACTERIA TUBERCULOSIS No approval required DIR PRB 87556 M.TUBERCULO DNA AMP PROBE IADNA MYCOBACTERIA TUBERCULOSIS No approval required AMP PRB 87557 M.TUBERCULO DNA QUANT IADNA MYCOBACTERIA TUBERCULOSIS No approval required QUANTIFIUMINB0AD MTRA76IN DNA ITRA. YCOBACTERIA AVIUM- No approval required INTRACLRE DIR PRB 87561 M.AVIUM-INTRA DNA AMP PROB IADNA MYCOBACTERIA AVIUM- No approval required INTRACLRE AMP PRB 87562 M.AVIUM-INTRA DNA QUANT IADNA MYCOBACTERIA AVIUM- No approval required INTRACLRE AMP PRB 87562 M. AVIUM -INTRA DNA QUANT IADNA MYCOBACTERIA AVIUM- No approval required INTRACLRE AMP PRB 87562 M.AVIUM-INTRA DNA QUANT IADNA MYCOBACTERIA AVIUM- No approval required INTRACELLULAR PROGRAM 87562 ASMA GENITALIUM No approval required AMPLIFIED PROBE TECH 87580 M.PNEUMON DNA PROBE IADNA MYCOBACTERIA AVIUM- No approval required No approval required DIRECT PROBE TQ 87581 M.PNEUMON DNA AMP PROBE IADNA MYCOPLSM PNEUMONIAE No approval required AMPLIFIED PROBE TQ MCOPLEUPN58 IAE No approval required QUANTIFICATION

87590 N.GONORRHOEAE DNA DIR PROB IADNA NEISSERIA GONORRHOEAE No approval required DIRECT PROBE TQ 87591 N.GONORRHOEAE DNA AMP PROB IADNA NEISSERIA GONORRHOEAE No approval required AMPLIFIED 7QUARRHOEAE N.87590 N.GONORRHOEAE DNA AMP PRO B IADNA NEISSERIA GONORRHOEAE. GONORRHOEAE No approval required QUANTIFICATION 87623 HPV LOW RISK TYPES IADNA HUMAN PAPILOMAVIRUS LOW- No approval required RISK TYPES 87624 HPV HIGH RISK TYPES IADNA HUMAN PAPILOMAVIRUS HIGH- No approval required RISK TYPES 87625 HPV TYPES 16 & I1ADUS NO. required 16 & 18 ONLY 87631 RESP VIRUS 3- 5 TARGETS IADNA BREATHING PROBE & REV no. Approval required TRNSCR 3-5 TARGET 87632 RESP VIRUS 6-11 TARGET IADNA BREATH PROBE & REV no. Approval required TRNSCR 6-11 TARGETS 87633 1 GET RESPIRS PROBE- I25 Approval required TRNSCR 12-25 TARGETS 87634 RSV DNA/RNA AMP PROBE IADNA DNA/RNA RSV AMPLIFIED PROBE No approval required TECHNIQUE 87640 STAPH A DNA AMP PROBE IADNA S AUREUS AMPLIFIED PROBE TQ No approval required 87641 METHOD AMP-AUREUSHRES DNA SAMP-AUHREUSHRES No approval required AMP PROBE TQ 87650 STREP A DNA DIR PROBE IADNA STREPTOCOCCUS GROUP A No approval required DIRECT PROBE TQ 87651 STREP A DNA AMP PROBE IADNA STREPTOCOCCUS GROUP A No approval required AMPLIFIED PROBE TQ 87651 Authorization required QUANTIFICATION 87653 STREP B DNA AMP PROBE IADNA STREPTOCOCCUS GROUP B No authorization required AMPLIFIED PROBE TQ 87660 TRICHOMONAS VAGIN DIR PROBE IADNA TRICHOMONAS VAGINALIS No authorization required DIRECT PROBE TQ 87653 TRICHOMONAS PLAYA 87660 S No authorization required AMPLIFIED PROBE TECH 87660 62 ZIKA DNA VIRUS /RNA AMP PROBE IADNA DNA/RNA ZIKA VIRUS AMPLIFIED No approval required PROBE TQ 87797 DETECT AGENT NOS DNA DIR IADNA NOS DIRECT PROBE TQ EACH No approval required ORGANISM 87798 DETECT AGENT NOS DNA AMP IADNABEUT 9 AMPLIFIED NO. AGENT NO DNA QUANT IADNA NOS QUANTIFICATION EACH No approval required ORGANISM 87800 DETECT AGNT MULT DNA DIREC IADNA MULTIPLE ORGANISMS DIRECT No approval required PROBE TQ 87801 DETECT AGNT MULT DNA AMPLI IADNA MULTIPLE A PROBEuth AMTREED 8 B ASSAY M/OPTI C IAADIADOO STREPTOCOCK GROUP B None approvals required 87803 CLOSTRIDIUM TOXIN A W/OPTIC IAADIADOO CLOSTRIDIUM DIFFICILE No authorization required TOXIN 87804 INFLUENZA ASSAY W/OPTIC IAADIADOO INFLUENZA No authorization required 87806 WOOODIB WOOODIES HIV/HIVANTIADIGEN WOOI 1 IV1 & No authorization required HIV2 ANTISTOFFERS 87807 RSV ASAY W/OPTIC IAADIADOO RESPIRATOR NOT SYNCTIC None Authorization Required VIRUS 87808 TRICHOMONAS ANALYSIS W/OPTIC IAADIADOO TRICHOMONAS VAGINALIS No Authorization Required 87809 ADENOVIRUS ANALYSIS W/OPTIC INFECTMUNOAS ANALYSIS W/OPTIC IAADIADOO TRICHOMONAS VAGINALIS No Authorization Required 87809 ADENOVIRUS ANALYSIS W/OPTIC INFECTMUNOS ANALYSIS NO. AIM08 CHYLMD TRACH ANALYSIS W/OPTIC CHLAM YDIA TRACHOMATIS No Authorization Required 87811 SARS -COV-2 COVID19 W/OPTIC IAADIADOO SEVERE AQT RESPIR SIN No Authorization Required CORONAVIRUS 87850 N. GONORRHOEAE ANALYSIS W/OPTIC IAADIADOO NEISSERIA GONORRHOEAE No Authorization Required 878880 IAADIADOO STREPOOAT Auth. Required 87899 AGENT NOS ANALYSIS W /OPTIC IAADIADOO NOT OTHERWISE SPECIFIED No approval required 87900 PHENOTYPE INFECTIOUS AGENT DRUG NFCT AGT SUSPECT DRUG PHENOTYPE No approval required PREDICTION 87901 DNA GENOTYPE HIV REVERS T NFCT GEXIDP REQUIRED HIV TREVIC NR 8 GE09 AKVI RUCLE 2 NOTIPA DNA/ RNA HEP C NFCT AGNT GENOTYPE NUCLEIC ACID No Approval Need to Know HEPATITIS C VIRUS 87903 HIV DNA PHENOTYPE W/CULTURE NFCT PHEXYP RESIST TISS CUL HIV FIRST No Approval Required 1-10 DRUGS 87904 HIV DNA PHENOTYPE W/CLT ADD NFCT PHEXYP NO. 5 SIALIDASE ENZYME ANALYSIS INFECTIOUS AGENT ENZYME ACTV No authorization required OTH/THN VIRUS 87906 HIV DNA/RNA GENOTYPE NFCT GEXYP DNA/RNA HIV 1 OTHER No authorization required REGION 87910 CYTOMEGALOVIRUS GENOTYPE ACNFCT NEGATIVE AGT Auth 87912 HEPATITIS B DNA GENOTYPE NFCT AGENTS HEPATITIS GENOTYPE B No Authorization Required VIRUS 87999 MICROBIOLOGICAL PROCEDURE UNLISTED MICROBIOLOGY Authorization Required Pathology & Laboratory Complete Clinical Examination 88000 BONE EXPOSURE (NOCROPSY) COMMITMENT GROUP GROSS EXAMINATION ONLY Required 8/00 CY5 AUTOPSY WCR00 AUTOPSY (ONLY) SS TRAINING EXAMINATION GROUP No Authorization Required W /BRAIN 8800 7 ODUCTION (NOCROPSY) GROSS NECROPSY GROSS EXAMINATION No approval required W/BRAIN & SPINE 88012 ODUCTION (NECROPSY) GROSS NECROPSY GROSS EXAMINATION No approval required DILUTION W/GRONESS CROPSY 8Y0SS AM No approval required STILLBORN/NEWBORN W /BRAIN 880 16 AUTOPSY (NOCROPSY) AUTOPSY GROUP CLOSE EXAMINATION MACERATED No approval required STILLBORN 88020 AUTOPSY (NOCROPSY) COMPLETE AUTOPSY GROSS & MICROSCOPIC U/O No CNS approval required

88025 OBDUCTION (NOCROPSY) COMPLETE NECROPSY GROSS & MICROSCOPIC No clearance required W/BRAIN 88027 OBDUTY (NOCROPSY) COMPLETE ODUCTION GROSS & MCRSCP BRAIN & no clearance required SPINAL CORD 88028 COMPROPSY) uth Required CHILD W/BRAIN 88029 AUTOPS Y (AUTOMPSY) COMPLETE ODUCTION GROSS&MCRSCP MCRSCP No Authorization Required DEAD/NEWBORN BRAIN 88036 LIMITED OBJECTION NECROPSI LIMITED GROSS&/MCRSCP No Authorization Required REGIONAL 88037 LIMITED OBJECTION NECROPSI ALIMCD NECROPSI ALIMITED 040 JUDICIAL OBJECTION (NOCROPSI) FORENSIC INVESTIGATION No Authorization Required 88045 Coroner's AUTOPSY (NOC ROPSI) NECROPSI CALL Coroner no, he didn't authorization required 88099 AUTOPSY PROCEDURE (OBDUCTION) AUTOPSY PROCEDURE NOT LISTED. Authorization required Pathology and Laboratory Complete Clinical Examination 88104 FILLING FLUSH CYTOPATH FLUSJ FLUSH CYTOPATH FL. uth Required C/V SMRS INTERPJ 88106 CYTOPATH FL NONGYN FILTER CYTP FLU BR/WA XCPT C/V FILTER METH No authorization required INTERPJ ONLY 88108 CYTOPATH CONCENTRATE TECH CYTP CONCENTRATION SEARS & No authorization required 88112 CYTOPATH TE CH CELLCY ENQUICHENCE REQUIRED PT C/V 88120 CYTP URNE 3-5 PROBES EA SPEC CYTP INSITU HYBRID URNE SPEC 3-5 No authorization required PROBES EA MNL 88121 CYTP URNE 3-5 PROBES CMPTR CYTP INSITU HYBRID URNE SPEC 3-5 No authorization required 5CPTOP 8 1CPTOPLOG 5 ATHOLOGY FORENS IC No Auth Required 88130 SEX CHROMATIN IDENTIFICATION SEX CHROMATIN IDENTIFICATION CURRENT No body authorization required 88140 SEX CHROMATIN IDENTIFICATION IDENTJ PERIPHERAL No authorization required BLOODSMAR 88141 CYTORPVIN REQIN 88141 CYTORPVIN REQIN CVA uth Required PHYS. CIAN 8814 2 CYTOPATH C/V THIN LAYER CYTP CERV/VAG AUTO THIN LAYER PREP No approval required MNL SCREEN 88143 CYTOPATH C/V THIN LAYER REDO CYTP C/V FLU AUTO THIN MNL No approval required SCR&RESCR PHYS 88147 CYTOPATH C/V AUTOMATED CYTP Auth SYSTEM PHYS SUPV 88148 CYTOPATH C/V AUTO RESCREEN CYTP SM RS C/V SCR AUTO SYS MNL No authorization required RESCR PHYS 88150 CYTOPATH C/V MANUAL CYTP SLIDE C/V MNL SCR POD PHYS 8 AUTO 8PATH C/V CYTP 1 REQUIRED C/V MNL SCR&CPTR RESCR No Approval Required PHYS 88153 CYTOPATH C/V REDO CY TP SLIDES C/V MNL SCR&RESCR PHYS No Approval Required 88155 CYTOPATH C/V INDEX ADD-ON CYTP SLIDES No AMON Authen C/V DEVALTH SMEAR OTHER SOURCE CYTP SLIDES SMRS ALL OTHER SRC SCR&INTERPJ No approval required 88161 CYTOPATH SMEAR OTHER SOURCE CYTP SMRS ALL OTHER SRC PREPJ No approval required SCR&INTERPJ 88162 CYTOPATH SMEAR OTHER SOURCE USED OTHER SOURCE ST5 SLIDE 88164 CYTOPATH TBS C/V MANUAL CYTP SLIDE CERV/VAG MNL SCRN No approval required PHYSICIAN SUPV 88165 CYTOPATH TBS C/V REDO CYTP SLIDES C/V MNL SCR&RESCR PHYS no authorization required SUPV 88166 CYTOPATH REDOPSCRSCRNL CYTOPATH CTRVRES CCRV No authorization required PHYS SUPV 88167 CYTOPATH TBS C/V SELECT CYTP SLIDES C/V MNL SCR&CPTR RESCR No authorization required CELL S&I 88172 CYTP DX EVAL FNA 1ST EA SITE C YTP FINE NDL ASPIRATE NDL ASPIRATE 88172 8 8 ASPIRATE 8 TH EVAL FNA REPORT CYTP EVAL FINE NEEDLE ASPIRATE No approval required INTERP & REPORT 88174 CYTOPATH C/V AUTO I FLUID CYTP C/V AUTO THIN LYR PREPJ SCR SYS No Approval Required PHYS 88175 CYTOPATH C/V AUTO FLUID REDO CYTP C /V A PREPTH AUT Required MNL RESCR PHYS 88177 CYTP FNA EVAL EA ADDL CYTP FIN NDL ASPIRATE IMMT No Approval Required CYTOHIST STD EA EVAL 88182 FLOW CELL LABELING STUDY CYTOMETRY CELL CYCUS/DNA No authorization required and 8 ANA ANA LABATOLOGY 1T 1 .SAMPLE/ TC 1 MARKER FLOW CYTOMETRY CELL SURF MARKER No authorization required Pathology and Laboratory - TECHL 1. Cytopathology ONLY 88185 FLOWCYTOMETRY/TC ADDITIONAL FLOW CYTOMETRY CELL SURF MARKER Not required authorization Pathology and Laboratory - TECHL EA Cytopathology ONLY 88187 FLOWCYTO METRY/TC ADDITIONAL FLOW CYTOMETRY CELL SURF MARKER 2-8 No authorization required MARKERS 88188 FLOW CYTOMETRY/READ 9-15 FLOW CYTOMETRY INTERPJ 9-15 No authorization required MARKER 88189 FLOW CYTOMETRY/READ 16 & > FLOW CYTOMETRY INTERPRETATION 9-15 No Authorization Required MARKERS 88189 FLOW CYTOMETRY/READING 16 & > FLOW CYTOMETRY INTERPRETATION 9-15 UNDER UNSETTLED CYTOPATHOLOGY Authorization Required Pathology & Laboratory - Full Clinical Review PROCEDURE Surgical Pathology 88245 CHROMOSOMANALYSIS 20-25 CHRMSM USING BASELINE SISTER Authorization required Genetic testing and full clinical examination 20-25 CLL consultation 88248 CHROMOSOMANALYSIS SIS 50-100 BASELINESM authorization 50- 100 BASELINESM authorization 50-100 BASELINESM authorization 5. -100 CLL consultation 88249 CHROMOSOMANALYSIS 100 CHRMSM BRANDSYNDS SCORE 100 Authorization required Genetic test and full clinical examination CLL consultation 88261 CHROMOSOMANALYSIS 5 CHROMOSOMANALYSIS 5 CHRMSM NUMBER 5 CELL 1KARYOTYPE Authorization required C22 testing BAND 8 Full retesting and full retesting BAND-8 ANALYSIS 15-20 CHRMSM NUMBER 15-20 CLL 2KARYOTYPE authorization required Genetic testing and full clinical examination BANDING consultation 88263 CHROMOSOMANALYSIS 45 CHRMSM NUMBER 45 CELL MOSAICISM Authorization required Genetic testing and full clinical examination 2KARYOTYPE consultation 882064 CHROMOS SM-2 ANALYSIS 2-0 ANALYSIS 2 ANALYSIS 2-0 CELLS authorization required Genetic testing and full clinical examination consultation 88267 PLACENTA CHROMOSOMANALIZER CHRMSM ANALYSIS AMNIOTIC/VILUS 15 Approval required genetic testing and full clinical examination consultation with CELL KARYOTYPE 1

88269 CHROMOSOMANALYSIS AMNIOTIC CHRMSM SITU AMNIOTIC CLL 6-12 Authorization required Genetic testing and full clinical examination COLONY 1KARYOTYPE consultation 88271 CYTOGENETICS DNA PROBE MOLECULAR CYTOGENETICS Full CACH-DNA approval required 7 8 co-dna approval and E82 CYTOGENETICS 3-5 MOLECULAR CYTOGENETICS CHRMOML authorization required Genetic testing and full clinical review ISH 3-5 CELL consultation 88273 CYTOGENETICS 10-30 MOLECULAR CYTOGENETICS CHRMOML authorization required Genetic testing and full clinical review ISH 10-30 CLL consultation 88274 CYTOGENET 994 MOCULAR CYTOGENS 994 Genetic authorization 25 tic test and Full clinical review INTERPHASE ISH 25-99 CLL consults 88275 CYTOGENETICS 100-300 MOLEC CYTG INTERPHASE ISH ANALYSIS Approval required Genetic testing and full clinical exam 100-300 CLL consults 88280 CHROMOSOMIKARYOID KARYOTYPE ST ANALYSIS STANDARD test Genetic test and full clinical exam required EACH STUDY ko unseling 88283 CHROMOSOMAL STUDY BAND CHRMSM ANALYSIS ADDL SPECIALIZED Authorization required Genetic testing and full clinical examination BANDING counseling 88285 CHROMOSOMETIC ADDITIONAL CHRMSM ANALYSIS ADDL-CELLS Authorization required Retesting and full clinical examination EVERY STUDY COUNTS 8828RM STUDY 8289RM STUDY CO unselY SIS ADDL HIGH -authorization required Genetic testing and full clinical review RESOLUTION STUDY consultation 88291 CYTO/MOLEKYLE REPORT CYTOGENETIC&MOLEC CYTOGENETIC Authorization required Genetic testing and full clinical review INTERP&REP consultation 88299 CYTOGENETIC STUDY UNSETTLED STUDY CYTOGENETIC Complete studies Cytogenetic studies Authoritative studies and clinical studies 88300 SURGICAL SPI BRUTO LEV EL I SURGERY GROSS PATHOLOGY No Auth EXAMINATION REQUIRED ONLY 88302 TISSUE EXAMINATION BY LEVEL II SURGICAL PATHOLOGY No approval required GROSS & MICROSCOPIC EXAMINATION 88304 TISSUE EXAMINATION BY LEVEL III SURGICAL PATHOLOGY GROUP 5 AuthMIC 8 88304 AM EXAMINATION BY LEVEL IV SURGICAL PATHOLOGY PATHOLOGY No approval required GROSS OSS&MICROSCOPIC EXAMINATION 88307 TISSUE EXAMINATION BY PATHOLOGY LEVEL V SURGICAL PATHOLOGY No approval required GROSS AND MICROSCOPIC EXAMINATION 88309 TISSUE EXAMINATION BY PATHOLOGY VI. Levels Surgical pathology No approval of rough and microscopic overview 88311 REQUIRING REQUIREMENT 82 REQUEST 82 INS GROUP 1 Special color Group 1 No approval Microorganisms I & R 88313 Special color Group 2 SPCL STN 2 I & R Excpt No approval MicroRG / Enzim / IMCYT 88314 HISTOCHEMICAL STAIN SPECIAL STAIN I&R HISTOCHEMICAL No approval required W/FROZEN TISSUE 88319 ENZYME HISTOCHEMICAL EESVERIGE AND SPECIAL STAIN I&R 88321 MIC ROSLIDE CONSULTATION CONSULTJ&REP RT GLASS PREPARED No. Approval Required Elsewhere 88323 CONSULTUPION CONSULTUPION & REPR MATERIAL NOT REQUIRED Approval Required PrepJ Slides 88325 Comprehensive Data Review CONSLTJ COMPRE RECRE REPREST NOT RESPONSIBLE Approval Excellent Intro Match Control 88325 AUT Review Data. SURG REQUIRED 88331 STE CONSULT INTRAOP 1 BLOK VE CONSLTJ SURG 1ST BLK FROZEN No Authorization Required SCTJ 1 SPEC 88332 PATH CONSULT INTRAOP ADDL PATH CONSLTJ SURG EA ADDL BLK No Authorization Required FROZEN SECTION 88333 INTRAOP CYTO PATH CONSULT 1 PATH CONSLTJ SURGICAL CYTOLOGY EXAMINATION 88338 . CONSULT 2-PATH CONSLTJ CYTOLOGY EXAMINATION No Authorization Required ADDL SITE 88341 IMMUNOHISTO ANTB ADDL SLIDE IMHISTOCHEM/CYTCHM EA ADDL No Authorization Required ANTIBODY SLIDE 88342 IMMUNOHISTO ANTB 1ST STAIN IMHISTOCHEM/CYTCHM 1ST ANTIBODY REQUIRED 88342 Auth Y SLIDE IMHISTOCHEM/CYTCHM EA MULTIPLEX No approval required ANTIBODY SLIDE 88346 IMMUNOFLUOR ANTB 1. PLEVE IMMUNOFLUORESCENCE PR. SPEC 1. Approval not required SINGL ANTB-PLEVE 88348 ELECTRON MICROSCOPY ELECTRON MICROSCOPY DIAGNOSIS Approval not required 88350 IMMUNOFLUOR ANTB ADDLEC REQUIRED No. ANTB Spot 88355 Skeleta Morphometric Analysis No Closing Morphometric Analysis Non-Approval Non-approval Non-approval Non-approval Non-approval Needs 88360 Tumor or Immunohistochemical / Hand M / PHMTRC Analysis Required Tumor Imh Chemical Disease and Acid. ology 88361 TUMOR IMMUNOHISTOCHEM/COMPUT M/PHMTRC ALYS TUMOR IMHCHEM EA No Authorization Required Pathology & Laboratory - ANTBDY CMPTR ASST Surgical Pathology 88362 NERVE TEASING PREPARATION NERVE TEASING PREPARATION Authorization Required Pathology & Laboratory - Complete Clinical Examination Surgical Examination thology 88363 XM ARCHIVE TISSAN SELECTION No Red pathology and laboratory - MOLECULAR ANALYSIS surgical pathology 88364 INSITU HYBRIDIZATION (FISH) IN SITU HYBRIDIZATION EA ADDL PROBE Authorization required Pathology and laboratory - Full clinical examination FLET surgical pathology 88365 INSITU HYBRIDIZATION (FISH) IN SITU authorization and STAIN PROBE STAIN authorization 1 - STAIN PROBE STAIN. AIN Surgical Pathology 88366 INSITU HYBRIDIZATION (FISH) IN SITU HYBRIDIZATION EA MULTIPLEX Authorization Required Pathology and Laboratory - Full Clinical Review PROBE STAIN Surgical Pathology 88367 INSITU HYBRIDIZATION AUTO M/PHMTRC ALYS ISH CPTR-ASSTINATION Pathology and Laboratory Required Surgical Pathology 8 8368 INSITU HYBRIDIZATION GUIDE M /PHMTRC ALYS IN SITU No approval required Pathology and Lab - HYBRIDIZATION EA PROBE MNL Surgical Pathology 88369 M/PHMTRC ALYSISHQUANT/SEMIQ M/PHMTRC ALYS REQUIRED ISP QUANT QUANT and Lab EACH Surgical Pathology 88371 PROTEIN WESTERN BLOT PROTEIN TISSUE WESTERN BLOT ANAL TISSUE None Clearances Required Pathology & Lab - W/INTERP&REPO Surgical Pathology 88372 PROTEIN ANALYSIS W/PROBE PROTEIN ALYS WSTRN BLOT Required Pathology 88373 W/ PHMTRC ALYS ISHQUANT/SEMIQ W/PHMTRC ALYS ISH QUANT/SEMIQ No Clearance Required Pathology & Lab - CPTR PO SPEC. EACH Surgical Pathology 88374 M/PHMTRC ALYS ISHQUANT/SEMIQ M/PHMTRC ALYS ISH QUANT/SEMIQ Pathology & Laboratory Required Pathology & Laboratory Required EACH MULTIPRB Surgical Pathology

88375 OPTICAL ENDOMICROSCOPY INTERP OPTICAL ENDOMICROSCOPIC IMAGE No approval required Pathology & Laboratory - INTERP & REPORT surgical pathology 88377 M/PHMTRC ALYS ISHQUANT/SEMIQ M/PHMTRC ALYS ISH QUANT/SEMIQALYS ISH QUANT/SEMIQ Clinical Review Lab. 8380 MICRODISSECTION LASER MICRODISSECTION PREP IDENTIFIED No authorization required TARGET LASER 88381 MICRODISSECTION MANUAL MICRODISSECTION PREP IDENTIFIED No authorization required TARGET MANUAL 88387 TISS EXAM MOLECULAR STUDY MACRO AND PREP 88 388 TISS EX MOLECULAR STUDY SUPPLEMENT MACR EXM DISS&PRP NONMICR No authorization required IMPR NT/CONSLT / FRZ SEE 88399 surgical pathology 88720 BILIRUBIN TOTAL TRANSCUT TRANSCUT TRANSCUT BILIRUBIN 8GB required 88720 BILIRUBIN TOTAL TRANSCUT TRANSCUT TRANSCUT 8GB 8GB TRANSCUTANEOUS HGB QUANTITATIVE TRANSCUTANEOUS No approval required 88740 TRANSCUTANEOUS C ARBOXYHB HEMOGLOBIN QUANTITY TC PER DAY No approval required CARBOXYHEMOGLOBIN 88741 TRANSCUTANEOUS METHB HEMOGLOBIN QUANTITY TC PER No . approval required DAN METHEMOGLOBIN 88749 IN VIVO LAB SERVICE NOT LISTED IN VIVO LAB 4. CHCT FOR MINOR HYPERTHERMIA CAFFEINE HALOTHANE CONTRACT No approval required TEST 89050 BODY FLUID CELL COUNT CELL COUNT MISCELLANEOUS BODY No approval required FLUID 89051 BODY FLU ID CELL COUNT MISCELLANEOUS BODY FLUID OCCURRING No Clearance Required W/DIFFERENTIAL COUNT 89055 LEUKOCYTE READINGS -/SOLUTION GUIDE 89055 SEMI-QUANTITATIVE 89060 EXAMINATION SYNOVIAL FLUID CRYSTALS LIGHT MICROSCOPY ANALYSIS CRYSTAL ID No Clearance Required TISS/ANY FLUID 89125 FAT SAMPLE DISCHARGE ING FAT B LASTING FESES URINE/BREATH No authorization required SECRETIONS 89160 EXAMINATION OF FACES FOR MEAT FIBERS MEAT FIBERS FACES No authorization required 89160 EXAMINATION OF FACES FOR MEAT FIBERS OPHILIC No authorization required 89220 SPUTUM SAMPLE Collection of sputum spec. aerosol for obtaining without author

90287 BOTULINUM ANTITOXIN BOTULINUM ANTITOXIN KONJ SVAKO Nije potrebno odobrenje ROUTE 90288 BOTULISM IG IV BOTULISM IMUNO GLOBULIN HUMAN Nije potrebno odobrenje INTRAVENSKA UPORABA 90291 CMV IMMU IGLOVIN HUMAN potrebno MAN IV 90296 DIPHTHERIA ANTIT OXIN DIFTERIJA ANTITOKSIN KONJ BILO KOJE Nije potrebno odobrenje ROUTE 9 0371 HEP B IG IM HEPATITIS B IMMUNOGLOBULIN HBIG No approval required HUMAN IM 90375 RABIES IG IM/SC RABIES IMMUNE GLOBULIN RIG HUMAN No approval required IM/SUBQ 90376 RABIES IG RABIES REQUIRED HEAT TREATED 90378 RSV MAB IM 50MG RESPIRATORY SYNCY TIAL VIRUS IG IM 50 Approval required Administration Drug Full Clinical Review MG E 90384 RH IG FULL DOSING IM RHO(D) IMMUNOGLOBULIN HUMAN No approval required FULL DOSING IM 90385 IM 90385 MAN No approval required MINI-DOSING IM 90386 RH IG IV RHO(D) IMMUNOGLOBULIN HUMAN IV No approval required 90389 TETANUS IG IM TETANUS IMMUN GLOBULIN TIG No authorization required HUMAN IM 90393 IM VACCINE GLOBIN Auth IM 90396 VARICELLA-ZOSTER IG IM VARICELLA-ZOSTER IMMUN GLOBULIN No authorization required HUMAN IM 90399 IMMUNO GLOBULIN UNLIST ED IMMUNE GLOBULIN Authorization required Drug Administration Complete Clinical Review 90460 IM ADMIN 1. /REQUIRED ONLY COMPONENT IMMUNOGLOBULIN ADM. T VAC/TOX 90461 IM ADMIN EACH COMPONENT ADDL IM ADM UNTIL 18 EACH RTE ADDL No Approval Required VAC/TOX COMPT 90471 IMMUNIZATION ADMIN IM ADM PRQ ID SUBQ/IM NJXS 1 No Approval Required VACCINE 90472 IMMUNIZATION SOUTH ADMIN ADMQ ADDL No VACCINE Required 90473 IMMUNE ADMIN ORAL/NASAL IM ADM INTRANSL/ORAL 1 VACCINE No authorization required 90474 IMMUNE ADMIN ORAL/NASAL ADDL IM ADM INTRANSL/ORAL EA VACCINE No. DENOVIRUS VACCINE TYPE 7 AD ENOVIRUS VACCINE TYPE 7 LIVE FOR No approval required ORAL 90581 ANTHRAX VACCINE SC OR IM ANTHRAX VACCINE SUBCUTANEOUS/IM No approval required. 90586 BCG VACCINE INTRAVESICAL BACILLUS CALMETTE-GUERIN VACCINE No approval required INTRAVESICAL 90587 DENGUE VACC QUAD 3 DOSE SUBQ DENGUE VACC QUAD LIVE 3 DOSE No approval required SCHEMA SUBQ USE 90619 MENACWY-TT VACCINE SE-VACCINE IN MENACWY NUMBER A- 90620 MENB - 4C Vacc 2 doses im menb-4c recombnt prot & outer no author 1 DOSE LIVE No approval required FOR ORAL USE 90630 FLU VACC IIV4 NO PRESERV ID INFLUENZA VACC IIV4 SPLIT VIRUS No approval required PRSRV GRATIS ID 90632 HEP EN VACCINE FOR ADULTS HEPA -VACCINES DOSAGE FOR ADULTS DOSAGE FOR ADULTS US 9 PACCE 3 OL 2 DOSAGE HEPA VACCINE 2 DOSAGE No PED/ADOLESC IM USE Approval Required 90634 HEPA VACC PED/ADOL 3 DOSE HEPA VACCINE 3 DOS SCHEDULE No PED/ADOLESC IM USE Approval Required 90636 B HEP A 90 636 B HEP A 90636 B HEP A VACCINE A -HEPB No approval required ADULT IM 90644 HIB-MENCY VACCINE 4 DOSE IM HIB-MENCY VACC 4 DOSE 6 WKS- No approval required 18 MONTHS IM 90647 HIB PRP-OMP VACC 3 DOSE IM HIB -MENCY VACC Auth Required SCHEDULE IM USE 90648 HIB PRP-T VACCINE 4 DOSE IM HIB PRP-T VACCINE 4 DOSE SCHEDULE No approval required IM USE 90649 4VHPV VACCINE 3 DOSE IM 4VHPV VACCINE 3 DOSE SCHEDULE REQUIRED FOR 90649 4VHPV VACCINE 3 DOSE IM 2VHPV VACCINE 3 DOSAGE FOR No approval required IM USE 90651 9VHPV VACCINE 2/3 DOSE IM 9VHPV VACC 2/3 DOSAGE IM USE No approval required 90653 IIV ADJUVANT VACCINE IM IIV ADJUVANT US 90653 IIV ADJUVANT VACCINE IM IIV ADJU VANT US F05 VACC IIV3 NO CANZE ID INFLUENZA VACC IIV3 SPLIT VIRUS No approval required PRSRV FREE ID 90655 IIV3 VACC NO PRSV 0.25 ML IM IIV3 VACC PRESRV FREE 0.25 ML No approval required DOSAGE IN USE 90656 PIV03 VACC NR MLACCIVEER 3 ML No approval required DOSAGE U U SE 90657 IIV3 VACCINE SPLT 0.25 ML IM IIV3 VACCINE SPLIT VIRUS 0.25 ML No approval required DOSAGE IM USE 90658 IIV3 VACCINE SPLT 0.5 ML IM IIV3 VACCINE SPLIT VIRUS 0.5 REQUIRED No 60 ML INE INTRANASAL LAIV3 LIVE INTRANASAL VACCINE No authorization required ed.USE 90661 CCIIV3 VAC NO PRSV 0.5 ML IM CCIIV3 PRESERVATIVE-FREE VACCINE 0.5 No authorization required ML IM USE 90662 IIV NO PRSV ENHANCED AG IM IIV PRESERVATIVE-FREE VACCINE ENHANCED AG 9 CONA Auth PRESIV 6TRAIVIC NO Authen L LAIV PANDEMIC VACCINE FORMULA No Auth Required FOR INTRANSAL USE 90666 FLU VAC PANDEM PRSRV GRATIS IM FLUENZA VACCINE PANDEMIC SPLT No Authorization Required PRSRV GRATIS IM 90667 IIV VACC PANDEMIC ADJUVANT IM IIV VACCINE PANDEMIC ADJUVANT No US Authorization Required

90668 IIV PANDEMIC VACCINE IM IIV PANDEMIC VACCINE FOR INTRAMUSCULAR USE No authorization required 90670 PCV13 VACCINE IM PCV13 VACCINE FOR INTRAMUSCULAR USE No authorization required USE 90672 LAIV4 VACCINE INTRANASAL 90672 IV3 VACCINE WITHOUT PRESERVATION IM RIV3 VACCINE PRESERVATIVE FREE FOR No authorization required IM USE 90674 CCIIV4 VAC NO PRSV 0.5 ML IM CCIIV4 PRESERVATIVE FREE VACCINE 0.5 No approval required ML IM USE 90675 RABIES VACCINE IM RABIES VACCINE INTRAMUSCULAR No RABIES VACCINE Authority required 90680 RV5 VACC 3 DOSE LIVE ORAL RV5 VACCINE 3 DOSE SCHEDULE LIVE No approval required FOR ORAL USE 90681 RV1 VACC 2 DOSES LIVE ORAL RV1 VACCINE 2 DOSING SCHEDULE LIVE No approval required FOR ORAL USE 90682 RIV4 VACC RECOMBINANT DNA RECOMBINANT DNA RECOM RIVANT no. A4 VACCIO RECOMBINANT IM 90685 IIV4 VACC NO PRSV 0.25 ML IM IIV4 VACC PRSRV FREE 0.25 ML DOS FOR No approval required IM USE 90686 IIV4 VACC NR VACC SPLIT VIRUS 0.25 ML DOS FOR No approval required IM USE 90688 IIV4 VACCINE SPLT 0.5 ML IM IIV4 VACC SPLIT VIRUS 0.5 ML DOS FOR No approval required IM USE 90689 VACC IIV4 NO PRSRVACC IN 0.25 PRIV .25ML DOSE IM USE 90690 TYPHOID VACCINE ORAL TYPHOID VACCINE LIVE ORAL No approval required 90691 VACCINE AGAINST TYPHOID IM TYPHOID VI VACCINE CAPSULE No approval required POLYSACCHARIDE IM 90694 VACC AIIV4 NO PRSRVACC IN. uth Need 0.5ML DOS IM USE 90696 DTAP-IPV VACCINE 4-6 YEARS IM DTAP-IPV-VACCINE CHILD 4-6 YEARS FOR No approval required IM USE 90697 DTAP-IPV-HIB-HEPB-VACCINES IM DTAP-IPV-HIB - HEPB VACCINE No approval required INTRAMUSCULAR VINE VACCINE 90698 IM DTAP-IPV/HIB VACCINE FOR No approval required INTRAMUSCULAR USE 90700 DTAP VACCINE < 7 YEARS IM DIPHTH TETANUS TOX ACELL KIGGHOG No approval required VACC IM TDAP VACCINE 7 YEARS/> IM No. approval for VACC LIVE-VACCINE VACCINE 9Q016 LIVEUBAN. EOUS No approval required USE 90717 YELLOW FEVER VACCINE SUBQ YELLOW FEVER VACCINE LIVE SUBQ No approval required 90723 DTAP-HEP B-IPV-VACCINES IM DTAP-HEPB-IPV-VACCINES No approval required INTRAMUSCULAR 90723 VACCRSVIM/30723 DTAP-HEP B-IPV-VACCINES IP V VACCINE 2 YEARS OR OLDER FOR No authorization required SUBQ/IM USE 90733 MPSV4 VACCINE SUBQ MPSV4 VACCINE GROUPS ACYW-135 No authorization required SUBQ USE 90734 MENACWYD/MENACWYCRM VACC IM MENACWYD/MENACWY-CRM ACWIM ACWIM NO AuthV7 INE LIVE SUBQ ZOSTER VACCINE HZV LIVE FOR No approval required SUBCUTANEOUS USE 90738 INACTIVATED VACC IM JAPANESE ENCEPHALITIS VACCINE No approval required INACTIVE IM 90739 HEPB VACC 2 DOSE ADULT IM HEPB VACCINE ADULT 2 OVERDOSE NO. ACC 3 DOSE IMMUNSUP IM HEPB VACCINE DIALYSE /IMMUNSUP No approval required PAT 3 DOSE IM 90743 HEPB VACC 2 DOSE ADOLESC IM HEPB VACCINE ADOLESSENT 2 DOSE No approval required SCHEDULE IM 90744 HEPB VACC 3 DOSE PED/ADOLES IM HEPB Squire Aquir ed. IM 90746 HEPB VACCINE 3 DOSE IM ADULT HEPB VACCINE ADULT 3 DOSE No approval required SCHEDULE FOR IM USE 90747 HEPB VACC 4 DOSE IMMUNSUP IM HEPB VACCINE DIALYSIS/IMMUNSUP No approval required PAT 4 DOSE IM 90748 IMMUNSUP IMMUNSUP 90748 INTRAMUSCULAR USE 907 49 TOXOID FOR VACCINE NOT LISTED ID Authorization for ID VACCINE/TOXO drug administration required Full clinical examination 90750 HZV VACC RECOMBINANT IM HZV ZOSTER VACC RECOMBINANT No approval required ADJUVANT IM USE 90756 NO VACCIM CCIIV40 .5 No approval required ML DOS IM USE 90785 PSYTX COMPLEX INTERACTIVE PSYCHOTHERAPY COMPLEX No approval Re requested INTERACTIVE 90791 PSYCHODIAGNOSTIC EVALUATION PSYCHIATRIC DIAGNOSTIC EVALUATION No approval required 90792 PSYCH DIAG. EVAL W/MED SRVCS PSYCHIATRIC W8/AUT. SYTX W PT 30 MINUTES PSYCHOTHERAPY WITH/PATIENT 30 No approval required MINUTE 90833 PSYTX W PT W E/M 30 MIN PSYCHOTHERAPY WITH/PATIENT W/E&M No approval required SRVCS 30 MIN 90834 PSYTX W PT 45 MINUTES PSYCHOTHERAPY WITH/PATIENT 45 None Approx. required oval SRVCS 30 MIN. CO THERAPY WITH PATIENT W/E&M No Approval Required SRVCS 45 MIN 90837 PSYTX W PT 60 MINUTES PSYCHOTHERAPY W/ PATIENT 60 No Approval Required MIN 90838 PSYTX W PT W E/M 60 MIN PSYCHOTHERAPY W/ PATIENT REQUIRED No Approval W/ PATIENT

90839 PSYTX CRISIS INITIAL 60 MIN CRISIS PSYCHOTHERAPY INITIAL 60 MINUTES No Approval Required 90840 PSYTX CRISIS EA ADDL 30 MIN CRISIS PSYCHOTHERAPY EACH No Approval Required ADDL 30 MINUTES 5 REGISTRATION 90 MINUTES REGISTRATION 90 MIN. 90846 FAMILY PSYTX W/PT 50 MIN FAMILY PSYCHOTHERAPY NO PATIENT Currently no approval required 50 MIN 90847 FAMILY PSYTX W/PT 50 MIN FAMILY PSYCHOTHERAPY NO PATIENT Currently no approval required 50 MIN. PSYCHOTHERAPY No approval required 90863 PHARMACOLOGICAL MGMT W/PSYTX PHARMACOLOGICAL MANAGEMENT No approval required W/PSYCHOTHERAPY 90865 NARCOSYNTHESIS NARCOSYNTHESIS PSYC DX&THER No approval required PURPOSE 90867 TCRANIAL MAGN STIM TX PLAN REP INITIAL WMA/Rep. THRESHLD/DEL&M Health and Behavioral Assessment/Intervention 90868 TCRANIAL MAGN STIM TX DELI THERAP REPETITIVE TMS TX SUBSEQ Authorization Required General Medicine - Full Clinical Review DELIVERY & MNG Health and Behavioral Assessment/Intervention 90869 TCRAN MAGN STIM REDETEMINE REPET TMS TX REQ UIRED Full Medical Review - Full Medical Exam REQUIRED - MOTRHLD REQUIRED General Medical Screening W/DELIV & MN Health & Behavioral Assessment/Intervention 90870 ELECTROCONVULSIVE THERAPY ELECTROCOVULSIVE THERAPY Clearance Required General Medicine - Full Clinical Examination Health & Behavioral Assessment/Intervention 90875 PSYCHOPHYSICAL THERAPY INDIV PSYCHOVULSIVE TREATMENT NO. PSYCHOPHYSIOLOGICAL THERAPY INDIV PSYCHOPA BIOFEED TRAIN No approval required W/PSYTX 45 MIN 90880 HYPNOTHERAPY HYPNOTHERAPY No approval required 90882 ENVIRONMENTAL MANIPULATION ENVIRONMENT IVNTJ MGMT No approval required PURPOSE PSYC PT 90885 PSYCORD PSY E RE CVAL. Approval Required DX PURPOSE 90889 REPORT PREPARATION PREPARATION REPORT PT MENTAL STATUS No Approval Required AGENT/PAYER 90899 PSYCHIATRIC SERVICE/THERAPY NOT SET PSYCHIATRIC Clearance Required General Medicine - Complete Clinical Review SERVICES/PROCEDURE Health and Behavioral Assessment/Intervention 90912 BFB TRAINING 1 15 MON. /MIN. BF. - 1. 15 MIN CNTCT Health & Behavior Assessment/Intervention 90913 BFB TRAINING EA ADDL 15 MIN BFB TRAINING W/EMG&/MANOMETRY EA No Approval Required General Medicine - ADDL 15 MIN CNTCT Health & Behavior Assessment/Intervention 90935 HEMODIAL MANUFACTURING/WEMODIAL MANUFACTURING None approval required Dialysis, Hemodialysis PHYS/QHP EVALUATION and Peritoneal Dialysis 90937 HEMODIALYSIS REPEAT EVAL HEMODIALYSIS PX REPEAT EVAL W/WO No approval required Dialysis, Hemodialysis REVJ DIALYS RX and HACCODIALYSIS STUDIODISE900 STUDIODIS 9 YSIS APPROACH FLOW STUDY No approval required 90945 DIALYSIS ONE EVALUATION DIALYSIS OTHER / END HEMODIALYSIS 1 No Authorization Required Dialysis, Hemodialysis PHYS/QHP EVAL and Peritoneal Dialysis 90947 DIALYSIS REPEAT EVAL DIALYSIS OTHER/THN HEMODIALYSIS REPEAT No Authorization Required Dialysis PHYS/QHP Dialysis PHESQ0 Dialysis i 9,951 ESRD SERV 4 VISIT P MONTH No Authorization Required OLD 2 /3 VISIT 90962 ESRD SERV 1 VISIT P MO 20+ SVC ASSOCIATED WITH ESRD MONTHLY 20&/>YRS No approval required OLD 1 VISIT 90963 ESRD HOME PT SERV P MO

90989 DIALYSIS TRAINING PATIENT COMPLETE DIALYSIS TRAINING No Authorization Required Dialysis, Hemodialysis COMPLETED COURSE and Peritoneal Dialysis 90993 DIALYSIS TRAINING INCOMPLETE DIALYSIS TRAINING PATIENT PER No Authorization Required Dialysis, Peritoneal Dialysis S9Modialysis, Peritoneal Dialysis sis S90993 FUSION HEMOPERFUSION No Authorization Required. Dialysis, Hemodialysis Full clinical examination required PATIENT/AMBOLUT and Peritoneal Dialysis 91010 ESOPHAGEAL MOTILITY STUDY ESOPHAGEAL MOTILITY STUDY No approval required M/INTERP&RPT 91013 ESOPHGL MOTIL W/STIMPHUS STIMPHUS STUDY/STIMPHUS/STIM. IM/PERFUSION 91020 GASTRIC MOTILITY STUDIES GASTRIC MOTILITY MANOMETRY No approval required STUDY 91022 DUODENAL MOTILITY STUDY MANOMETRY No approval required STUDY 91030 ESOPHAGEAL ACID PERFUSION Required ESOPHAGEAL ACID PERFUSION E9HOP T EST REQUIRED E9HOP REFLUX TEST GASTRO-OESOPH G REFLKS TEST W/CATH no. Clearance Required PH ELTRD PLCMT 91035 G- ESOPH REFLX TST W/ELECTRODE GASTROESOPHAGEAL REFLX TEST No Clearance Required W/TELEMTRY PH ELTRD 91037 ESOPH IMPED FUNCTIONAL TEST GASTROESOPHAGEAL REFLX TEST Clearance Required General Medicine - Other Complete Clinical Examination W/INTRLCTUML IMP 08 ESOPH FUNCTIONAL TEST IMP08 ESOPHUS IMP08 Services and Procedures 1HR ESOPHGL FUNCJ G-ESOP RFLX IMPD Authorization Required General Medicine - Other Full Clinical Examination ELTRD PROLNG Services and Procedures 91040 ESOPH BALLON DISTENSION TST ESOPHGL BALO DISTENSION DX STD No Authorization Required W/PROVOCATION 91065 BREATH/BREATH LOUD/ BREATH OUT LOUD/BREATHING OUT LOUD uth required 91110 GI TRACT CAPSULE ENDOSCOPY GI IMAG INTRALUMINAL ESOPHAGUS - Authorization required General Medicine - Other Full Clinical Exam ILEUM W/I&R Services and Procedures 91111 ESOPHAGEAL CAPSULE ENDOSCOPY GASTROINTESTINAL TRACTI TRACTI Full CAPSLIN approval and E IMAGING SOPHAGE/General required Medical Clearance and Procedures 91112 GI Wireless Capsule Measures GI Transit and Pres Measurement Thread License Required General Medicine - Other Full Clinical Review Capsule with Interp Services and Procedures 91117 Colonic Motility 6 HR Study Colonic Motility Stdy Min. 6 hours RECTAL SESSION TONE AND COMPLIANCE No approval required TEST 91122 ANAL PRESSURE RECORDING ANORECTAL MANOMETRY No approval required 91132 ELECTROGASTROGRAPHY ELECTROGASTROGRAPHY DX No approval required TRANSCUTANEOUS ELEPH.GASTROF. DX TRANSCUT No Authorization Required W/PROVOCTVE TSTG 91200 LIVER ELASTOGRAPHY LIVER ELASTOGRAPHY W/O IMAG No Authorization Required W/I&R 91299 GASTROENTEROLOGIC PROCEDURE NOT LISTED DIAGNOSTIC Authorization Required General Medicine - Other Complete Clinical Review GASTROENTEROLOGICAL PROCEDURE services and procedures 91300 SARSCOV2 VAC 30MCG/ 0, 3ML VACCINE DIAGNOSTIC authorization no. REML Auth. IM USE 91301 SARSCOV2 VAC 100MCG/0.5ML IM SARSCOV2 VACCINE 100 MCG/0.5 ML No approval required IM USE 92002 EYE EXAM NEW PATIENT OPHTH MEDICAL XM&EVAL No approval required INTERMEDIATE NEW PT 92004 MEDICAL EXV. NEW PT 1/> VST 92012 ESTABLISH PATIENT EYE EXAMINATION OPHTH MEDICAL XM&EVAL No Authorization Required INTERMEDIATE ESTAB PT 92014 EYE EXAM&TX ESTAB PT 1/>VST OPHTH MEDICAL XM&EVAL No Authorization Required COMPRHNSV ESTAB PT 92014 EYE EXAM&TX ESTAB PT 1/>VST OPHTH MEDICAL XM&EVAL No approval required COMPRHNSV ESTAB PT 92014 DEFR ATE No approval required 92018 NEW EYE EXAMINATION AND TREATMENT OPHTH XM&EVAL ANES W/WO MINOR No approval required GLOBE COMPL 92019 EYE EXAMINATION AND TREATMENT OPHTH XM&EVAL AN ES W/WO MINOR No approval required GLOBE LMTD 92020 SPECIAL EYE EVALUATION PROGRAM SE20 GONIOSCOPY SE2 PHY COMPUTERIZED CORNEA No approval required TOPOGRAPHY UNI/ BI 92060 SPECIAL EYE EVALUATION SENSOR MOTOR XM W/MLT TARGET No approval required OCULAR DEVIJ W/I&R SPX 92065 ORTHOPTIC/PLEO PTIC TRAINING ORTHOPTIC I/PLEOPTIC TRAINING None Approvals Required W/MEDICAL 92065 CONTACT FTXJET MEDICINK 9206 5 LENSES TX Ocular SURFACE No approval required DISEASE 92072 CONTACT LENS IMPLEMENT FOR MANAGMNT CONTACT LENS IMPLEMENT FOR MNGT OF No approval required KERATOCONUS 92081 VISUAL FIELD EX AMINATION(S) VISUAL FIELD XM UNI/BI M /INTERPRETJ No approval required VISU 2EX2A S) VISUAL FIELD XM UNI/ BI W/INTERP No approval required BETWEEN EXAMINATION 92083 VISUAL FIELD EXAMINATION(S) VISUAL FIELD XM UNI/BI W/INTERP No approval required EXTENDED EXAMINATION 92100 SERIAL TONOMETRY EXAMINATION(S) ) Serial Tonometry Required in Serial Tonomet Pres 92132 CMPTR OPHTT CMPTR Ophthalmic DX IMG ANT No approval SEGMT W / I & R UNI / Bi 92133 CMPTR PHTH IMG Optical Nerve Computerized Ophthalmic Shooting CPTR21 PRES 92 133 CMPTR OPHTH IMG UTIZED OPHTHALMIC IMAGE Br approval required RETINA 92136 OPHTHALMIC BIOMETRY OPH BMTRY PRTL COHER INTRF RMTRY No approval required IO LENS PWR CAL 92145 CORNEAL HISTERESIS DETER CORNEA HISTERESIS DETERMIN Approval required General Medicine - Other Full Clinical Review IMPULSE STIMPY 20J and RETINA 92136 UNI/ BI OPSCPY EXPAND RTA DRAWING & SCL No Approval Required DEPRSN I&R UNI/BI 92202 OPSCPY EXTND ON/MAC DRAW OPSCPY EXTND OPTIC NRV/MACULA No Approval Required DRAWING I&R UNI/BI

92227 REMOTE DX RETINL IMAGING REMOTE IMG DX RETINL DIS W/ALYS & No approval required REPORT UNI/B 92228 REMOTE RETINLIMAGING MGMT REMOTE IMAGING MGT RETINL DISSE W/ALYS & No approval required DISEASE W/I&2PHEX230B 92228 I ANGIOSC OPY Approval not required INTERPRETATION AND REPORT 92235 FLUORESCEIN ANGPH UNI/BI FLUORESCEIN ANGPH W/MULTIFRAME No Authorization Required I&R UNI/BI 92240 ICG ANGIOGRAPHY UNI/BI INDOCYANINE GREEN ANGPH No Authorization Required W/MULTIFRAMIO FLUORCE IGRIOIN/92240 PHY FLUORESCEIN ICG ANG RPH No Authorization Required W/MULTIFRAM I&R UNI / BI 92250 EYE EXAMINATION WITH FUNDUS PHOTO PICTURES No Approval Required W/INTERPRETATION AND REPORT 92260 OPHTHALMOSCOPY/DYNAMOMETRY OPHTHALMODYNAMOMETRY No Approval 92265NED. Y 1/ XOC MUSC No Approval Required 1/BOTH EYES W/ I&R 92270 ELECTRO-OCULOGRAPHY ELECTRO-OCULOGRAPHY No Approval Required W/INTERPRETATION & REPORT 92273 FULL FIELD ERG W/I&R FULL FIELD ELECTRORETINOGRAPHY No Approval Required W/IRG& R MULTIFELEC. GRAPHICS No approval required M/I&R 92283 COLOR VISION TEST COLOR VISION XM EXPANDED No approval required ANOMALOSCOP/EQUIV 92284 EYE EXAMINATION DARK ADAPTATION DARK ADAPTATION XM No approval required M/INTERPRETATION AND REPORTING 92285 EYE PHOTOGRAPH PHY XTRNL OCULAR PHOTOGRAPH Auth. INTERNAL EYE PHOTOGRAPHY ANT SGM IMAGING W/ MICROSCOPY No approval required ENDOTHELIUM ANALYSIS 92287 INTERNAL EYE IMAGING ANT SGM IMAGING W/FLUOROSCEIN No approval required ANGIO & I&R 92310 CONTACT LENS FITTING RX&FITG C-LENS SUPVENS 1 CONTACT 1 FAST SUPVJ 9 ACT CONTACT LENSES FITTING LENSES RX&FITG CONTACT CORNEAL LENSES No approval required APHAKIA 1 EYE 92312 FITTING CONTACT LENSES RX&FITG CONTACT CORNEAL LENSES No approval required APHAKIA BOTH EYES 92313 CONTACT LENS TEACHER RX&FITG CORNEOSCLERAL LENSES No approval required 92314 CONCRETING LISE ES No approval required XCPT APHAKIA 92315 RX C NTACT LENS APHAKIA 1 EYE RX CONTACT APHAKIA CORNEAL LENS 1 No approval required EYES 92316 RX CNTACTUAL LENS APHAKIA 2 EYE RX CONTACT APHAKIA CORNEAL LENS No approval required BOTH EYES 92317 RX CORNEOSCLERAL CNTACTUAL LENS APHAKIA 2 EYES RX CONTACT COR NEAL LENS APHAKIA No approval required. CONTACT LENSES MODIFY CONTACT LENX SPX SUPVJ No authorization required INSTALLATION 92326 REPLACEMENT CONTACT LENSES REPLACEMENT CONTACT LENSES No authorization required 92340 FIT GLASSES MONOFOCAL FITTING GLASSES XCPT APHAKIA No authorization required MONOFOCAL 92341 FIT GLASSES Acquired BIFOCAL GLASSES Auth AL 92342 FIT GLASSES MULTIFOCAL CLOSURE ANJE GLASSES XCPT APHAKIA No authorization required MULTIFOCAL 92352 FIT APHAKIA SPECTCL MONOFOCL FITTING GLASSES PROSTH APHAKIA No Authorization required MONOFOCAL 92353 FIT APHAKIA SPECTCL MULTIFOC FITTING GLASSES PROSTH APHAKIA No authorization required MULTIFOCAL 92354 FIT SPECTACL SY STEM Aquid red AID 1 ELMNT 92355 FIT GLASSES GLASSES FOR COMPOSITE LENSES FITTING LW SHOW No approval required HELP TLSCP 92358 APHAKIA PROSTH SERVICE TEMP PROSTHESIS SERVICE APHAKIA No approval required TEMPORARY 92370 REPAIR & FIT GLASSES RPR & REFITG GLASSES EXCEPT No approval required APHAKIA GLASSES & SPACFI ADJUST EXTACULAR PROSTHESIS No approval required APHAKIA 92499 EYE SERVICE OR PROCEDURE NOT LISTED OPHTHALMOLOGY General approval medicine - other Complete clinical examination SERVICES / PROCEDURE services and procedures 92502 EAR & THROAT EXAMINATION ENT EXAMINATION UNDER No approval required GENERAL ANESTHESIA 92504 EAR MICROSCOPY EXAMINATION DOSX BINOCULAR SP07 REQUIRED NO2 EAC/HEARING THERAPY TX SPEECH LO NG VOICE COMMJ No approval required & /AUDITORY PROC IND 92508 SPEECH/HEARING THERAPY TX SPEECH LANGUAGE VOICE COMMJ No Authorization Required AUDITRY 2/>INDIV 92511 NASOPHARYNGOSCOPY NASOPHARYNGOSCOPY W/ENDOSCOPE SP2X AUTH. INVESTIGATIONS No authorization required 92516 FACIAL NERVE FUNCTION TEST FACIAL NERVE FUNCTION INVESTIGATION No authorization required 92520 LARYNGAL FUNCTION INVESTIGATION LARYNGAL FUNCTION INVESTIGATION No authorization required 92521 SPEECH FLUENCY ASSESSMENT SPEECH FLUENCY ASSESSMENT No authorization required (STEECH2525 SPEECH SOUND ASSESSMENT) No vet approval required MANUFACTURING ITEMS KL 92523 SPEECH SOUND LONG UNDERSTANDING EVAL SPEECH SOUND PRODUCT No authorization required LANGUAGE KNOWLEDGE 92524 ANALYSIS OF VOICE BEHAVIOR QUALITY VOICE ANALYSIS BEHAVIOR AND QUALITY No authorization required AND RESONANCE 92526 TREATMENT OF ORAL FUNCTION THERAPY/KV. EDING 92531 SPONTANEOUS NYSTAGMUS STUDY SPONTANEOUS NYSTAGMUS W/GAZE No authorization required 92532 POSITIONAL NYSTAGMUS TEST POSITIONAL NYSTAGMUS TEST No authorization required 92533 CALORIC VESTIBULAR TEST CALORIC VESTIBULAR TEST EACH No authorization required IRRIGATION 92534 OPTOKINETIC NYSTAGMUS TEST OPTOKINETIC NYS TAGMUS TEST OPTOKINETIC NEWSTAGMUS A9TBUT required 92532 /REC CALORIC VETIBULAR TEST W/REC BI No approval required BITERMAL

92538 CALORIC VSTBLR TEST W/REC CALORIC VESTIBULAR TEST W/REC BI No authorization required MONOTHERMAL 92540 BASIC VESTIBULAR ASSESSMENT VSTBLR FUNCJ NYSTAG FOVL&PERPH No authorization required STIMJ OSCIL TRK 92540 SPONTOUS NYSTAGMUS TRK 9254 0 Authorization required 92 542 POSITIONAL NYSTAGMUS TEST POSITIONAL NY STAGMUS TEST No. Authorization required 92544 OPTOKINETIC NYSTAG MOUSE TEST OPTKINETIC NYSTAG No authorization required BIDIR/FOVEAL/PERIPH STIM W/REC 92545 OSCILLATION TRACKING TEST OSCILLATION TRACKING TEST No authorization required W/RECORDING 92546 ROTSIAL 92546 ROTSIDA 92546 RIGHT SIDE ROTATION TEST required uth 92544 7 ADDITIONAL ELECTRICAL TEST USING VERTICAL ELECTRODE No approval required 92548 CDP-SOT 6 COND W/I&R CDP-SOT 6 CONDITIONS Approval required General Medicine - Other Complete Clinical Examination W/INTERPRETATION & REPORT services and procedures 92549 CDP-SOT CDP-SOT CDP-CT W/I&R TERMS W/I&R W/ MCT Authorization Required General Medicine - Other Complete Clinical Exam & ADT Services & Procedures 92550 TYMPANOMETRY & REFLEX TURN TYMPANOMETRY & REFLEX No Approval Required THRESHOLD MEASUREMENT 92551 TEEN PURE TONE HEARING NO TRENEST TONE HEARING red 92552 PURE TONE A UDIOMETRY AIR PURE TONE AUDIOMETRY AIR ONLY No approval required 92553 AUDIOMETRY AIR & BONE PURE TONE AUDIOMETRY AIR & BONE No approval required 92555 AUDIOMETRY SPEECH THRESHOLD SPEECH AUDIOMETRY 9 COMP. TE SPEECH AUDIOMETRY THRESHOLD No authorization required SPEECH RECOGNITION 92557 COMPREHENSIVE HEARING TEST COMPRESS AUDIOMETRIC THRESHOLD No authorization required EVAL SP RECOGNIJ 92558 EVALUED HEARING TEST QUALITY EFFECTIVE OTOACOUSTIC EMISSION No authorization required AUTOANALYSIS SCREEN 9255 9 GROUP AUDIOMETRIC TESTING GROUP Authentic Testing AUDIOMETRIC AUDIOMETRIC 92559 SCREEN BEKESY AUDIOMETRY SCREENING No. authorization required 92561 BEKESY AUDIOMETRY DIAGNOSTICS BEKESY AUDIOMETRY DIAGNOSTICS No Authorization required 92562 VOLUME BALANCE TEST VOLUME BALANCE No Authorization required BINAURAL/MONO 92563 HEARING CONNECTION TEST TONE CONNECTION TEST No authorization required 92564 SIENSSI HEAR ING TEST USAGE 5 RODS TEST PURE TONE RODS TEST P UR TONE Br Auth Required 9 2567 TYMPANOMETRY TYMPANOMETRY No Authorization Required 92568 ACOUSTIC REFL THRESHOLD TST ACOUSTIC REFLECTIVE THRESHOLD No Authorization Required 92570 ACOUSTIC IMITATE TEST ACOUSTIC IMMITTEST No Auth/2ACODER SPEECH TEST HEARING FILTERED SPEECH TEST No Authorization Required 92572 SPONDAIC WORD TEST IN WORDS WORDS WORDS STAGGERED SPONDAIC WORDS No authorization required 92575 SENSORINEURAL ACUITY TEST SENSORINEURAL ACUITY LEVEL No authorization required 92576 SYNTHETIC SENTENCE TEST SYNTHETIC SENTENCE IDENTIFICATION No authorization required WAND TEACHER TEST 92576 79 VISUAL AUDIOMETRY (VRA) VISUAL GAIN AUDIOMETRY No authorization required 9 2582 CONCERT AUDIOMETRY CONCERT AUDIOMETRY Not approval required 92583 AUDIOMETRY IMAGE SELECT AUDIOMETRY IMAGE SELECTION No approval required 92584 ELECTROCOCHLEOGRAPHY ELECTROCOCHLEOGRAPHY ELECTROCOCHLEOGRAPHY AUDIOMETRY AUTHOR 92584 ELECTROCOCHLEOGRAPHY AUDI ED POTENTIAL No approval required COMPREHENSIVE 92586 AUDITOR E VOKE POTENT LIMIT AUDITORY EVOQUED POTENTIAL No approval required LIMITED 92587 AUDITORY TEST LIMITED CONVERSION PRODUCT EVOKED Not required approval OTOACOUSTIC EMISNS LIMITD 92588 EVOKED AUDITORY TST COMPLETE DISTRT PROD EVOKD OTOACOUSTIC No approval required t EMSNS COMP/DX EVAL 0AM HEARING 925 HEARING 925 Approval required SELECT MONAURAL 92591 HEARING AID EXAM & HEARING AID EXAMINATION & No approval required STAGE SELECT URAL 92592 HEARING AID Check One Hearing Appliance Check Only Aid No Approval Needs Approval 92593 Check Biracement No No Allowed Approval ELECEST4 ELECTRO Needs Approval MONAURAL 92595 ELECTRO AUDENCE EVAL 92596 EAR PROTECTION EVALUATION ATTITUDE EAR PROTECTION No approval required MEASURES 92597 ORAL DEVAL EVAL EVAL EXT. NT ORAL SPEEC 92601 COCHLEAR IMPLT F/UP EXAMINATION Approval Required Hearing Aids Complete Clinical Examination SBSQ REPRGRMG 92605 EX FOR NON-SPEECH DEVICE RX EVAL RX N-SP-GEN AUGMT ALT No Approval Required COMMUN DEV F2F 1ST HR 92606 NON-SPEECH DEVICE SERVICE THER-WORTH General medicine DEVICE TER-WORTHY Medicine other Complete clinical review PRGRMG&MODIFICAJ services and procedures 92607 EX FOR SPEAKING UNIT RX 1HR RX SP-GENRATJ AUGMNT&COMUNICAJ No approval required DEV 1ST HR 92608 EX FOR SPEAKING UNIT RX ADDL RX SP-GENRATUNICA 3 DE 2609 USE OF SPEAKING UNIT THER SP-GENRATJ DEV Approval Required General Medicine - Other Full Clinical Review PRGRMG&MODIFY Services & Procedures 92610 EVALUATE EXTINGUISH FUNCTION EVAL ORAL&PHARYNGEAL SWLNG No Approval Required FUNCJ 92611 MOTION MOTION/ FLUALLOWLuth C/V REC Required

92612 ENDOSCOPY SLAL (FEE) WIDE FLEXIBLE ENDOSCOPIC EVAL SLACK No approval required C/V REC 92613 ENDOSCOPY SLAL (FEEE) I&R FLEXIBLE ENDOSCOPIC EVAL OFF No approval required C/4SCYSO 1RSCOP 9261 REC 92613 FLEXIBLE ENDOSCOPIC EVAL LA RYN No approval required SENSOR Y C / V REC 92615 LARYNGOSCOPIC SENSORY I&R FLEXIBLE ENDOSCOPIC EVAL LARYN No Approval Required SENS C/V REC I&R 92616 FEES W/LARYNGEAL SENSORY TEST FLEXIBLE NDSC EVAL SWLNG&LARYN SLARENS 9/6V REC 92616 I&R FLEXIBLE NDSC E VAL SWLNG&LARYN No Approval Required SENS C/V I &R 92618 EX FOR NON-SPEECH RX RX ADD EVAL RX N-SP-GEN AUGMT ALT No authentication required COMMUN DEV ADD 30 MIN 92620 AUDITORY FUNC. 60 MIN EVAL CENTRAL AUGMT NO Auth0 FUNC. 92621 AUDIT FUNC + 15 MIN EVAL CENTRAL AUDIT FUNC No approval required W/REPRT EA 15 MIN 92625 TINITUS EVALUATION TINITUS EVALUATION No approval required 92626 EVAL AUD FUNC. FUNC. V 1ST HR 92627 EVAL AUD FUNCJ EA ADDL 15 EVAL AUD FUNCJ CAND/PO SURG IMPLT No approval required DEV EA ADDL 15 92630 AUD REHAB PRE-LING HEARING LOSS AUDITORY REHABILITATION No approval required PRE-LINGUAL HEARING LOSS red POST-PRODUCT HEARING LOSS 92 640 AUD BRAIN STEM IMPLT PROGRAM ANALYSIS W/ PRGRMG AUD BRAIN STEM No authorization required IMPLANT PR HR 92700 ENT PROCEDURE/SERVICE NON-CALL ENT OTORHINOLARINGOLOGY Authorization required General Medicine - Other Complete clinical review SERVICE services and procedures PRQARTDIQ10 COMLART 10 ANGIOPLASTICS No authorization required EN ART/BRANCH 929 21 PRQ CARDIAC ANGIO ADDL ART PRQ TRLUML CORONARY ANGIOPLASTIC No authorization required ADDL BRANCH 92924 PRQ CARD ANGIO/ATHRECT 1 ART PRQ TRLUML CORONARY No authorization required ANGIO/ATHERECT/9 ADDLAT 92924 PRQ PRQ TRLUML CORONARY No authorization required ANGIO/ATHEREC ADDL BRANCH 92924 8 PRQ CARD STENT M /ANGIO 1 VSL PRQ TRLUML CORONARY STENT No Approval Required W/ANGIO ONE ART/BRNCH 92929 PRQ SHORT STENT W/ANGIO ADDL PRQ TRLUML CORONARY. ADDL ART/BRNCH 92933 PRQ SHORT STENT/ATH/ANGIO PRQ TRLUML CORONARY No approval required STENT/ATH/ANGIO ONE ART/BRNCH 92934 PRQ SHORT STENT/ATH/ANGIO PRQ TRLUML CORONARY No approval required STENT/ATH PRANGQ9 REVASC BYP GRAFT 1 VSL PRQ TRLUML CORONARY BYP GRFT No approval required REVASC ONE VESSEL 92938 PRQ REVASC BYP GRAFT ADDL PRQ TRLUML CORONARY BYP GRFT No approval required REVASC ADDL VESSEL 92941 PRQ TRQ T1 uth REVASC MI ONE VSL required 92943 PRQ CARD REVASC CHRONIC 1VSL PRQ TRLUML CORONARY CHRONIC No approval OCCLUS REVASC ONE VSL 92944 PRQ CARD REVASC CHRONIC ADDL PRQ TRLUML CORONRY CHRNIC OCCLUS REVASC ONE VSL 92944 PRQ CARD REVASC CHRONIC ADDL PRQ TRLUML CORONRY CHRNIC OCCLUS No approval 92944 PRQ card REVASC CHRONIC ADDL Monar REV Co. No approval required 92953 TEMPORARY EXTERNAL PACING TEMPORARY TRANSCUTANEOUS No authorization required PACING 92960 CARDIOVERSION ELECTRIC EXT CARDIOVERSION OPTIONAL No authorization required ARRHYTHMIA EXTERNAL 92961 CARDIOVERSION ELECTRIC INT CARDIOVERSION ELECTRIC SPEC NO ARRIOVERSION SPECIAL 9M0 IST INTERNAL CARDIOASSIST-METH CIRCULATORY No authorization required ASSIST INTERNAL 92971 CARDIOASSIST EXTERNAL CARDIOASSIST -METH CIRCULATORY Required approval of cardiovascular surgery Complete clinical review ASSIST EXTERNAL system 92973 PRQ CORONARY MECH THROMBECT PRQ TRANSLUMINAL CORONARY No authorization required MECHANICAL THROMBECTOMY 92974 CATH PLACE CARDIO BRACHYTX RTCADJ PLACEMENT ATX RTCATJ PLACEMENT ATX S 2975 DISSOLVE KOROGER CARDIOVASCUL AR THROMBOLYSIS INTRACORONARY NFS No authorization required SLCTV ANG PH 9 2977 DISSOLVE KOROGER HEART VESSELS THROMBOLYSIS CORONARY Clearance not required INTRAVENOUS INFUSION 92978 ENDOLUMINAL CORONARY IVUS OCT C 1. ENDOLUMINAL CORONARY IVUS OCT No Clearance required I7&9 C V7 9 & 9 EA ENDOLUMINAL CORONARY IVUS OCT No Clearance required I&R ADDL VESSEL 92986 AORTIC VALVE REVISION PR Q BALLOON VALVULOPLASTY AORTA No vet required VALVIL 92987 MITRAL VALVE REVISION PRQ MITRAL VALVE BALLOON No approval required VALVIL 92990 PULMONARY VALVE REVISION PRQ BALLOON VALVULOPLASTIC VALVE 92990 PULMONARY VALVE REVISION PRQULLAVALENT PRQ BALLOON REVISION 92992 HEART CHAMBER REVISION ATRIAL SEPTIC/SEPTIC No approval required OZNI BALLOON 92993 ATRIUM REVISION HEART CHAMBERS SEPTECT/SEPTOSTOMY BLAD No approval required METHOD 92997 PUL ART BALLON REPR PERCUT PRQ TRLUML LUNG ART No approval required BALLON ANGIOP 1 VSL 929ART PEMLPRUT BALLON PLUMONY PLUMONY NO. Approval Required BALLON ANGIOP EA VSL 93000 ELECTROCARDIOGRAM Full EKG ROUTINE EKG W/MIN 12 LDS No Approval Required W/I&R 93005 ELECTROCARDIOGRAM MONITORING ECG ROUTINE EKG W/MIN 12 LDS No Approval Required TRCG ONLY U/O I&R 93010 ELECTROCARDIOGRAM ONLY RED 93015 Cardiovascular STRESS TEST CV STRS TST XERS&/OR RX CONT EKG No approval required W/SI&R

93016 CARDIOVASCULAR STRESS TEST CV STRS TST XERS&/OR RX CONT ECG No Authorization Required U/O I&R 93017 CARDIOVASCULAR STRESS TEST CV STRS TST XERS&/OR RX CONT ECG No Authorization Required TRCG ONLY CVRS CARDIOVAS TEST COURSE 93016 T ECG No Authorization Required ONLY I&R 93024 CARDIAC STRESS TEST ERGONOVINE PROVOCATION TST No authorization required 93025 MICROVOLT T-WAVE ASSESS MICROVOLT T-WAVE ASSESS No authorization required VENTRICULAR ARRITHAM0 RGHM0 1-3 LEAD No authorization required W/INTERPRETATION AND REPORTS 93041 RHYTHME ECG TRAC ECG RHYTHM MONITORING 1-3 LEAD ONLY No approval required W/O I&R 93042 RHYTHM ECG REPORT RHYTHM ECG 1-3 LEAD No approval required W/O I&R 93042 RHYTHM ECG REPORT RHYTHM ECG 1-3 LEDs No approval required INTERPRETATION AND DECISION 93042 PATTERN ANALYZER No approval required ed . CENTRAL ART PRESSURE 93224 EKG MONIT/REPORT UP TO 48 HOURS XTRNL EKG & 48 HR RECORD SCAN STOR No Approval Required W/R&I 93225 EKG MONIT/REPRT UP TO 48 HOURS XTRNL EKG/ 48 HR EKG RECORD/ 48 HR EKG/ 48 HR RECORD SCAN STORE REQ UIRED 2 NO. 9P2RT UP TO 48 HOURS EXTERNAL ECG SKIN ANALYSIS No approval required REPORT 93227 ECG MONIT/REPRT UP TO 48 HOURS XTRNL EKG CONTINUOUS RHYTHM No approval required W/I&R UP TO 48 HOURS 93228 DREMOTE X R32228 DREMOTE X R32EVRY X General Medicine - Other Full Clinical Review required W/I&REPORT 30 DAY Services & Procedures 93229 REMOTE 30 DAY EKG TECHNICAL SUPP XTRNL MOBILE CV TELEMETRY Authorization Required General Medicine - Other Full Clinical Review W/TECH SUPPORT Services & Procedures 93260 PRGRMPMGLT DEBLV EVAL PRGRMPGLT DEBLV EVAL IPLV EVAL SUBQ No Authorization Required DFB MANAGEMENT SYSTEM 93261 TEST SUBQ DEFIB TEST EVAL F2F IMPLANT Authorization not required SUBQ LEAD DEFIB 93264 REM MNTR WRLS P-ART PRS SNR REMOTE MNTR PRS WIRELESS A- DCG Required no. 3 Required A- D0 RECORD/REPORT XTRNL PT ACTIVE ECG TRANSMIT W /R&I No approval required

93316 ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL CONGEN PROBE No authorization required PLCMT ONLY 93317 ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL IMAGE ACQUISJ No authorization required INTERP & REPORT 93318 ECHO TRANSESOPHAGEAL ECHO TRANSESOPHAGEAL HEART PUMP FUNCTION 93320 DOPPLER ECHO HEART EXAMINATION DOPPLER ECHO PULSE WAVE No approval required WITH SPECTRAL DISPLAY 93321 DOPPLER ECHO HEART EXAMINATION DOP EHOKARD PULSE WAVE No Approval Required W/SPECTRAL F-UP/LMTD STD 93325 DOPPLER COLOR FLOW ADD-ON DOP EHOKARD COLOR FLOW RATE S9 ATH 3 ATH 3 ATH 3 RC R-T 2D W/WO M-MODE No Approval Oval Required COMPLETE REST&ST 93351 STRESS TTE COMPLETE ECHO TTHRC R-T 2D W/WO M-STATE No Approval Required REST&STRS CONT ECG 93352 ADMIN ECG CONTRAST AGENTS USE OF ECHO CONTRAST AGENTS AT. 3HES REQUIRED 5OP TREK 5. AGEAL (TEE) ECHO TEE GUID TCAT ICAR/VAR/VAR No approval required STRUCTURAL INTVN 93356 MYOCRD STEM IMG SPCKL TRCK MYOCRD STEAM IMG SPECLE TRCK No approval required ASSMT MYOCRD MECH 93451 RIGHT HEART CATHED I NO. 93452 LEFT HRT CATH W/ VENTRCLGRPHY L HRT CATH W/NJX L No Authorization Required VENTRICULOGRAPHY IMG S&I 93453 R&L HRT CATH W/VENTRICLGRPHY R & L HRT CATH W/NJX L VENTRICULOG No Authorization Required IMG S&I 93454 CORONARY ANALYSIS No Authorization Required ART ANGIO IMG S & I 93455 Coronary Art/Grft Angio S & I Cath PLMT & NJX CORONARY No approval Art/Grft Angio IMG S & I 93456 R HRT CORONARY ARTERS ANGIO CATHT PLMT R HRT & ARTS & AMUTRA AUTH R3MG RQ ART PLMT ARTS/GRFTS No Approval Required W/NJX& ANGIO IMG S&I 93458 L HRT ARTERY/VENTRICLE ANGIO CATH PLMT L HRT & ARTS W/NJX & No Approval Required ANGIO IMG 59GRFT HANGIO 9 CATH PLMT L HRT/ARTS/GRFTS WNJX & No Approval Required Angio img s & i 93460 R&L HRT art/ventricle angio r & l hrt cath winjx hrt art & l no approval required ventr img 93461 r & l hrt langiov art/injec hrt no approval art/grft i l ventl i 93462 l hrtt OF TRANSEPTAL No approval required PUNCTURE 93463 MEDICINE ADMINISTRATION & HEMODYNAMIC MEASURES MEDICINE ADMIN & HEMODYNAMIC 6/4 HEMODYNAMIC 6 MODENAMIC MEASURES PHYSIOLOGY EXERCISE STUDY & No approval required HEMODYNAMIC MEASURES 93503 INSE RT/TRAIN HEMODYNAMIC CATHETER INSERTION FLOW- DIRECTIVE CATHETER No approval required SUPERVISION 9350 5 BIOPSY OF THE HEART PANEL ENDOMIOCARDIAL BIOPSY No Authorization Required CA0RT CHEAT GENITHETER 93505 AL No Authorization Required HEART ANOMALY 93531 R & L HEART CATH CONGENITAL CMBN R HRT & RETROGRADE L HRT No Authorization Required CATHJ CGEN ANOMA 93532 R & L HEART CATH CONGENITAL CMBN R HRT T -SEPTAL L HRT CATHJ NTC No Authorization Required SEPTUM CGEN 93533 R & L HEART CMBN- CONGENITAL H L T HRT CATHJ No Authorization Required SEPTAL OPNG CGEN 93561 CARDIAL OUTPUT INDIC DIL STD ARTL&/OR VEN CATHJ No Authorization Required W/OUTPUT 93562 CARD OUTPUT SUBQ INDIC DIL STD ARTL&/OR VEN CATHJ No. 63 Inject Card Cath NJX SEL HRT Art Congenital HRT No Approval Cath w/S & I 93564 Inject HRT Conngntl Art/Grft NJX SEL HRT ART/GRFT Congenital No Approval Required HRT Cath W/S & I 93565 INVECT L VENTRIO/GRT NJXI required CATH W/S&I 93566 INJECT R VENTR/ATRIAL ANGIO NJX SEL R VENT/ATRIAL ANGIO HRT No approval required CATH W/S&I 93567 INJECT SUPRVLV AORTOGRAPHY NJX SUPRAVALV AORTOGRAPHY NJX SUPRAVALV AORTOG AND PULM ART HRT CATH NJX LUNG ANGIO HRT CA TH Not required approval W/S&I 93571 MEASURE OF CARDIAC FLOW RESERVE IV DOP VEL&/OR PRESS C/FLO RSRV No approval required. TARGET 1. VSL 93572 RESERVE FLOW OF THE HEART TARGET/R. MEAS ADDL VSL Required 93580 TRANSCATH CLOSURE ASD PRQ TCAT CLSR CGEN INTRATRL No Approval Required COMUNICAJ W/IMPLT 93581 TRANSCATH CLOSURE VSD PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/52CA CGEN VENTR DFCT W/52CA Required C 9 P DA PERCUTAN TRANSCATH CLOSURE PAT No authorization required CANAL ARTERIOSUS 93583 PERQ TRANSCATH SEPTAL REDUXN PERCUTANEOUS TRANSCATHETER No authorization required SEPTAL REDUCTION THER 93590 PERQ TRANSCATH CLS MITRAL PERQ TRANSCATH CLS PARAVALTRAVRCAANSE LEAK 1 MI3 9 Required 1 TR5Q 1 TR5Q 1 Au th AORTA PERQ TRANSCATH CLS PARAVALVR LEAK No authorization required 1 AORTIC VALVE 93592 PERQ TRANSCATH CLOSE EACH PERQ TRANSCATH CLS PARAVALVR LEAK No Authorization Required EACH OCCLS DEV 93600 WORLD OF HIS RECORD WORLD OF HIS RECORD No Authorization Required 93602 INTRA-ATRICAL RECORDING INTRA-ATRICAL RECORDING INTRA-ATRICAL RECORDING REAL 90 RECORDING Auth RIGHT VENTRICLE HONORABLE RECEIVING ANJE No Approval required 93609 CARD TACHYCARDIA ADD-ON INTRA-VENTRIC&/ATRIEL MAPG No approval required. INTRACARDIAC ELECTROPHYSIOLOGICAL No approval required 3D MAPPING

93615 ESOPHAGEAL RECORDING ESOPHGL REC ATRIAL W/WO No approval required VENTRICULAR ELECTOGRAMS 93616 ESOPHAGEAL RECORDING ESOPHGL REC ATRIAL W/WO VENTR No approval required ELECTRGRAM W/PACG ARTHYND 83616 ESOPHAGEAL RECORDING Electrical No approval required ed. PACING 93619 ELECTROPHYSIOLOGY EVALUATION COMPRE ELECTR OPHYSIOLOGIC W/O No approval required ARRHYTHM INDUCTION 93620 ELECTROPHYSIOLOGY EVALUATION COMPRE ELECTROPHYSIOLOGIC No approval required ARRHYTHMY INDUCTION 93621 ELECTROPHYSIOLOGY EVALUATION COMPRE ELECTROPHYSIOL Auth Auth P32C REQUIRED ARRHYTHMY INDUCTION YSIOLOGIC EVALUATION COMP RE ELECTROPHYSIOL XM M/LEFT No approval required VENTR PACNG /REC 9362 3 STIMULATION PACING CARDIAC PROGRAMMED STIMJ & PACG AFTER IV No Authorization Required DRUG NFS 93624 ELECTROPHYSIOLOGY STUDY ELECTROPHYSIOLOGY MONITORING No Authorization Required W/PAC/REC W/ARRHYT 93631 CARDIAC PAYING REQUIRED INTRAOPG 93631 CARDIAC PAYING REQUIRED INTRAOPG A9 PACING & NO MA0 EVAL UATION CARDIAC DEVICE EPHYS EVAL PACG CVDFB LDS INITIAL No Authorization Required IMPLAN/REPLACEMENT 936 41 ELECTROPHYSIOLOGICAL EVALUATION EPHYS EVAL PACG CVDFB LDS W/TSTG No Authorization Required PULSE GEN 93642 ELECTROPHYSIOLOGICAL EVALUATION EPHYS EVAL PACG REQUIRED CVPRGRCMG 9 NO. TROPHYSIOLOGY EVALUATION EPHYS EVAL SUBQ IMPLANT No approval required DEFIBRILLATOR 93650 ABLATE CARDIAC DYSSHYRRTHYM FOCUS ICAR ABLATION CATHETER ATRIOVENTR No approval required NODE FUNCTION 93653 EP & ABLATE SUPRAVENT ARRHYT EPHYS EVAL M/ABLATION SU PRAVENT No approval required ARRHYTHMIA TRYG 93654 ARRHYT 4 /ABLATION VENTRICULAR Not required approval TACHYCARDIA 93655 ABLATE ARRHYTHMIA ADD ON ICAR CATHETER ABLATION No authorization required ARRHYTHMS ADD 93656 TX ATRIAL FIB PLAN VEIN ISOL EPHYS EVL TRNSPTL TX ATRIAL FIB No authorization required ISOLATE PLUMBAL VEIN 93657 TX L/R ATRIAL FIB/ R ATRIAL FIB required PULM VENA 93660 TILT-BOARD ASSESSMENT OF CARDIOVASCULAR FUNCTION EVAL No approval required W/VIPE-TABLE W/MNTR 93662 INTRACARDIAC EKG (ICE) INTRACARD EHOKARD M/THER/DX No approval required IVNTJ INCL I INCL ICL3MG S&8PHRI REPHAR 93662 IAL DISEASE REHAB None approvals required PR SESSION 93701 BIOIMPEDANCE KV ANALYSIS PHYSIOLOGICAL ANALYSIS FROM BIOMPEDANCE required General Medicine - Other Full Clinical Examination CV ANALYSIS services and procedures 93702 BIS XTRACELL FLUID ANALYSIS BIS EXTRACELLULAR FLUID ANALYSIS Complete EXTRACELLULAR FLUID INSTRUCTIONS Complete CMP ALYSMIC authorization Complete authorization and procedure with 9372 4 ANALYSIS PACEMAKER SYSTEM ELECTRONIC ANALYSIS ANTITAKY No approval required PACEMAKER SYSTEM 93740 TEMPERATURE GRADIENT EXAMINATION TEMPERATURE GRADIENT EXAMINATION Approval required General Medicine - Other Complete Clinical Examination Services and Procedures 93745 SETTING HARDIOVERT TOP-UP AND RE-ESTABLISHMENT FROM 1 PRHJUDIGHJ. required BEARDIG CVDFB 93750 EXAMINATION WHAT PERSONAL EXAMINATION WHAT PERSONAL No approval required W/PHYS/QHP ANALYSIS 93770 VENOUS PRESSURE MEASUREMENT VENOUS PRESSURE DETERMINATION No approval required 93784 AMBL BP MNTR W/SOFTWARE W/SOFTWARE W/SOFTWARE NR A2 REC SCAN ALYS I&R 93786 AMBL BP MNTR W/SW REC ONLY OUTPATIENT BP MNTR W/SW 24 HR+ No approval required RECORD ONLY 93788 AMBL BP MNTR W/SW A/R OUTPATIENT BP MNTR W/SW 24 HR+ 9 AUT 3 AMCRANNING required/90 MNTR W /SW I&R AMBULANCE BP MNTR W/SW 24 HR+ No authorization required REVIEW W/I&R 93792 PT/HOME CAREGIVER TRAINING INR PT/HOME CAREGiver TRAINING No authorization required HOME INR MNTR 937AG93 FORMAGANTOMGIN PT No authorization required TAKING WARF ARIN 93797 HEART PRESSURE AMOLULAT HEART FEELING U/ O No authorization required CONT EKG MONITOR 93798 HEART REHAB/MONITOR AMOLULATE HEART REHAB M/CONT No authorization required 93798 HEART REHAB/MONITOR AMOLULATE HEART REHAB M/CONT No authorization required 93798 HEART REHAB/MONITOR AMOLULATE HEART FANNING M/CONT No approval required 93798 HEART FANNING /MONITOR AMOLULATE HEART FANNING M/CONT No approval required 93798 HERTEFANNING/MONITOR AMOLULATE HEART FANNING M/CONT No approval required 93798 HEART FANNING/MONITOR AMOLULATE HEART FANNING M/CONT No approval required 93798 ASC Approval required ULAR General Medicine - other Full clinical review SERVICES/PROCEDURE services and procedures 93880 EXTRACRANIAL BILL STUDY DUPLEX SCAN EXTRACRANIAL ART No approval required COMPL BI STUDY 93882 EXTRACRANIAL UNI/LTD DUPLEX SCAN EXTRACRANIAL ART STUDY No approval required INTRALM3TD INTRALM3TD IND/9 IAL DOPPLER STDY No approval required INTRACRANIAL ART COMPL 93888 INTRACRANIAL CONCEPT NSET STUDY TRANSCRANIAL DOPPLER STDY No approval required INTRACRANIAL ART LMTD 93890 TCD VASOREACTIVITY STUDY TRANSCRANIAL DOPPLER INTRAKRAN No approval required ART VASOREAC STDY 93892 TCD EMBOLISM DEVELOPMENT IN TRANSCRANIUM Auth. EMBOLI DETECT 93893 TCD EMBOLI DETECT W/INJ TRANSCRAN DOPPLER INTRACRAN ART No Authorization Required MICROBOBBLE INJ 93895 CAROTID INTIMA ATEROMA EVAL CAROTID INTIMA MEDIA & CAROTID Authorization Required General Medicine - Other Complete Clinical Review ATHEROMA EVAL BI Services & Procedures 93922 UPR/L XTREMITY STILLEVYS ATEROM EVAL BI services and procedures. required EXTREMITY ART LEVEL 2 93923 UPR/LXTR ART STDY 3+ LVLS NON-INVASIVE PHYSIOLOGICAL STUDY No approval required EXTREMITY LEVEL 3 93924 LWR XTR VASC STDY BILAT N-INVAS PHYSIOLOGICAL STD LXTR Required No

93925 LOWER EXTREMITY STUDY DUP-SCAN LXTR ART/ARTL BPGS COMPL No Approval Required BI STUDY 93926 LOWER EXTREMITY STUDY DUP-SCAN LXTR ART/ARTL BPGS No Approval Required UNI/LMTD STUDY UPPERSCART 939 EXTREM STUDY 939 EXTREM BPGS No Approval Required COMP L BI STUDY 93931 UPPER EXTREMITY STUDY DUP-SCAN UXTR ART/ARTL BPGS No Authorization Required UNI/LMTD STUDY 93970 EXTREMITY STUDY DUP-SCAN XTR VENNER COMPLETE No Authorization Required BILATERAL STUDY XTREM STUDY 93970 INS No Authorization Required UNILATERAL /Limited Study 93975 Vascular Study DUP - Scan Artl Flo No Author Required ABDL/PEL/SCROT &/RPR ORGN COM 93976 VASCULAR STUDY DUP-SCAN ARTL FLO NO AUTH AUTA IVC ILIAC No Authorization Required VASCL/BPGS COMPLETE 93979 VASCULAR STUDY DUP-SCAN AORTA IVC ILIAC No Authorization Required VASCL / BPGS UNI /LMTD 93980 PENIS VASCULAR STUDY DUP-SCAN ARTL INFL&VEN COMPUTER V/F PEN V PEN V OP -SCAN ARTL INFL&VEN O/F PEN VSL No approval required F-UP/LMTD STD 93985 DUP-SCAN HEMO COMPL BI STD DUPLEX SCAN ARTL INFL&VEN O/F No Approval Required HEMO COMPL BI STD 93986 DUP-SCAN STD HEDSCAN ARTL INFL&VEN O/F No Approval Required HEMO COMPL UNI STD 93990 DOPPLER FLOW STUDY DUPLEX SCAN HEMODIALYSIS ACCESS No Approval Required 93998 NONINVAS VA SC DX STUDY PROC. NONINVASIVE NONINVASIVE FLOW TEST DUPLEX SCAN HEMODIALYSIS ACCESS No approval required 93998 NONINVAS VASC DX STUDY PROC NONINVASIVE FLOW TESTING Full VASCULAR medical procedure - DANSKULAR VASCULAR authorization STUDY 94002 VENT MGMT INPAT INIT DAY VENTILATION ASSIST & MGMT No approval required PATIENT DAY 1 94 003 VENT MGMT INPAT SUBQ DAN VENTILATION ASSIST & MGMT No approval required INPATIENT EA SBSQ YES 94004 VENT MGMT NF uth PR. DAY ASSISTANCE PO 005 HOME WAIT MGMT MONITORING HOME VENTILATOR MGMT CARE No approval required EXAM 30 MIN/> 94010 RESPIRATORY CAPACITY TEST SPMTRY M/VC EXHAUST FLOW M/WO No approval required MXML VOL VNTJ 94011 SPIROMETRY UP TO 2 SPIROMETRY UP TO 2 CR . FLO DILUTION&/2 Y 94012 SPIRMTRY W/BRNCHDIL INF-2 YRS MEASURE SPIRO FRCD EXP FLO PRE&POST No approval required BRONCH INF/2YRS 94013 MEASURE LUNG VOLUMES 2 YRS MEASURE LUNG VOLUMES No approval required PACHILD/201 INFANTRYSPI9401 INF ANTRY PT-START SPIROMETRY RECORDING No PHYS/QHP R&I Clearance Required 94015 ADMISSION PATIENT INITIATED SPIROMETRY PATIENT INITIATED SPIROMETRY No Clearance Required 94016 PATIENT INITIATED SPIROMETRY AND PATIENT EXAMINATION SPIROMETRY REQUIRED 94016 PATIENT EXAMINATION SPIROMETRY INITIATED AND PATIENT REQUIRED SPIROMETRY 6 HEEZING BRNCDI LAT RSPSE SPMTRY BEFORE&POST - No Approval Required BRNCDILAT ADMN 94070 HEIGHT ASSESSMENT BRNCSPSM PROVOCATION EVAL MLT No Approval Required SPMTRY W/ADMN AGT 94150 VITAL CAPACITY TEST VITAL CAPACITY TOTAL SEPARATE No Approval Required PROCEDURE 94200 LUNG FUNCTION TEST/VOLUNTARY VENT REQUIRED 94250 EXPIRED GAS COLLECTION EXPIRED S PURCHASE OF GAS QUANTITY 1 No approval required PROCEDURE SPX 9437 5 RESPIRATORY FLOW VOLUME LOOP BREATHING FLOW VOLUME LOOP No approval required 94400 RESPIRATORY RESPONSE CURVE REQUIRED FOR CO2 RESPONSE H05 REQUIRED FOR CO2 RESPONSE H05 RESPIRATORY RESPONSE CURVE TO HYPOXI No approval required 94452 HAST W/ REPORT TEST HIGH ALTITUDE SIMULATIONS W/PHYS No Approval Required INTERP&REPORT 94453 HAST W/ILTTITRATE HIGH ALTITUDE SIMULATJ W/PHYS I&R No Approval Required W/O2 TITRATION 94610 SURFACTANT APPLICATION DONE/ADMIN. QHP 94617 EXERCISE TEST BRNCSPSM EXERCISE TEST FOR BRONCHOSPASM No authorization required 94621 LOWER-PULMONARY EXERCISE TESTING Cardiopulmonary stress testing No authorization required 94640 AIRWAY TREATMENT INHALATION PRESSURE/NON-PRESSURE No authorization required INHALATION 94640 AIR AY INHALATION TREATMENT. IDINE AERSL INHALATION No Authorization Required PNEUMOCYSTIS/PROPH 94644 CBT 1ST HOUR OF CONTINUOUS INHALATION TREATMENT No Authorization Required 1st HR 94645 CBT EACH ADDITIONAL HOUR OF CONTINUOUS INHALATION TREATMENT No Authorization Required EA ADDL HR 94660 POS RESPIRATORY PRESSURE CPAP V ENTILATION CPAP No Authorization Required INITIATION&MGMT 94 662 PRESS REQUIRED VALVE PLACEMENT REQUIRED CSU PRESS VALVE. required VENTJ INITIAT&MGM 94664 EVALUATE PT INHALER USE DEMO&/ EVAL OF PT UTILIS AERSL No approval required GEN/NEB/INHLR/IP 94667 CHEST ROCK MANIPULATION LESS CH WALL FACILITY LNG FUNCJ No approval required 1 DEMO&/EVAL 94668 CHEST ROCK MANIPULATION LESS CHEST WALL FUNC. 4669 MECHANICAL COFFEE OSCILL MECHANICAL CHEST WALL OSCILLATION Authorization Required DME Full Clinical Examination LUNG FUNCTION 94680 EXHAUST AIR ANALYSIS O2 O2 UPTK EXP GAS ANALYSIS REST&XERS No Authorization Required DIRECT SIMP 94681 EXHAUST AIR 2CO EXHAUST O 2CO EXHAUST 2 OUTPUT No Authorization Required % O 2 XTRC 94690 EXHAUST AIR ANALYSIS O2 RECORDS EXP GAS ANALYSIS OTHER No approval required INDIRECT SPX 94726 PULM FUNCT TST PLETYZMOGRAPHY PLETYZMOGRAPHY LUNG VOLUMES No approval required MODE W/WOIST

94727 GAS LUNG FUNCTION TEST GAS DILUTION/LUNG VOLUME CLEANING No approval required W/WO DISTRIB VENT&V 94728 AIRWY RESIST BY OSCILLOMETRY AIRWAY RESISTANCE OSCILLOMETRY No approval required CDIIF7AC DFU 94728 AIRWY RESIST BY OSCILLOMETRY ACITY No approval required 94750 COMPLIANCE STUDY P COURSE LUNG COMPLIANCE STUDY No approval required 94760 BLOOD OXIDE LEVEL MEASUREMENT NON-INVASIVE EAR/PULSE OXIMETRY No approval required SINGLE DETER 94761 BLOOD OXIDE LEVEL MEASUREMENT NON-INVASIVE EAR/PULSE OXIMETRY No approval required MSU L2GENY EVEL NON-INVASIVE EAR/PULSE OXIMETRY No approval required VERN RIGHT MONITOR 94770 EXHAUST CARBON CARBON DIOXIDE TEST DIOXIDE EXP GAS SHIELD No approval required INFRARED ANALYZER 94772 RECORDING DISA BEARBUND CIRCADIAN RESPIRATORY PATTERN REC No approval required 12-24 HR INFANT 947 RESPIRATE Auth. required ATTACHMENT PHYS I&R 94775 PED HOME APNEA REC HK-UP PEDIATRIC APNEA MONITOR No approval required ATTACHMENT 94776 PED HOME APNEA REC DOWNLD PEDIATRIC APNEA MONITOR ANALYZER No approval required COMPUTER 94777 PED HOME APNEA REC REPORT PEDIATRIC REVIEW OF APNEA RECORDING IN 8 FT-12 MONTHS 60 MIN CAR SEAT/BED TEST INFT FOR 12 MO Approval not required 60 MIN 94781 CARS/BD TST INFT-12MO +30 MIN. CAR SEAT/BED TEST INFT FOR 12 MONTHS No approval required EA ADDL 30 MIN 94799 PULSE SEAT/PRODUCTION TEST Writer General Medicine - Other Complete clinical review SERVICES/PROCEDURE services and procedures 95004 PERCUTA ALLERGY SKIN TESTS PERCUTANEOUS TESTS W/ALERGEN No approval required EXTRA CTS 95012 FUEL NITRIC OXIDE MEASUREMENT NITRIC OXIDE Extinguished Gas 901 GAS EXERCISE 90G TEST POISON ALLG TSTG PERQ & IC POISONS IMMED No approval required REACT W/I&R 95018 PERQ&IC ALLG TEST DRUGS/BIOL ALLG TEST PERQ & IC DRUG/BIOL No approval required IMMED REACT W /I&R 95024 ICUT AIR ALLERGEN TEST/BIO TEST 95027 ICUT ALLERGEN TITRATE INTRACUTANEOUS AIR TEST No approval required W/ALLERGEN XTRCS AIR 95028 ICUT ALLERGEN TEST DELAYED IC TSTS W/ALLERGEN XTRCS SOUND TYPE RXN No approval required W/REATCHING TLIAPPING P4CATCHING EST SPECIFIER No approval required NUMBER OF TESTS 95052 PHOTO PATCH TEST PHOTO PATCH TEST SPECIFY NUMBER No approval required TSTS 95056 PHOTO SENSITIVITY TEST PHOTO TEST No approval required 95060 EYE ALLERGY TEST EYELID MUCOSA NOT REQUIRED T5G0 NASAL MUCOSA No approval required TEST 95070 BRONCHI INHLJ ALLERGY TEST BRNCL CHALLENGE TSTG No approval required M /HISTAM/METACHOL 95071 BRONCHAL ALLERGY TESTS INHLJ BRNCL CHALLENGE TSTG No approval required W/AGS/GAS 95076 ENTRY CHALLENGE INI 120 MIN ENTRY IN CHALLENGE 50 MIN CHALLENGE 90 MIN. INTAKE CHALLENGE ADDL 60 MIN INTAKE CHALLENGE TEST EACH No approval required ADDL 60 MINUTES 95115 IMMUNOTHERAPY SINGLE INJECTION PROF SVCS ALLG IMMNTX X W/PRV No approval required ALLGIC XTRCS 1 NJX 95117 IMMUNOTHERAPY INJECTION PROF SVCS ALLG ALLG IPRC SJ 9 120 IMMUNOTHERAPY SINGLE INJECTION PROF SV CS ALLG IMMNTX W /PRV No Approval Required ALLGIC XTRC 1 NJX 95125 IMMUNOTHERAPY 2/> INJECTIONS PROF SVCS ALLG IMMNTX W/PRV No Approval Required ALLGIC XTRC 2/> NJX 95130 IMMNTX 1 INSECT STING WPRV STquired ATX INSECT TS 95131 IMMNTX 2 INSECT STITCH PROF SVCS ALLG IMMNTX W/PRV XTRC No Approval Required 2 STITCH INSECTS 95132 IMMNTX 3 STITCH INSECTS PROF SVCS ALLG IMMNTX W/PRV XTRC No Approval Required 3 STITCH 5 STITCH 5INSF 3 STITCH 5 INSF 3 G IMMNTX W/PRV XTRC No Approval Re requested 4 STITCH INSECT 95134 IMMNTX 5 STINGS INSECTS PROF SVCS ALLG IMMNTX W/PRV XTRC No authorization required 5 STINGS INSECT 95144 ANTIGEN THERAPIES SERVICES PREPARATION AND ANTIGEN Auth FIRST ALLERGEN AND 5 OTHER PRIM ALLERGENS 5 THERAPIES SERVICES PREPARATION AND ANTIGEN ALLERGEN No approval required IMMUNOTHERAPY 1 INSECTS 95146 ANTIGEN THERAPY T JENESTER PREPJ& ANTIGEN ALLERGEN No approval required IMMUNOTHERAPY 2 INSECT 95147 ANTIGEN THERAPY SERVICES PREPJ& ANTIGEN ALLERGEN No approval required 5 IMMUNOTHERAPY 5 IMMUNOTHERAPY EPJ & ANTIGEN ALLERGEN No approval required IMMUNOTHERAPY 4 INSECT 9 5149 ANTIGEN TREATMENT SERVICES PREPJ & ANTIGEN ALLERGEN It is not approval required IMMUNOTHERAPY 5 INS EKT 95165 ANTIGEN THERAPY SERVICES PREPJ & ALLERGEN IMMUNOTHERAPY No approval required 1/MLT ANTIGEN 95170 ANTIGEN THERAPY SERVICES PREPJ& ANTIGEN ALLERGENS No approval required 1/MLT ANTIGEN 95170 ANTIGEN THERAPY SERVICES PREPJ & ANTIGEN ALLERGENS IMM. RAPID DESENSITIZATION PROCEDURE Approval not required HOURLY 95199 ALLERGY IMMUNOLOGY SERVICES ALLERGY WITHOUT ASSISTANCE/ CLINICAL Approval not required IMMUNOLOGY SRVC/PX 95249 KONT GLUC MNTR PT PROV EQP CONT GLUC PATIENT MONITORING Authorization required General Medicine - Full Clinical Exam INSURED EQUIPMENT health and behavioral assessment/intervention

95250 CONT GLUC MNTR PHYS/QHP EQP CONT GLUC MNTR PHYSICIAN/QHP Authorization Required General Medicine - Full Clinical Exam INSURED EQUIPMENT Health & Behavior Assessment/Intervention 95251 CONT GLUC MNTR ANALYSIS I&R ANALYSIS Full Medical Exam I&R D IRECTION Full Authorization I&R DIRECTION CONT. LYSIS I&R Health & Behavioral Assessment/Intervention 95700 EEG CONT REC W/VID EEG TECH EEG TECH EEG CONT REC W/VIDEO BY TECH MIN 8 No Approval Required CHANNELS 95705 EEG U/O VID 2-12 HR UNMNTR EEG U/O VIDEO FROM TECH 2-12 HR No authorization required UNMONITORED 95706 EEG WO VID 2-12HR INTMT MNTR EEG U/O VIDEO BY TECH 2-12 HR No authorization required INTERMITTENT MNTR 95707 EEG U/O VID 2-12HR CONT MNTR EEG-BY12HR No authorization required CONTINUOUS R-T Required MNTR 95708 EEG WO VID EA 12-26HR UNMNTR EEG W/O VID BY TECH EA INCR 12-26HR No Approval Required UNMONITORED 95709 EEG W/O VID VID MTEABY6 TECH 12-26HR INCR 12-26HR No Approval Required HR INTMT MNTR 95710 EEG W/O VID EA 12-26HR CONT EEG U/O VID TECH EA INCR 12-26 HR No approval required CONT R-T MNTR 95711 VEEG VUN 2-12 HOURS 2 -12 HOURS No approval required NO SUPERVISION 95712 VEEG 2- 12 HR INTMT MNTR VEEG BY TECH 2-12 HR INTERMITTENT No approval required MONITORING 95713 VEEG 2-12 HR ACCOUNT MNTR VEEG BY TECH 2-12 HOURS REQUIRED TECH 2-1 95714 VEEG EA 12-26 HR UNMNTR VEEG BY TECH EA INCR 12 - 26 HR No approval required UNADTENDED 95715 VEEG EA 12-26HR INTMT MNTR VEEG BY TECH EA INCR 12-26HR INTERNET 12-26HR. 26 HOURS CONT MNTR VEEG BY TECH EA INCR 12-26 HR CONT No approval required R-T MNTR 95717 EEG PHYS/QHP 2-12 HR NO VISION EEG PHYS/QHP 2-12 HR NO No approval required VIDEO 95718/QHP HR W/VEEG EEG PHYS/QHP 2-12 HR S VEEG No authentication required 95719 EEG PHYS/QHP EA INCR U/O VID EEG PHYS/QHP EA INCR>12HR12HR3636 No authentication required HR36036 No authentication required HR606 No authentication required HR84 HR NO VID EEG COMPLETE STD PHYS/QHP>84 HR No Approval Required U/O VID 95726 EEG PHY/QHP>84 HR W/VEEG EEG COMPLETE STD PHYS/QHP>84 HR No Approval Required 95 W/QHP POLYSOM PARAMTRS POLYSOM No Approval Required Sleep Studies ADDL PARAM ATTND 95783 POLYSOM PARAM POLYSOM ALL AGES SLEEP STATES 1-3 Approval Required Sleep Studies Full Clinical Review ADDL PARAM ATTND Valid Jan. 2021 Temporary Change: Network Validation 95/YRS 95/40/40/40/40 > PARAM POLYSOM 6/>YRS SLEEP 4/> ADDL Authorization Required Sleep Studies Full Clinical Review PARAM ATTND Effective Jan. 2021 Temporary Change: Network Validation Review 95811 POLYSOM 6/>YRS CPAP 4/> PARM POLYSOM 6/>YRS SLEEP CPAP 4/> Approval Required Sleep Studies Full Clinical Review ADDL PARAM ATTND Valid Jan. 2021 Temporary Change: Network Validation Review 95812 EEG 41-60 Minutes Electroencephalogram Extension Required Approval General Medicine-Full Clinical Review 8 Mink-Review 60 Mine Coluty Monitoring and Neurology 60-60 Minutes EEG EXTND MNTR 61-119 MIN EEG EXPECT MOVELY 61-119 No Authorization Required MINUTE 95816 EEG AWAKE AND SLEEP ELECTROENSPHALOGRAM W/REC No Authorization Required AWAKE&DROWSY 95819 Download AWAKE&DROWSY 95819 Download AEPWA AWAKE&SLEEP 95822 EEG COMA OR SLEEP ONLY ELECTROENSP HALOGRAM REC No Authorization Required COMA/SLEEP ONLY

95824 EEG ONLY CEREBRAL DEATH ELECTROENCEPHALOGRAM CERE No Approval Required DEATH EVAL ONLY 95829 SURGERY ELECTROCORTICOGRAM ELECTROCORTICOGRAM SURGERY SPX No Approval Required 95830 INTROSERTION INSERT NO. required EEG PHYS/QHP 95836 ECOG IMPLTD BRN NPGT No approval required STUDIES 95921 AUTONOMIC NRV PARASYM INERV TSTG ANS FUNCJ CARDIOVAGAL No approval required INNERVAJ PARASYMPS 95922 AUTONOMIC NRV ADRENRG INERV TSTG ANS FUNCJ VASOMOTOR No approx. oval ADRENERGIC INNERVAJ required 95923 AUTONOMIC NRV ADREN RG INERVJ TSTG ANS FUNCJ VASOMOTOR No approval required FUNCTION 95924 ANS PARASYMP & SYMP W/TILT TSTG ANS FUNCJ PARASYMP&SYMP No approval required W/5 MIN PASSIVE TILT 95925 SOMATOSENSORY SHORT LATENCY TESTING SOMATOSENS EP STD No approval required approval UPR-LIMBS 95926 SOMATOS ENZOTOR SHORT LATENCY TESTING SOMATOSENS EP STD No approval required LEVRE LEMMER OSENS EP Approval required for STD General Medicine - Complete Clinical Review TRNK/HEAD Neurology and Neuromuscular Procedures 95928 C MOTOR EVOQUE UPPR LIMB CTR MOTOR EP STD TRANSCRNL No approval required MOTOR STIMJ UPR UDOVA 95929 C MOTOR CAUSED LWR UDOVA CTR MOTOR EP STD STD TRANSCRNL no. EP TEST CNS W/I&R VISUAL EP TEST CNS EXCEPT No Authorization Required GLAUCOMA W/I&R 95933 BLINK REFLEX TEST ORBICULARIS OCULI REFLX No Authorization Required ELECTRODIAGNOSTIC TEST 95937 NEUROMUSCULAR JUNCTEUROMCTION Author Complete Clinical Review ANY 1 METH 95938 SOMATOSENS SORY TEST SHORT LATENCY EP STD Authorization full clinical exam required UPR & LOW LIMB 95939 C MOTOR CHALLENGED UPR&LWR limbs CTR MOTR EP STD TRANSCRNL MOTR Authorization Full clinical exam required STIM UPR & LOW LI 95940 MIN. 15. IN/15. ANCE Authorization Required General Medicine - Complete Clinical Examination EVERY 15 MINUTES Neurological & Neuromuscular Procedures 95941 IONM REMOTE/>1 PT OR PR. HR IONM FAR/NEAR/>1 PATIENT I Authorization Required General Medicine - Complete Clinical Examination OR ON THE HOUR Neuromuscular Procedures and Neuromuscular Procedures

95943 PARASYMP&SYMP HRT RATE TEST PARASYMP & SYMP NRV FUNCJ HRT No approval required RATE VARIABILITY 95954 EEG MONITORING/DRUG PRIORITATION RX/PHYSICAL EEG ACTIVAJ PHYS/QHP No approval required EEGIN 95 DURINGC IAL SURGERY No approval required 959 57 EEG DIGITAL ANALYSIS DIGITAL ANALYSIS Not required approval ELEKTROENSPHALOGRAM 95958 EEG MONITORING/FUNCTIONAL TEST WADA HEMISPHERE ACTIVATION TEST No approval required FUNCTION W/EEG 95961 ELECTRODESTIMULATION BRAIN FUNCTION TABLE & SUBCORT MAPG PH ATTELENDHR REQUIRED 9C DE STIM BRAIN APPENDIX FUNCJAL CORT & SUBCORT MA PG No approval required PHYS/QHP ATTND ADDL HR 95965 ME SPONTANEOUS MAGNETOENCEPHALOGRAPHY SPON No approval required BRAIN ACTIVITY 95966 MEG EVOLVED SINGLE MAGNETOENCEPHALOGRAPHY EVOLVED No approval required FIELD 59 MODALITY FIELD 5966 MEG EVOLVED PY EVOLVED No approval required FIELD EACH ADDL 959 70 ALYS NPGT BEZ PRGRMG ELEK ALYS IMPLT NPGT PHYS/QHP U/O Br approval required fox PROGRAMMING 95971 ALYS SMPL SP/PN NPGT W/PRGRM ELEK ALYS IMPLT NPGT SMPL SP/PN No approval required NPGT PRGRMG 95972 ALYS CPLX SP/PN CPLX SP/PN CMPLTGRM NPGTCNPPRYSGTPL SP/PN No approval required PRGRMG 95976 ALYS SMPL CN NPGT PRGRMG ELEC ALYS IMPLT SMPL CN NPGT No Authorization Required PRGRMG 95977 ALYS CPLX CN NPGT PRGRMG ELEC ALYS IMPLT CPLX CN NPGT No Authorization 95977 ALYS CPLX CN NPGT PRGRMG ELEC ALYS IMPLT CPLX CN NPGT NO Auth 9ST 5 ST ALYS NSTIM PLS GEN GASTRIC None approvals Required INTRAOP M/PRGRMG 95981 IO ANAL GAST N-STIM SUBSQ ELEC ALYS NSTIM GEN GASTRIC SBSQ No approval required U/O REPRGRMG 95982 IO GA N-STIM SUBSQ W/REPROG NORD ELEC. SBSQ M/REPRGRMG 95983 ALYS BRN NPGT PRGRMG 15 MIN ELEK ALYS IMPLT BRN NPGT PRGRMG No Approval Required 1. 15 MIN. 95984 ALYS BRN NPGT PRGRMG ADDL 15 ELEK ALYS IMPLT BRN NPGT PRGRMG No approval required 1. 15 MIN. REPOSITIONING PROC CANALITH REPOSITION PROCEDURE No Authorization Required 95999 NEUROLOGY PROCEDURE UNLIS Authorization Required General Medicine - Full Clinical Exam NEUROLOGICAL/NEUROMUSCULAR DX Neurological & PX Neuromuscular Procedures 96000 MOVEMENT ANALYSIS VIDEO/3D COMPRE CPTR MTNINGALYS Authorization Full CTNING ALYS Medicine VIDEO -3 General CTNING ALYS Authorization -3 rology and neuromuscular procedures 96001 MOVEMENT TEST W/FT PRESSURE TARGET COMPRE CPTR MTN ALYS W/DYN PLNTR Authorization required General medicine - Complete clinical examination PRES MEAS WALKG Neurology and neuromuscular procedures 96002 DYNAMIC SURFACE EMG DYN SURF EMG WALKG/1 A-9 0 REQUIRED ACMUSC/FUNCJ2 DYNAMIC FINE WIRE EMG DYN FINE WIRE EMG WALKG/FUNCJAL No Authorization Required ACTV 1 MUSC 96004 PHYS EXAMINATION OF MOVEMENT TESTS PHYS/QHP R&I CPTR MTN ALYS Authorization Required General Medicine - Full Clinical Exam WALK/REFUNCJL No Urology WALK/REFUNCJL Neurology Procedure WALK/REFUNCJL Neurology Procedure WALK/REFUNCJL ALL BRAIN MAPPING TEST SELECT & ADMN FUNCTL BRAIN No authorization required MAP PHYS/QHP 96040 GENETIC COUNSELING 30 MIN MEDICAL GENETIC COUNSELING EACH Authorization required Genetic testing & full clinical exam 30 RECORD Counseling 96105 APHASESSIA APHASESSIA/ Auth Required HOURLY REPORT 96110 DEVELOPMENT SCREEN W/SCORE DEVELOPMENT SCREEN W/SCORING No Authorization Required & DOC STD INSTRM 96112 DEVEL TST PHYS/QHP 1. HR DEVELOPMENT ST ADMIN No Authorization Required General Medicine - PHYS/HOURHP Central Nervous System Assessment, Mental status , Speech Test) 96113 DEVEL TST PHYS/QHP EA ADDL DEVELOPMENTAL TST ADMIN No Authorization Required General Medicine - PHYS/QHP EA ADDL 30 MIN Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Test) 961 XM PHY/QHP EA ADDL HR NEUROBIBEHAVIORAL STATUS XM No Authorization Required General Medicine - PHYS/QHP EA ADDL SAT Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Testing) 96125 COGNITIVE TESTING TO AUTHC EXCESS STANDARD No PERFORMANCE TEST 96127 BRIEF EMOTIONAL/BEH AVIOR ASSMT BEHAVIOR ASSMT W /SCORE & No Endorsement Required DOCD/STANDARD INSTRUMENT 96130 PSYCL TST EVAL PHYS/QHP 1. PSYCHOLOGICAL TST EVAL SVC No Endorsement Required - PHIRSTQ Central Nervous System Assessment/PHIRSTQ/PHIRST. (neurocognitive, mental status, speech test) 96131 PSYCL TST EVAL PHYS/QHP EA PSYCHOLOGICAL TST EVAL SVC No approval required General Medicine - PHYS/QHP EA ADDL HOUR CNS assessments/tests (neurocognitive, mental status, speech) test)

96132 NRPSYC TST EVAL PHYS/QHP 1. NEUROPSYCHOLOGY TST EVAL No Authorization Required General Medicine - PHYS/QHP 1. SAT Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Testing) 96133 NRPSYCPHEAPHYCSTEUR EQOPSYC. No Endorsement Required General Medicine - PHYS/QHP EA ADDL HR Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Test) 96136 PSYCL/NRPSYC TST PHY/QHP 1ST PSYL/NRPSYCL TST PHYS/QHP Auth 2+ TST General Medicine Required - 130 MINUTES Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Testing) 96137 PSYCL/NRPSYC TST PHY/QHP EA PSYCL/NRPSYCL TST PHYS/QHP 2+ TST No Clearance Required General Medicine - ADDL 30 MIN Central Nervous System Assessments/Tests Nervous System (Neurocognitive, Mental Status, Speech Testing) 96138 PSYCL/NRPSYC TECH 1ST PSYCL/NRPSYCL TST TECH 2+ TST 1ST 30 No Endorsement Required General Medicine - MIN Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Testing) 96139 PSYCL/NRPSYC TST TECH EA PSYCL/NRPSYC TST TECH 2+ TST EA No Endorsement Required General Medicine - ADDL 30 MIN Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Test) 96146 PSYCL/NRPSYC TST AUTORESULT PSYCL/NRPSYC TST ELEC PLATFORM No Authorization Required General Medicine - AUTORESULT Central Nervous System Assessments/Tests (Neurocognitive, Mental Status, Speech Test) 96156 HLTH BHVMENT ASHEAL ASSESSMENT/REASSESSMENT- No Authorization Required General Medicine - ASSESSMENT health and behavioral assessment/intervention 96158 HLTH BHV IVNTJ INDIV 1ST 30 HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST No Clearance Required General Medicine - 30 MIN Health and Behavioral Assessment/Intervention 96159 ADJHLTH 96159 ADJHLTH INDIV BEHAVIOR IVNTJ INDIV F2F EA No Clearance Required General Medicine - ADDL 15 MIN Health and Behavioral Assessment/Intervention 96 160 HLTH FOCUSED ON PT -RISK ASSMT PT-FOCUSED HLTH-RISK ASSMT SCORE No Approval Required DOC STND INSTRM INSTRM 96160 CISK 96160 SCORE No Approval Required DOC STND INSTRM 96164 HLTH BHV IVNTJ GRP 1ST 30 HEALTH BEHAVIOR IVNTJ GROUP F2F No Approval Required General Medicine - 1 30 MIN. health and behavioral assessment/intervention 96165 HLTH BHV IVNTJ GRP EA ADFLORHE General Medicine - ADDL 15 MIN health and behavioral assessment/intervention 96167 HLTH BHV IVNTJ FAM 1ST 30 HEALTH BEHAVIOR IVNTJ FAM W/PT No approval required General Medicine - F2F 1ST 30 MIN . health and behavioral assessment/intervention 96168 HL IVNTJ FAM W/PT No approval required General Medicine - F2F EA ADD 15 MIN health and behavioral assessment/intervention 96170 HLTH BHV IVNTJ FAM WO PT 1. HEALTH BEHAVIOR IVNTJ FAM U/O PT No approval required General Medicine - F2F MIN 1ST 30 Behavioral Assessment/Intervention 96171 HLTH BHV IVNTJ FAM U/O PT EA HEALTH BEHAVIOR IVNTJ FAM U/O PT No Authorization Required General Medicine - F2F EA ADDL 15 Health and Behavioral Assessment/Intervention 96360 HYDRATION IV INFUSION INIT IV INFUSION H31 No approval required 1 HOUR 96361 HYDRATE IV INFUSION ADDON IV INFUSION HYDRATION EACH No approval required ADDON HOUR 96365 THER/PROPH/DIAG IV INF INIT IV INFUSION TREATMENT/PROPHYLAXIS No approval required FOR 9 /D16RAG 9 /D16R/6RAG IV INF ADDON IV INFUSION TREATMENT PROPHYLAXIS /DX No approval required EA HOUR 96367 TX/PROPH/DG ADDL SEQ IV INF IV INFUSION THER PROPH ADDL No approval required SEQUENTIAL FOR 1 HOUR 96368 THER/DIAG REQUIRED IN CONCECTION WITH/DIAG REQUIRED IN A PROPH. CONCURRENT NFS Required 96372 THER/PROPH/DIAG INJ SC/IM THERAPEUTIC PROPHYLAXIAL/DX No Approval Required INJECTION SUBQ/IM 96374 THER/PROPH/DIAG INJ IV PUSH THER PROPH/DX NJX IV PUSH PUSH None AUDR/3ST TX/3ST Required PRO /DX INJ NEW DRUG ADD THERAPEUTIC INJECTION IV PUSH EACH No approval required NEW MEDICAL 96379 THER/PROP/DIAG INJ/INF PROC UNKNOWN THERAPEUTIC PROPH/DX No approval required IV/IA NJX/NFS/NFS CHEMOLQANT 964 IM CHEMOTX ADMN SUBQ/IM NO- Approval of HORMONAL ANTI-NEO is not required

96402 KEMO HORMON ANTINEOPL SQ/IM CHEMOTX ADMN SUBQ/IM HORMONAL No approval required ANTI-NEO 96405 KEMO INTRALESIONAL TO 7 APPLICATION OF CHEMOTHERAPY No approval required INTRALESIONAL 7 96405 KEMO INTRALESIONAL OPTIL 7 Q 1/1ST No application roval Required SBST /DRUG 96411 CHEMO IV PUSH ADDL DRUG CHEMOTX ADMN IV PUSH TQ EA No approval required SBST/DRUG 96413 CHEMO IV INFUSION 1 HR CHEMOTX ADMN IV NFS TQ UP 1 HR No approval required 1/1ST 96413 CHEMO IV INFUSION 1/1 HR 96413 APY ADMN IV INFUSION TQ no . no approval required EA HR 96416 CHEMO LANG INFUSEING W/PUMP CHEMOTX ADMN TQ INIT PROLNG No approval required CHEMOTX NFUS PMP 96417 CHEMO IV INFUS EACH ADDL SEQ CHEMOTX CHEMOTX ADMN IV Required 9 ADMN IV Required 1 0 KEMO IA PUSH TECHNIQUE CHEMOTHERAPY ADMIN INTRA-Y. No Approval Required ARTERIAL PUSH TQ 96422 CHEMO IA INFUSION UP TO 1 HOUR CHEMOTHERAPY ADMIN INTRA- No Approval Required ARTERIAL INFUS 8 HR PRTBLE No Approval Required IMPLT4PTRACHEN CHEMOTEX INTRA-CHEMOT. PLEURAL CAVITY No approval required REQ&W/ THORACIC 96446 CHEMOTX ADMN PRTL CAVITY CHEMOTX ADMN PRTL CAVITY No approval required PORT/CATH 96450 CNS CHEMOTHERAPY CHEMOTX ADMN CNS REQ SPINAL No approval required PUNCTURE 96521 REFILL/REFILL/REFILL requested PUMP 96523 IR RIG UNIT FOR DRUG DELIVERY IRRIGATION IMPLNTD VENOUS ACCESS No approval required DRUG DELIVERY SYSTEM 96549 CHEMOTHERAPY UNSPECIFIED UNSPECIFIED CHEMOTHERAPY PROCEDURE Approval required General Medicine - Complete Clinical Review Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions and PMLDTTRN Chemotherapy and PMLDTTRN 9DSTRN 9DS56oth Chemotherapy and PRMLG LES SKN ILLUM/ ACTIVJ Authorization Required General Medicine - Full Clinical Exam PER DAY Health & Behavior Assessment/Intervention 96570 PHOTODYNMC TX 30 MIN ADDITIONAL PDT NDSC ABL ABNOR TISS THROUGH ACTIVJ No Authorization Required RX 30 MIN 96571 PHOTODYNMC TX 30 MIN. ACTIVJ No Authorization Required RX A 15 MIN 96573 PDT DSTR PRMLG LES PHYS/QHP PDT DSTR PRMLG LES SKN ILLUM/ACTIVJ Authorization Required General Medicine - Complete Clinical Exam PHYS/QHP Health & Behavioral Assessment/Intervention 965PMLG 96574 DEDBRDMT PRMLGE MENT PRMLG No Authorization Required HYPERKERATOTIC LES W/PDT 96900 ULTRAVIOLET LIGHT THERAPY ULTRAVIOLET LIGHT THERAPY No approval required 96902 TRICHOGRAM MCRSCP XM STICK/HAIR ROD No approval required 96 B96B0CN0CNTS/96 B9ST0CTHOD 96 B96B0CN BODY COVER No app roval required PHOTO 96910 PHOTOCHEM OTER API S UV -B FOTOCHEMOTX No approval required TAR&UVB/ PETROLATUM/UVB 96912 PHOTOCHEMOTHERAPY WITH UV-A PHOTOCHEMOTX No authorization required PSORALENS & ULTRAVIOLET PUVA 96913 PHOTOCHEMOTHERAPY OTHER UV PHOTOTHERAPY OTHER PHOTOCHEMOTHERAPY Aqui-A 8 RS SUPERVISION 96931 RCM CELULR SUBCE LULR IMG SKN RCM CELULR & SUBCELULR SKN IMGNG authorization required general Medicine - Other Full Clinical Examination IMG ACQ I&R 1ST Services & Procedures 96932 RCM CELULR SUBCELULR IMG SKN RCM CELULR & SUBCELULR SKN IMGNG Authorization Required General Medicine - Other Full Clinical Examination IMG AQUISITIONS-96932 RCM CELULR SUBCELULR RCM CELULR & SUBCELULR SKN IMGNG Authorization Required General Medicine - Ph.D Full Clinical Review I&R 1ST LES Services & Procedures 96934 RCM CELULR SUBCELULR IMG SKN RCM CELULR & SUBCELULR SKN IMGNG Approval Required General Medicine - Other Full Clinical Services I3R & Procedures IMG 9 & 6 9 RCM CELULR SUBCELULR IMG SKN RCM CELULR & SUBCELULR SKN IMGNG Authorization Required General Medicine - Other Full Clinical Examination IMG ACQ EA ADDL Services & Procedures 96936 RCM CELULR SUBCELULR IMG SKN RCM CELULR & SUBCELULR SKN IMGRL Authorization - Other Full Approval CELIN IMG ADDL Services & Procedures 96999 DERMATOLOGY PROCEDURE UNLISTED SPECIAL DERMATOLOGY Request for the approval of the ed. General medicine - other Complete clinical review SERVICES/PROCEDURE services and procedures 97010 HOT OR COLD THERAPY APPLICATION MODALITY 1/> PHANICAL 1/> PHAN10S REQUIRED TRACTION THERAPY APPLICATION MODALITY 1/> TRACTION AREA No approval required MECHANICAL 97014 TERA ELECTRICAL STIMULATION PY MODALITY APPLICATIONS 1/> AREAS ELEC STIMJ No approval required UNSUPERVISED 97016 VASOPNEUMATIC THERAPY DEVICE MODALITY DE0VIC NO. 8 PARAFFIN BATH THERAPY METHOD OF APPLICATION 1/> AREAS PARAFFIN No approval required BATH 97022 WHIRLPOOL THERAPY METHOD OF APPLICATION 1/> AREAS No approval required WHIRLPOOL 97024 DIATHERMY E.g. MODALITY OF MICROWAVE APPLICATION 1/> AREA No DIATHERM approval is required

97026 INFRARED THERAPY APPLICATION MODALITY 1/> AREA No approval required INFRARED 97028 ULTRAVIOLET THERAPY APPLICATION MODALITY 1/> AREA No approval required ULTRAVIOLET 97032 ELECTRICAL STIMULATION APPLICATION. 5 MIN 97033 THERAPY WITH ELECTRIC CURRENT APPLICATION MODALITY 1 /> AREAS No approval required IONTOPHORESIS EA 15 MIN 97034 THERAPY WITH CONTRAST APPLICATION MODALITY 1/> AREAS CONTRAST No approval required BATH EA 15 MIN 97035 ULTRASOUND THERAPY APPLICATION MODALITY 1/> REQUIRED No AUS 0 MIN 0 NEEDED. HYDROTHERAPY APPLICATION MODALITY 1/ > HUBBARD AREAS No Approval Required TANK EA 15 MIN 97039 PHYSICAL THERAPY UNWRITTEN MODALITY SPEC TYPE AND TIME Approval Required General Medicine - Other Full Clinical Examination PERMANENT PRESENCE OF SERVICES AND PROCEDURE 97110 THERAPEUTIC EXERCISE ISES 1/>EXERCISES 5 THERAPY EXERCISES 5 MIN EXERCISES 97112 NEUROMUSCULAR REDUCATION PX 1/> AREAS EVERY 15 MIN. No approval required NEUROMUSC REEDUCA 97113 AQUA THERAPY/EXERCISES THER PX 1/> AREA EVERY 15 MIN. AQUA NO Approval required s/xerss ther 97116 the Eaning rait/1 5th floor No approval required exercise w/stairs 97124 Massage therapy Ther PX 1/> Areas every 15 minutes no approval required massage 97129 the ivntj 1. 15 min ivntj COG FUNCJ CNTCT 1. MINUTES Auth. 15. General health assessment and 15 MIN. 97130 THER IVNTJ EA ADDL 15 MIN THER IVNTJ COG FUNCJ CNTCT EA ADDL No Clearance Required General Medicine - 15 MINUTES Health & Behavioral Assessment/Intervention 97139 PHYSICAL MEDICINE PROCEDURE NOT LISTED THERAPEUTIC PROCEDURE Full Medical License SPEC9 required Full C90 MANUAL TREATMENT MENT 1/> REGIONS MANUAL THERAPY TQS 1/> REGIONS No approval required EVERY 15 MINUTES 97150 GROUP THERAPY PROCEDURES THERAPY PROCEDURES GROUP 2/> No approval required INDIVIDUALS 97151 BHVESS PERSONAL ID CHOICE KIT General Medicine - PHYS/QHP EA 15 MIN. central nervous system assessments/tests (neurocognitive, mental status, speech testing) 97152 BHV ID SUPRT ASSMT OF 1 TECHNICAL BEHAVIORAL SUPPORT ID SUPPORT ASSMT OF 1 No authorization required General Medicine - TECHNICAL EA 15 MIN. assessments/tests (neurocognitive, mental status, speech test) 97153 ADAPTIVE BEHAVIOR TX BY TECHNIQUE ADAPTIVE BEHAVIOR TX BY PROTOCOL No approval required General Medicine - TECHNICAL EA 15 MIN. central nervous system assessments/tests (neurocognitive, mental status, speech tests) 97154 GRP ADAPT BHV TX BY TECH GROUP ADAPTIVE BHV TX BY PROTOCOL No approval required General Medicine - TECH EA 15 MIN. central nervous system assessments/tests (neurocognitive, mental status, speech tests) 97155 ADJUSTED BEHAVIOR/QHTXP BEHAVIOR. BHV TX PRTCL MODIFICATION No approval required General Medicine - PHYS/QHP EA 15 MIN. central nervous system assessments/tests (neurocognitive, mental status, speech test) 97156 FAM ADAPT BHV TX GDN PHY/QHP FAMILY ADAPT BPHYS/Q GDNHP No general medical clearance required - EA 15 MIN central nervous system assessments/tests (neurocognitive, mental status , speech test) 97157 MULT FAM ADAPT BHV TX GDN MULTIPLE FAM GROUP BHV TX GDN No authorization required General Medicine - PHYS/QHP EA 15 MIN Central nervous system assessments/tests (neurocognitive, mental status, speech test) 97158 GRP ADAPT BHV TX AF PHY/QHP GRP ADAPT BHV PRTCL MODIFCAJ No approval required General Medicine - PHYS/QHP EA 15 MIN Central nervous system assessments/tests (neurocognitive, mental status, speech test) 97161 PT EVAL LOW COMPLEX 20 MIN PHYSICAL THERAPY EVALUATION LOW No approval required ed . Complex 20 min 97162 PT Rating Mod complex 30 min Physical Treatment Rating 3 COMPLEX 9 Rating 3 COMPUTS OF GH COMMPECTS 45 min Physical therapy Evaluation High No need No need Request estimate EST Plan Care Physical therapy re-eval EST PLAN No approval required NURSING 20 MIN. 30 MIN 97166 OT EVAL MOD COMPLEX 45 MIN OCCUPATIONAL THERAPY EVAL MOD No approval required COMPLEX 45 MIN 97167 OT EVAL HIGH COMPLEX 60 MIN OCCUPATIONAL THERAPY EVAL HIGH No approval required COMPLEX 60 MIN.

97168 OT RE-EVAL EST PLAN CARE OCCUPATION THER RE-EVAL EST No approval required PLAN CARE 30 MIN 97169 ATHLETIC TRN EVAL LOW CMPLX ATHLETIC TRAINING EVAL LOW No approval required COMPLEX 15 MINS 9717 EVALET 9717 EVALET EVALET 9717 EVAL 30 MOD required in COMPLEX. MINE. 97171 ATHLETIC TRAIN EVAL HIGH CMPLX ATHLETIC TRAINING EVAL HIGH No approval required COMPLEX 45 MIN. 97172 ATHLETIC TRN RE-ASSESSMENT PLAN CR ATHLETIC TRAINING RE-ASSESSMENT EST PLAN DEN 90 50 REQUIRED PLAN DEN 90 CRAIV UT ACTVITY DIRECT PT No approval required CONTACT EVERY 15 MIN 97533 SENSOLY INTEGRATION SENSORY INTEGRATIVE TECHNIQ General Medicine UES approval required - full clinical exam EVERY 15 MINUTES Health and Behavioral Assessment/Intervention 97535 SELF-CARE TRAINING SELF-CARE/DISCHARGE FROM HOME 5 MIN. COMMUNITY WORK REINTEGRATION/WORK REINTEGRATION No approval required TRAINING EA 15 MIN 97542 WHEELCHAIR MANAGEMENT TRAINING WHEELCHAIR MGMT EA 15 MIN No approval required 97545 WORK HENDING WORK HENDING/CONDITIONING required 9. 52 HR. WORK TEMPERING/CONDITIONING No approval required PER HOURS 97597 RMVL DEVITAL TIS 20 CM/NDLES U/U ELEC No Authorization Required STIMJ INIT 15 MIN 97811 ACUPUNCT U/O STIMUL ADDL 15M ACUPUNCTURE 1/> NDLS U/O ELEC No Authorization 35 MIN ACUP1 STIMUL 97811 /STIMUL 15 MIN ACUPUNCTURE 1/> NDLS M/ELEC STIMJ None approval required 1. 15 MIN 97814 ACUPUNKT W/STIMUL ADDL 15M AKUP 1/> NDLS W/ELEC STIMJ EA 15 No approval required MIN. 9-19 MON. -2 REGIONS OSTEOPATHIC MANIPULATIVE TX 1-2 No approval required BODY SECTIONS 98926 OSTEOPATH MINOR 3-4 REGIONS OSTEOPATHIC MANIPULATIVE TX 3-4 No approval required BODY SECTIONS 98927 OSTEOPATH MINOR 3-4 REGION. 5-6 No Authorization Required BODY REGIONS 98928 OSTEOPATH MINOR 7-8 REGIONS OSTEOPATHIC MANIPULATIVE TX 7-8 No Authorization Required BODY REGIONS 98929 OSTEOPATH MINOR 9-10 REGIONS OSTEOPATHIC MANIPULATIVE TX 9-10 BOD 8 Auth REG40 MANR. REGIONS CHIROPRACTIC MANIPULATION TX No Authorization Required SPINAL 1-2 REGIONS 98941 CHIROPRACTIC MANJ 3-4 REGIONS CHIROPRACTIC MANIPULATIVE TX No Authorization Required SPINAL 3-4 REGIONS 98942 CHIROPRACTIC MANJ 5 REGIONS CHIROPRACTIC MANIPULATION TX SPIN Auth RSPINL 1/> CHIROPRACTIC MANIPLTV TX No Authorization Required EXTRASPINAL 1/> REGION 98960 SELF-MGMT EDUCATION & TRAINING 1 PT EDUCATION & TRAINING SELF-MGMT No Approval Required NONPHYS 1 PT 98961 SELF-MGMT EDUCATION/TRAINING 2-4 PT EDUCATION & TRAINING SELF-MGMT No Approval Required SELF-MGMT 98961 SELF-MGMT EDUCATION/TRAINING 2-4 PT. 961 NMG2 EDUCATION/TRAINING 5-8 PT EDUCATION & TRAINING SAM-MGMT No approval required NONPHYS 5-8 PTS 98966 HC PRO PHONE CALL 5-10 MIN PHONE NO DOCTOR. ET No Approval Required ESTIMATE 11-20 MIN 98968 HC PRO PHONE CALL 21-30 MIN NO DOCTOR PHONE No Approval Required ESTIMATE 21-30 MIN 98970 QNHP OL DIG E/M SVC 5-10MIN.

99000 SAMPLE HANDLING OFFICE LAB HANDLING AND/OR SPEC FOR TR No approval required OFFICE TO LAB 99001 SAMPLE HANDLING PT-LAB HANDLG&/OR SPEC FOR TR No approval required FROM PT TO LAB. oval Mandatory OF - HOSPITAL EA HR 99050 AFTER HOURS MEDICATION DISTRIBUTION SERVICE DELIVERED SERVICES OTH/THN OFFICE No approval required REG SCHED HOURS/ MEDICOFF 99050 REG. EVN SCHEDULE No approval required WKEND/HOLIDAY HRS 99053 WITH SERVICE 10:00-8:00 24 HOUR FAC SERVICES BTW 10:00:00 & 8:00 No approval required 24 ISAN REQUEST PT 99058 OFFICE URGENT SVC FIRST EMER BASE IN OFFICE No approval required INTER RUPTIVE SVCS 99060 OUT OF OFFICE EMERG WITH SERVICE SVC FIRST OFFICE EXIT SWITCH No approval required OFFICE SVC 99070 SPECIAL SVC 99070 SPECIAL & SPECIAL & SPECIAL EVIDENCE No approval required PROV BY PHYS/ QHP 99071 PATIENT EDUCATIONAL MATERIALS FIRST SIDE EDUCATIONAL MATERIALS None approval required ed PHYS AT COST 9 9075 DOCTOR'S CERTIFICATE MEDICAL CERTIFICATE No approval required 99078 GROUP HEALTH EDUCATION REQUIRED PHYS/QHCSP 9 G0 0 SPECIAL REPORTS OR SPEC REPORT FORM > SPECIAL S No approval required COMUNICAJ/STAND RPRTG 99082 UNUSUAL MEDICAL TRIP ANJE'S UNUSUAL JOURNEY Not required authorization 990 91 COLLJ & INTERP J DATA EA 30 D COLLJ & INTERPJ PHYSICAL DATA MIN 30 No authorization required 300 EA 9 A 90 A 9 A 90 A 9 A 9 A 9 NESTHESIA EXTREME AGE PATIENT No authorization required UNDER 1 YEAR/< 99116 ANESTHESIA WITH HYPOTHERMIA ANES COMPLICJ USE TOTAL No approval required BODY HY POTHERMIA 99135 SPECIAL ANESTHESIA PROCEDURE USING ANESTHESIA COMPLEX No approval required Property hypotemia 99135 SPECIAL ANESTHESIA PROCEDURE USING ANESTHESIA COMPLEX No approval required EGENCYPOTENTIAL CONTROLLED HYPOTENSION EGENCY1S0 CY Not required approval TERMS SPECIFY 99151 MOD SED SAME PHYS/ QHP YRS 99153 MOD SED SAME PHYS/ QHP EA AGAINST SED SED OTHER PHYS /QHP EA MOD SED OTHER PHYS/QHP REQUIRED 15 MIN. 99155 MOD SED OTHER PHYS/QHP YEAR. 99157 MOD SED OTHER PHYS/QHP EA MOD SED OTHER PHYS/QHP EACH PHYS/QHP REQUIRED ADL9 A70 MIN 10 EXAM CHILD W IMAGE ANOGENITAL XM MAGNIFY No approval required CHILD/ERROR TR AUM W IMG 99172 Ocular FUNCTION DISPLAY VISUAL FUNCTION SCRNG AUTO SEMI- No authorization required AUTO BI QUAN DETERM 99173 VISUAL DISPLAY DISPLAY Auth. IVE BILAT 99174 OCULAR INSTRUMENT SCREEN BIL OCULAR SCR INSTRUMENT BASED BI No approval required M/RMT ANAL & RPT 99175 VOMIT INDUCTION IPECAC/SIMILAR ADMN EMEZIS&OBS No approval required GASTRIC EMPTY 99177 OCULAR INSTRUMENT SCREEN B ILON Required No ANALYSIS 99183 HYPERBARIC OLT THERAPY PHYS/ Q HP ATTN&SUPVJ HYPRBARIC Authorization Required General Medicine - Other Complete Clinical Review OXYGEN TX/SESSION Services & Procedures 99184 HYPOTHERMIA SICK NEONAT INITIATE SELECTIVE HEAD/BODY No Authorization Required HYPOTHERMIA TX/SESSION 99184 HYPOTHERMIA SICK NEONAT INITIATE SELECTIVE HEAD/BODY No Authorization Required HYPOTHERMIA TX / SESSION 8 DESCRIPTION FLUORIDE No approval required LAK OF PHS/ QHP 99190 SPECIAL PUMP SERVICES PUMP ASSEMBLY & OPERATION No approval required OXYGENATOR/HEAT EXCHANGE EA HR 99191 SPECIAL PUMP SERVICES ASSEMBLY & PUMP OPERATION No approval required OXYGENATOR/452 S SPECIAL PUMP AS MBLY&OPERJ PUMP No approval Oxygenator / Heat Exch 30 mi 99195 Phlebotomy Plebotomy Therapeutically Separate Procedure 99199 Special Service Required General Medicine - Other Complete Clinical Overview Procedure / Report Services 99201 Clinics / Ambolit Visit New Office OUTPATIENT TREATMENT ENT 102 OUTPATIENT NEW99202 PATIENT VISIT NEW OFFICE AMBULUT NEW 20 MINUTES No approval required 99203 OFFICE/AMBOLUT VISIT NEW OFFICE AMULATIVE NEW 30 MINUTES No approval required 99204 OFFICE/AMBOLUT VISIT NEW OFFICE AMOLUTIC REQUEST NEW 4590 VISIT NEW OFFICE AMULATIVE NEW 60 MINUTES Approval not required 99211 OFFICE/AMBOLUT VISIT EST OFFICE AMU LATE VISIT 5 MINUTES No approval required 99212 OFFICE VISIT/AMBOLUT EST VISIT AMOLUTIC OFFICE 10 MINUTES No approval required 99213 OFFICE VISIT/AMBOLNIC VISIT EST VISIT AMOLUTIC OFFICE 10 MINUTES No approval required 99213 OFFICE/AMBOLNIC VISIT No approval required 99214 OFFICE/ AMBOLUT VISIT EST OFFICE AMOLU TICK VISIT 25 MINUTES No approval required

99215 OFFICE VISIT/AMBOLUTU EST OFFICE VISIT AMMULATIVE VISIT 40 MINUTES No authorization required 99217 CARE OBSERVATION PRINTOUT OBSERVATION PRINTOUT Authorization not required MANAGEMENT 99218 Authentic OBSERVATION/OBS 30 PROTOCOL 99219 INITIAL OBSERVATION INITIAL CARE OBSERVATION/DAY 50 No approval required MINUTES 9922 0 INITIAL OBSERVATION OF HIM INITIALLY Observation/day 70 No minutes no minutes 99221 Home Hospital Hospital Hospital Care/Day 30 No Mun Authorization 992220 minutes 992220. MINUTE CLASS 99223 Home Hospital Hospital Care/Day 70 Not Required APPEARATION OF 9922 4 Subsequent observation SBSQ observation/ DAY 15 No approval required MINUTE 99225 MONITORING OBSERVATION SBSQ OBSERVATION 9MIN2SE required 9 MIN2SE 9.OBSERVATION TREATMENT SBSQ OBSERVATION TREATMENT/DAY 35 No approval required MINUTE 99231 MONITORING HOSPITAL CA RE SBSQ HOSPITAL CARE/DAY 15 MINUTES No approval required 992 32 HOSPITAL AFTER CARE SBSQ HOSPITAL CARE/DAY 25 MINUTES No authorization required 99233 HOSPITAL CMINUS/DAY UTES No authorization required 99234 OBSERVATION/HOSP SAME DATE OBSERVATION /HOSPITAL HOSPITAL No authorization required NURSING 40 MINUTES 99 235 OBSERVATION/HOSP OBSERVATION SAME DATE /IN-PATIENT HOSPITAL No authorization required NURSING DAY DISCHARGE FROM HOSPITAL DAY OF DISCHARGE FROM HOSPITAL No. Auth Pk fox ADMINISTRATION 30 MIN/< 99239 HOSPITAL DISCHARGE DAY HOSPITAL DISCHARGE DAY No approval required ADMINISTRATION > 30 MIN 99241 OFFICE CONSULTATION COUNSELING NY/ESTAB No author. PATIENT CONTROL required 9242 CONSULTATION BUILDING/OFFICE 924241 CONSULTATION No approval required PATIENT 30 MIN 99243 OFFICE COUNSELING OFFICE CONSULTATION NEW/ESTAB No Author. Needed PATIENT 40 MIN 99244 OFFICE CONSULTATION OFFICE CONSULTATION NY/ESTAB No author. PATIENT Needed 60 MIN 99245 OFFICE CONSULTS OFFICE CONSULTS NY/ESTAB. INITIAL PATIENT CONSULTATION No authorization required NEW/ESTAB PT 20 MIN 99252 PATIENT CONSULTATION INITIAL PATIENT CONSULTATION No authorization required NEW/ESTAB PT 40 MIN 99253 PATIENT CONSULTATION INITIAL PATIENT CONSULTATION No authorization required NEW/ESTAB PT 55 MIN PATIENT CONSULTATION TOM And required NEW/ESTAB PT 80 MIN no 99283 EMERGENCY DEPARTMENT VISIT No authorization required MODERATE 99284 EMERGENCY DEPARTMENT VISIT EMERGENCY DEPARTMENT VISIT No authorization required HIGH/URGENT SEVERITY 99285 EMERGENCY DEPARTMENT VISIT EMERGENCY DEPARTMENT VISIT HIGH No authorization required DAMAGES&THE REAT ADVANCED28VCJ DPHLIQJ 99285 P-DIRECTION EMERGENCY No authorization required MEDICAL SYSTEMS 99291 CRITICAL CARE FIRST HOURS CRITICAL CARE ILL/INJURIED PATIENT No authorization required INIT 30-74 MIN 99292 CRITICAL CARE ADDL 30 MIN CRITICAL CARE ILL/INJURIED PATIENT No authorization required ADDL 30 MIN 99 304 CASE CASE 25 No authorization Required RECORD 99305 NURSING FACILITY INIT PRIMARY NURSING CARE/ DAY 35 No approval required MINUTE 99306 NURSING FACILITY INITIAL CARE/ DAY 45 No approval required MINUTE 99306 NURSING FACILITY INITIAL CARE/ DAY 45 No approval required MINUTES 9Q07AC 9 . ITY CARE/DAY E/ M No authorization required STABLE 10 MIN 9930 8 HOSPITAL BED FAC CARE SUBSEQ SBSQ FACILITY CARE/DAY MINOR No authorization required COMPLJ 15 MIN 99309 FAC CARE SUBSEQ SBSQ FACILITY CARE/DAY NEW No Auth 90 CEQ 91 PRO DESCRIPTION SBSQ FACILITY CA RE/DAY No authorization required UNSTABL/NEW PROB 35 MIN 99315 HOSPITAL DISCHARGE FAC DAY DISCHARGE FROM HEALTH FACILITY No authorization required ADMINISTRATION 30 MINUTES 99316 NURSING FAC DAY DISCHARGE 9 MIN. 8 ANNUAL ASSESSMENT OF NURSING FACILITIES E/M ANNUAL ITS FACILITIES Assessment None Auth Required STAL 30 MIN 99324 DOMICIL/R HOME VISIT NEW PAT DOMICILE/RESH HOME NEW PT VISIT No approval required LOW SEVER 20 MIN 99325 DOMICIL/R HOME VISIT NEW PAT DOMICILE/RESH HOME NEW PT VISIT RESH HOME 3 MOD REQUIRED APARTMENT/HOME 0 MIN. 99326 DOMICIL/R-HOME VISIT NEW PAT DOMICIL/REST HOME NEW PT HI-MOD No approval required SEVER 45 MINUTES 99327 DOMICIL/R-HOME VISIT NEW PAT DOMICIL/REST HOME NEW PT60 VISIT SEVER 8 MIN 3 VISIT SEVER 8 MIN 8 MIN 8 MIN 3 R-HOME VISIT NEW PAT DOM/R-HOME E/M NEW PT SIGNIF Approval not required NEW TRIAL 75 MINUTES

99334 DOMICIL/R-HOME SEARCH EST PAT DOM/R-HOME E/M EST PT SELF- No approval required LMTD/MINOR 15 MINUTES 99335 DOMICIL/R-HOME VISIT EST PAT DOM/R-HOME E/M EST PT LW No approval required SEVERITY 25 MINUTE 99336 DOMICIL/R-HOME VISIT EST PAT DOM/R-HOME E/M EST PT MOD HI No approval required SEVERITY 40 MINUTE 99337 DOMICIL/R-HOME VISIT EST PAT DOM/MER EST PT SIGNIF NY No approval required PROB 60 MINUTES 99339 DOMICIL/R-HOME CARE SUPERVIS INDIV PHYS SUPVJ HOME/DOM/R- No approval required HOME MO 15-29 MIN 99340 DOMICIL/R-HOME CARE SUPVJ /R- No approval required HOME MO 30 MIN/> 99341 HOME VISIT NEW PATIENT HOME VISIT NEW PATIENT LOW No authorization required FOR 20 MINUTES 99342 HOME VISIT NEW PATIENT HOME VISIT NEW PATIENT 0 MOD no. Auth 3 REQUIRED REQUIRED 9 EW PATIENT HOME VST NEW PATIENT MOD-HI No authorization required AT SEVER ITY 45 MINUTES 99344 HOME VISIT NEW PATIENT HOME VISIT NEW PATIENT HIGH WEIGHT No authorization required 60 MINUTES 99345 HOME VISIT NEW PATIENT HOME NZNAK. PROB 75 MIN 99347 HOME VISIT EST PATIENT HOME VISIT EST PT ALONE No approval required LIMITED/SLIGHT 15 MINUTES 99348 HOME VISIT EST PATIENT HOME VISIT EST PT LOW MOD LABEL No approval required 3MIN 295 IT EST PT MOD -HIGH SEVERITY No approval required oval PER 40 MINUTES 9935 0 HOME VISIT EST PATIENT HOME VST EST PT UNSTABLE/SIGNIFICANT Approval not required ON NEW PROB 60 MIN. DIR CON 1ST HR 99355 LONG TRAVEL E&M/PSYCTX SERV O/P REQUIRED E&M/PSYCTX SVC OFFICE O/P No approval required DIR CON ADDL 30 99356 LONG TRAVEL SERVICE STATIONARY LONGER SERVICE I/P REQUIRED 9/5 REQ. ED SERVICE STATIONARY LONG TRIP SVC I/P REQ UNIT/FLOOR No Approval Required TIME EA 30 MIN 99358 LONG SERVICE NO CONTACT EXTEND E/M SVC BEFORE&/AFTER DIR No Approval Required PT CARE 1ST HRONG 99359 PRONGL CONT. E/M BEFORE&/AFTER CARE DIR Approval not required EA 30 MINUTES 99360 PHYSICIAN SERVICES ON STANDBY PHYS STANDBY SVC EXTENSION PHYS ATTN Approval not required EA 30 MINUTES 99366 TEAM CONF. CONF. CONF. Needed W/PROFACE. NO DOCTOR 99367 TEAM CONF. NO PAT OF PHYS TEAM CONFERENCES NON-FACE TO- No approval required FACE PHYSICIAN 99368 TEAM CONF. NO PAT HC PRO TEAM CONFERENCES NON-FACE TO- Approval not required FACE 4 SUPER 4 CVISION 4 CVISION 4 SUPVJ PT HOME HEALTH BUREAU MO Approval not required 15-29 MINUTES 99375 HOME HEALTH SUPERVISION SUPERVISION PT HOME HEALTH No approval required AGENCY MONTH 30 MIN/> 99377 HOSPICE Required SUPERVISION SUPERVISION 15-29 MIN 99378 HOSPICE NURSING SUPERVISION SUPERVISION HOSPIC No approval required PATIENT/MONTH 30 MINUTES/> 99379 SYGE NURSING FACILITY SUPERVISION SUPERVISION Nursing Facility PATIENT No approval required MO 15-29 MIN 99380 FACILITY FOR SUPERVISION IN HIS FACILITIES required MONTH 30 MIN/> 99381 INIT PM E/M NEW PAT DILUTION INITIAL PREVENTIVE MEDICINE NEW No approval required PATIENT 99391 PR. PM REEVAL EST PAT CHILD PERIODIC PREVENTIVE MEDICINE No approval required IDENTIFIED PATIENT 10 MIN. WITH ADVICE AND RISK FACTOR No approval required REDJ GRP SPX 30 M

99412 PREVENTIVE COUNSELING GROUP PREV WITH COUNSELING AND RISK FACTOR No approval required REDJ GRP SPX 60 M 99415 EXTEND CLINCL STAFF SVC EXTEND CLINCL STAFF SVC UNDER O/P No approval required E/M 1ST CL HR 99415 EXTEND CLINCL HR 9 STAFF SVC UNDER O / P No Clearance Required E/M EA 30 MIN 99421 OL DIG E/M SVC 5-10 MIN ONLINE DIGITAL E/M SVC EST PT NTRPROF PHONE/NTRNET/EPJ No Clearance Required General Medicine - ASSMT&MGMT 5/> MIN Central Nervous Assessments system /Tests (neurocognitive, mental status, speech test) 99452 NTRPROF PH1/NTRNET/EHR RFRL NTRPROF PHONE/NTRNET/EHR No approval required General medicine - REFERRAL SVC 30 MIN. central nervous system assessments/tests (neurocognitive, mental status, speech test) 99453 REM MNTR PHYSIOL PARAM SETUP REM MNTR PHYSIOL PARAM 1. SET UP No authorization required General Medicine - PT EDUCAJ EQP central nervous system assessments/tests (neurocognitive, mental status, speech test) 9945 DEV REM MNTR PHYSICAL PARAM 1. DEV No authorization required General medicine - EQUIPMENT EA 30 D Central nervous system assessments/tests (neuro-cognitive, mental status, speech test) 99455 WORK-RELATED DISABILITY TEST/S NO. 99456 CONDUCT EXAMINATION WORK RELATED/S DBLT XM No OTH/THN approval required TREATMENT PHYS 99457 REM PHYSIOL MNTR 1. 20 MIN. REMOTE PHYSIOLOGICAL MONITORING No authorization required 20 MIN MON central nervous system assessment 20 - (cognitive test 20 tive, mental status, speech test) 99458 REM PHYSIOL MNTR EA ADDL 20 REMOTE PHYSIOLOGICAL MONITORING EA No authorization required General Medicine - ADDL 20 MIN MO assessments/ central nervous system tests (neurocognitive, mental status, speech testing) 99460 DNBHO 1 D. 1. HOSP/FØDECENTRE CARE PR. No. Approval required DAN NML NB 99461 INIT NB EM PER DAY NON-FAC 1. CARE PER DAY NML NB XCPT No approval required HOSP/BIRTH 99462 SBSQ NB D. DG. DAY. No Approval Required NORMAL NEWBORN 99463 SAME DAY NB DISCHARGE 1ST HOSP/BIRTH NB ADMISSION No Approval Required & DSCHG SM DAT 99464 ATTENDANCE AT BIRTH ATTN AT BIRTH 1ST STABILIZATION N96 REQUI. RY/ ROOM No Authorization Required REINFORCEMENT 99466 PED CRIT CARE TRANSPORT CRITICAL CARE INTERFACILITY No Authorization Required TRANSPORT 30-74 MIN 99467 PED CRIT CARE TRANSPORT ADDL CRITICAL CARE INTERFACILITY No Authorization Required TRANSPORT EA 30 MIN 99468 CARENAT INCRIAL NEONAT NEON 28 DAYS / < 99469 NEONATAL CRITICAL CARE SUBSQ SUBQ I/P CRITICAL CARE PR DAY AGE 28 No approval required DAYS/< 99471 PED CRITICAL CARE INITIAL INITIAL PED CRITICAL CARE 29 DAYS No approval required MONTHS 2947 CSUBS Q PED CRITICAL CARE 29 DAYS No approval required THRU 24 MO 99473 SELF-MEASUREMENT BP PT EDUCAJ/TRAIN SELF-MEASUREMENT BP PT EDUCAJ/TRAING & No approval required DEV CALIBRATION 99474 SELF-MEASUREMENT BP 2 READG BID 30D SELF-MEASUREMENT BP 2 Required BPART AUT. 30 DAYS PD 99475 PED CRITICAL CARE AGES 2-5 INITIAL PED CRITICAL CARE 2 TO 5 No approval required YEAR 99476 PED CRITICAL CARE AGES 2-5 SUBSQ SUBSQ PED CRITICAL CARE 2 YEARS required NO.

99477 INIT DAY HOSP NEONAT CARE INITAL HOSP NEONAT 28 D/< NO No approval required CRITICALLY ILL 99478 IC LBW INF < 1500 GM SUBSQ SUBSQ INTENSIVE CARE DILUTION < None 500 4GRA 91 0W 500 491 0W required. 2500g Subs Subs SubSQ Intensive Care Monitoring No Approval Required 1500-2500 Grams 99480 IC INF PBW 2501-5000 G Subs Subs Subs Up-up INTEnse Dilution Required Approval Required 2501-5000 Grams 99485 SupRv Interfacility Transport No. MIN 99486 SUPRV INTERFAC TRNSPORT ADDL SUPERVISION INTERFACILITY No approval required TRANSPORT ADDL 30 MIN 99487 CMPLX CHRON CARE U/O PT VSIT CMPLX CHRON CARE MGMT U/O PT No approval required VST 1ST HR PER MO 99489 CMPLX CHRON CARE ADDL 30 MIN CMPLX CHRON CARE ADDL 3 Auth 9 Auth 9 Required CHRON CARE MGMT SRVC 20 MIN CHRON CARE MANAGEMENT SRVC 20 No Authorization Required MIN MONTHLY 99491 CHRNC CARE MGMT SVC 30 MIN CHRONIC CARE MGMT SVC MINIMUM 30 No Authorization Required General Medicine - MIN Test Per PON Central Nervous System Assessment , mental status, speech test) 99495 TRANS CARE MGMT 14 DAYS DISCH TRANSITIONAL CARE MANAGE SRVC 14 No approval required DAY PRINT 99496 TRANS CARE MGMT 7 DAYS DISCH TRANSITIONAL CARE MANAGE SRVC AD9 ADNCD 7 No. First 30 min advance planning 30 not REQUIRED AUTH REQUIRED MINS 99498 ADVNCD CARE PLAN ADDL 30 MIN ADVANCE CARE PLAN EA ADDL 30 NO AUTH REQUIRED MINS 99499 E&M SERVICE NOT REQUIRED ON LIST Evaluation and not required AUTH required ASSESSMENT 99501 HOME VISIT POSTNATAL HOME VIS IT POSTNATAL ASSMT&F -UP No approval required CARE 99502 HOME VISIT NB CARE NEWBORN CARE HOME VISIT & No approval required ASSESSMENT 9500 RESULT 99502 HOME VISIT NB CARE HOME VISIT NEWBORN CARE IS & No approval required ASSESSMENT TREATMENT No approval required NURSING 99504 MECH. VENTILATOR HOME VISIT MECHANICAL VENTILATION Br approval required CARE 99505 HOME VISIT CARE AND STOMA MAINTENANCE HOME VISIT CARE AND STOMA MAINTENANCE No approval required CLST&CSTOST 99506 HOME VISIT IM INJECTION REQUIRED IM INJECTION HOME VISIT97C HOME VISIT9 CATH VISIT MAINTENANCE HOME VISIT CARE AND CATH MAINTENANCE No appr needed oval 99509 HOME VISIT DAILY LIVING ACTIVITY HOME VISIT HELP DAILY No authorization required LIFE & PERSONAL CARE 99510 HOME VISIT SING/M/FAM COUNSELOR HOME VISIT INDIV FAM/Marriage No authorization required COUNSELING 99511 HOME VISIT FECMG Auth. MGMT&CLISTIR ADMN 99512 HOME VISIT FOR HEMODIALYSIS HOME VISIT HEMODIALYSIS No Authorization Required 99600 HOME VISIT NOT WRITTEN HOME VISIT Authorization Required NA Full Clinical Review SERVICES/PROCEDURE 99601 HOME INFUSION/VISIT 2 HOUR HOME NFS/VISIT BR ADMECTY Mandatory

0503F NURSING VISIT POSTPARTUM CARE VISIT No Approval Required 0505F HEMODIALYSIS PLAN DOCD HEMODIALYSIS CARE No Approval Required DOCUMENT 0507F PERITONEAL DIALYSIS PLAN DOCD CARE PERITONEAL CARE 5COND. LAN DOCD CARE PLAN FOR URINARY INCONTINENCE No approval required DOCUMENTED 0513F CARE PLAN FOR HIGH KT DOCD CARE PLAN FOR HIGH BLOOD PRESSURE No approval required DOCUMENTED 0514F CARE PLAN HGB DOCD ESA PT PLAN/HE INCRSD HGB LVL DOCD PT No approval required ON ESA THXP Y OF 0516F CARE PLAN HGB DOCD COMMENTED No approval required 0517F GLAUCOMA CARE PLAN DOCD GLAUCOMA CARE PLAN No approval required DOCUMENTED 0518F FALL CARE PLAN DOCD FALLS CARE PLAN DOCUMENTED No approval required 0519F KEMO PLAN DOCUMENTED PLAN required OF4 Auth START NEW TX 0520F RAD DOS LIMIT S B/4 3D WORK WORK DOSE LIMITATION EST PRIOR3D WORK FOR No approval required MIN 2 TIS/ORG 0521F CARE PLAN 4 PAIN DOCD CARE PLAN FOR PAIN MANAGEMENT No approval required DOCUMENT 0525F FIRST VISIT FOR Auth. 0526F SUBSCRIBER VISIT FOR EPISODE SUBSCRIPTION VISIT FOR EPISODE No approval required 0528F RCMND FLW-UP 10 YEAR DOCD RCMND FLLW-UP 2ND CLNSCPY 10/> No approval required YRS DOCD RPCDL 0526F RCMND FLW-UP 10 YEAR DOCD 3/> YEAR PTS LAST None approval required COLONOSCOPY DOCD 0535F DYSPNEA MNGMNT PLAN DOCD DYSPNEA MANAGEMENT PLAN No approval required DOCUMENT 0540F GLUCO MNGMNT PLAN DOCD GLUCORTICOID MANAGEMENT PLAN No approval required DOLL PLAN PUP 0540F GLUCO MNGMNT PLAN DOCD GLUCORTICOID MANAGEMENT PLAN FOR MDD MONITORING No approval required DOCD 0550F CYTOPAT REPORT NON GYN SPCMN CYTOPAT REPORT ON NONGYN No approval required SAMPLE 2 WKNG DAYS 0551F CYTOPAT REPORT NON-ROUTINE CYTOPAT REPORT NONGYN SPCMN No approval required DOCD NON-ROUTINE 0555F CYTOPATH SYMPLAN SYMPLAN SYMPLAN SYMPLAN No approval required NURSING TO CUMENT 0556F LIPID CONTROL CARE PLAN DOCD LIPID ACHIEVEMENT CARE PLAN No approval required CONTROL DOCUMENT 0557F CARE PLAN ANGNL SYMPTDOCD CARE PLAN FOR ANGINA MANAGEMENT No approval required SYMPTOMS DOCD 0575F HIV RNA CARE PLAN CONTROL DOCD PLAN CARE PLAN CONTROL DOCD 5 F MULTIDISCIPLINARY CARE PLAN MULTIDISCIPLINARY CARE PLAN No. approval required DEVELOPED/UPDATED 0581F PT TRNSFRD FROM ANESTH TO CC PT MOVED FROM No approval required Anesthesia to CC UNIT 0582F NO TRNSFR FROM ANESTH TO CC PT NOT MOVED FROM ANESTH TO CC PT NOT MOVED 8 TRANSFER OF CARE CHECKLIST USED No approval required 0584F NO TRANSFERCARE CHKLIST USED TRANSFER CARE CHECKLIST NO No approval required USAGE 1000F TOBACCO USE ASSESSED TOBACCO USE ASSESSED No approval required 1002F ASSESSMENT ANGIVMINAL SYMPHED AND ANGIVMINAL SYMPEL uth Required ASSESSED 1003F ACTIVITY LEVEL ASSESSED ACTIVITY LEVEL ASSESSED No approval required 1004 F CLIN SYMP VOL OVRLD EVALUATE CLINICAL SYMPTOMS VOL OVERLOAD No approval required RATED 1005F ASTHMA SYMPTOMS RATED ASTHMA SYMPTOMS RATED 6 REQUIRED ASSOSTHRIT 10EOUTHRIT0. IS SYMPTOMS & FUNCTIONS No approval required STATUS ASSESS 1007F ANTI-INFLM/ANLGSC OTC ASSESS ANTI-INFLAMMATORY/ANALGESIC No approval required SYMPTOM BURDEN ASSESSMENT 1008F GI/KIDNEY RISK ASSESSMENT GI & KIDNEY PRESCRIBED/OTC NSAID RISK None Approx. oval required FACTORS ASSES 1010F SEVERITY OF ANGINA ON ACTIVITY USING RESPONSIBILITY NO APPLYING RESPONSIBILITY 1011F ANGINA PRESENT ANGINA PRESENT No clearance required 1012F ANGINA NO ANGINA NO No clearance required 1015F COPD SYMPTOM ASSESSMENT COPD SYMPTOMS ASSESSED/TOOL No clearance required COMPLETED 1018F DYSPNOEA ASSESSMENT NOT PRESENT DYSPNEIA VUR NOT PRESENT DISPNEAASS AUTH19NATURAL PRESENT No Authorization Required 1022F PNEUMO IMM STATUS ASSESSMENT PNEUMOCOCCAL IMMUNIZATION STATUS No Authorization Required STATUS ASSESSED 1026F CO-MORBID STATUS ASSESSMENT CO-MORBID STATUS ASSESSED No Authorization Required 1030F FLU IMM STATUS ASSESSMENT IMMUNIZATION STATUS No Authorization Required ASSESSED 1 030F INFLUENZA IMM STATUS MOKE IN THE No Authorization Required HOME ASSESSMENT ERT 1032F SMOKER/EXPOSED TO 2ND TOBACCO CURRENT SMOKER/EXPOSED None Authority Required HEAVY SMOKING 1033F TOBACCO NON-SMOKING OR 2ND TOBACCO NON-SMOKING & NO No Authorization Required 2nd HAND EXPOSURE TO TOBACCO 1033F TOBACCO NON-SMOKING -SMOKING OR 2NDHND SMOKELESS TOBACCO & NO None Authentication Required 2HAND SMOKE EXPOSURE 1033F TOBACCO NON SMOKER OR 2NHAND TOBACCO NON SMOKER & NO None No Authentication Required 2HAND SMOKE EXPOSURE 1033F TOBACCO NON SMOKER Required 1035F SMOKELESS TOBACCO CURRENT USER SMOKE -FREE TOBACCO USER No Authorization Required 1036 F TOBACCO NON - CURRENT TOBACCO USER NON USER CAD No approval required CAP COPD PV DM 1038F PERSISTENT ASTHMA PERSISTENT ASTHMA MILD MODERATE No approval required OR SEVERE ASTHMA 1039F INTERESTING ASTHMA04. F DSM-5 INFORMATION MDD DOCD DSM-5 CRITERIA MDD DOCD VED No approval required INITIAL SCORE 1050F CHANGE CHANGE HISTORY CHART SHEET HISTORY NEW OR CHANGES MOLD BREAKER No approval required 1052F LOCATION TYPE ACTIVITY ASSESSMENT TYPE ANATOMY LOCATION required 5 FUNCTION 5 FUNCTION 5 FUNCTION 5 ASSESSMENT STATUS VISUAL FUNCTIONAL STATUS ASSESSED No authorization required 1060F DOC PERM/CONT/PAROX ATR FIB DOC PERM/PERSISTENT/PAROXYSMAL No authorization required ATRIAL FIB

1061F DOC MISSING PERM&CONT&PAROX FIB DOC ABSENCE No Authorization Required PERMANENT&PERSISTENT&PAROXISM ATRIAL FIB 1065F ISCHM STROKE SYMPTOMS LT3 HRSB/4 ISCHEMIC STROKE SYMPTOM ONSET /=3 No Authorization Required 7AR 0ARMESS PRINCESS 1000 MAJOR SYMPTOMS ARM ESTIMATED NONE Authorization Required CURRENT 107 1F ALARM SIMP ASSESSED- 1 + PRSNT ALARM SYMPTOMS ASSESSED 1/> No approval required CURRENT 1090F PRES/ABSN URINE INCON ASSESSMENT PRESENCE/ABSENCE OF URINE No approval required INCONTINENCE ASSESSED 1091F URINE INCON CHARACTER required No. 1100F PTFALLS ASSESSMENT-DOCD GE2>/ YR PT FALLS ASSESSMENT DOCD 2/> FALLS/FALL No Approval Required W/INJURY/YR 1101F PT FALLS ASSESSMENT-DOCD LE1/YR PT FALLS ASSESSMENT DOCD U/O No Approval Required FALLS/INJURY LAST YEAR PT FAC 110 FOR 60 DAYS PT DISCHARGE INPT INSIDE FACILITY No authorization required PAST 60 DAYS 1111F DSCHRG MED/CURRENT WITH FLUTING DISCHRG MEDS DISCHARGED No authorization required W/CURRENT MED LIST 1116F AURIC/PERI BOL ASSESSED ASSESSMENT/ PAURIĆ ASSESSED Auth 118F GERD SYMPPER ESTIMATED 12 MONTHS GERB SYMPTOMS ESTIMATED AFTER 12 No approval required. MONTHS OF PROCESSING 1119F INITIAL CONDITION EVALUATION INITIAL CONDITION EVALUATION No Approval Required 1121F SUBS EVAL FOR CONDITION SUBSEQUENT EVALUATION CONDITION AUT 123SS ER PLN TLKD & ALT DCSN MAKER No Approval Required DOCD 1124F ACP DISCUSS-NO DSCNMKR DOCD ADV CARE PLN/ NO ALT DCSN MKR No authorization required DOCD OR REFUSAL 1125F AMNT PAIN OBSERVED CHEST PAIN INTENSITY QUANTIFIED PAIN NOT REQUIRED P126 PRESENCE OF PAIN QUANTIFIED NO PAIN No authorization required CURRENT 1127F NEW EPISODE FOR CONDITION NEW EPISODE FOR CONDITION No authorization required 11 28F SUB EPISODE FOR CONDITION SUB EPISODE FOR CONDITION No Approval Required 1130F BK PAIN & FXN RATED BY DEVELOPMENT BK ASS. 1134F EPSD BK PAIN 6 WEEKS/< EPISODE BACK PAIN LAST SIX No approval required WEEKS/< 1135F EPSD BK PAIN LAST >6 WEEKS EPISODE BACK PAIN LAST >SIX No approval required WEEKS 1136F EPSD BK PAIN 12 WEEKS/< EPISODE 12 WEEKS . Required WEEKS/< 1137F EPSD BK PAIN FOR >12 WEEKS LAST EPISODE BACK PAIN >12 WEEKS No authorization required 1150F DOC PT RSK DEATH M/IN 1 YEAR DOC PT W/SIGNIFICANT RISK DEATH No authorization required BEFORE 1F IN 1F RSK. W/IN 1YR DOC PT U/O SIGNIFICANT RISK OF DEATH No Approval Required WITHIN 1 YEAR 1152F DOC ADVNCD DIS COMFORT 1ST DOC ADVANCED DISEASE DX NURSING No Approval Required TARGET COMFORT 1153F DOC ADVNCD DIS COMFORT No DOC CMFARE ADVNCD X TARGET NO COMFORT 1157F ADVNCD PLAN. NURSING AND RCRD ADVNC CARE PLAN OR EQV LGL DOC I No authorization required WITH RCRD 1158F ADVNC CARE PLAN TLK DOCD ADVNC CARE PLAN TLK DOCD I No authorization required WITH RCRD MEDIST 1159 No authorization required MEDICAL CARD 1160F RVW MEDS BY RX/DR I RCRD RVW ALL DRUGS FROM RXNG PRCTIONR OR No Authorization Required CLIN RPH DOCD 1170F FXNL STATUS ESTIMATED FUNCTIONAL STATUS ESTIMATED FUNCTIONAL STATUS ESTIMATED FUNCTION 11 ROBBED STVCWDESS FUNCTION STVCWDESS AL STATUS DEMENTIA ASSESSMENT No Authorization Required RESULTS RVWD 1180F RISK OF THROMBOMBIA ESTIMATED RISK OF THROMBOMBOLISM ESTIMATED Not Required approval 1181F ASSESSED NEUROPSYCHIATRIC SYMPTOMS ASSESSED NEUROPSYCHIATRIC SYMPTOMS ASSESSED No corroboration required REVIEWED RESULTS 1182F NEUROPSYCHIATRIC SYMPTOMS RATED ONE No corroboration required OR MORE PRESENT 1183F NEUROPSYCHIATRIC SYMPTOMS FROM NEUROPSYCHIATRIC SYMPTOMS No corroboration required. TYPE & FREQUENCY DOCD SEIZURE TYPE FREQUENCY No approval required DOCUMENTED 1205F EPI ETIOL SIN RVWD AND DOCD ETIOLOGY OF EPILEPSY SYNDROME No approval required RVWD & DOCD 1220F ETIOL SIN RVWD AND DOCD ETIOLOGY OF EPILEPSY SYNDROME No approval required oval. 00F PRKNS DIAGNOSIS PARKINSON'S DIAGNOSIS No approval required REPORTED 1450F SYMPTOMS IMPROVED/CONSISTENT SYMPTOMS IMPROVED/CONSISTENT No approval required W/TXMNT TARGETING 1451F SYMPTOM SHOW CLIN IMPORT DROP SYMPTOMS SHOW CLIN IMPRTNT DROP No approval required FROM EVENT/ DIAGNOSIS QUALIFIER CITY CARDS No PRIOR approval required 12 MONTHS 1461F NO QUAL CARD DIAG PRIOR12MON NO QUAL CARD EVENT/DIAG I No approval required PRIOR 12 MONTHS 1490F DEM SEVERITY CLASSIFIED MILD DEMENTIA CLASSIFIED SEVERITY MILD No approval required 1491F SEVERITY CLASSIFICATION REQUIRED No ERATE 14 93F DEM SEVERE HED DEMENTIA SEVERITY CLASS WEIGHT CLASSIFIED SWEDISH No Approval Required 1494F COGNIT ASSESSED AND REVIEWED COGNIT ASSESSED AND REVIEWED No Approval Required 1500F SYMPTOM&SIGN SYMM POLYNEURO SYMP&SIGN DISTAL SYMM No Approval Required POLITIALEUROPAT1 EJ INVALH INVALH INVALH INVALD INVALH INVALD INVALD INVALH INVALD INVALH ITIAL Approval Rating Not Required BE TERMINATED

1502F PT REQUESTED PAIN FXN W/ INSTR PT REQUESTED RE PAIN W/FUNC USER No approval required RELIABLE INSTRM 1503F PT REQUESTED SYMP RESP USUFF PT REQUESTED RE SIMP RESPIRATION No approval required PALIFELT INSTRM. BREATHING No authorization required INSUFFICIENCY 1505F PT NO RESP INSUFFICIENCY PATIENT NOT BREATHING No authorization required INSUFFICIENCY 2000F BLOOD PRESSURE MEASUREMENT BLOOD PRESSURE MEASURED No authorization required 2001F WEIGHT RECORD WEIGHT RECORDED None 20CLIN Auth. SIGNS VOLUME OVERLOAD No authorization required ASSESSED 2004F INITIAL EXAMINATION JOINTS INVOLVED INITIAL EXAMINATION JOINTS INVOLVED No authorization required 2010F REGISTERED VITAL SIGNS REGISTERED VITAL SIGNS REGISTERED No authorization required 2014F MENTAL STATUS ASSESSMENT MENTAL STATUS ASSESSMENT No authorization required 2 01 5F ASTHMA DIMASS MENT ASTHMA ASTHMA 60 F ASTHMA RISK ASSESSED ASTHMA RISK ASSESSED No approval required 2018F HYDRATION STATUS ASSESS HYDRATION STATUS ESTIMATED No approval required 2019F DILATED MACULAR EXAM DILATED MACULAR EXAM DONE No approval required 2020F DILATED FUNDUS EVAL DILATED FUNDUS EVALUATION No approval required MACULAR DEX DEX DONE MACULAR DEX DONE . FUNDUS EXAMINATION No Approval Required DILATED 2022F DILAT RTA XM EVC RTNOPTHY DILATED RETINA EXAMINATION W/PROOF No RETINOPATHY Clearance Required 2023F DILAT RTA XM U/O RTNOPTHY DILATED RETINA EXAM NO EVIDENCE No RETINOPATHY Clearance Required 2024 F RTNOPTHY ST7T 2024F RTNHOLDIN F RTNHOLDIN'S PHOTO No Approval Required W/EVC RTNOPTHY 2025F 7 FLD RTA PHOTO U/O RTNOPTHY 7 STANDARD FLD RETINAL PHOTO U/O No Approval Required EVC RTNOPTHY 2026F EYE IMG VALID EVC RTNOPTHY EYE IMG VALID MATCH DX 7 OPND 2026F EYE IMG N NERVE HEAD EVAL DONE OPTIC NERVE HEAD ASSESSMENT No authorization required DONE 2028F FEET EXAMINATION DONE FEET EXAMINATION DONE No authorization required 2029F Full SKIN PHYSICAL COMPLETE COMPLETE SKIN PHYSICAL No authorization required STPER0MAT 2029 HDR 2029F FULL SKIN PHYSICAL COMPLETE PHYSICAL PREG LED SKIN No vet approval required 2029F FULLY PHYSICAL SKIN EXAM EXAM US DOCD NORMAL No clearance required HYDRATED 2031F H2O STAT DOCD DEHYDRATE HYDRATION STATUS DOCUMENTED No clearance required DEHYDRATED 2033F EYE IMG VALID U/O RTNOPTHY EYE IMG VLD MTCH DX 7 STND FLD U/O No clearance required EVC RTNOPTHY 20 35F MOVEMENT TEST MEMBRANE TUBUNCA Auth 40F BK PN XM ON DATE OF INITIAL VISIT PHYSICAL EXAM ON DATE OF INITIAL VST FOR No approval required LBP DONE 2044F DOC MNTL TST B/4 BK TRXMNT DOC MNTL HLTH ASSES BEFORE INTVN No approval required BACK PAIN 6WKS 2050F EARLY CHAR SIZE WPRICD Equiter red DE WEDDING 2060F PT TALK EVAL HLTHWKR RE MDD PT INTRVWD OF EVAL CLINIC /EQUAL 40% 3023F SPIROM DOC REV SPIROMETRY RESULTS DOCUMENTED No Authorization Required AND EXAM 3025F SPIROM FEV/FVC /=70% WEVATY SPIROM 3025F SPIROM FEV/FVC C / =70% W202S URATION RESULTS No Authorization Required DOCUMENTED & REVIEWED 3035F O2 SATURATION55 No Authorization Required MM HG 3038F PULM FX W/IN 12 MAN B/4 SURG PULMONARY FUNCTION TEST IN 12 No Authorization Required MON BEFORE SURG 3038F PULM FX W/IN 12 MAN B/4 SURG FUNCTION LUNG VOLUME >/EQUAL 40% No Clearance Required PREVIOUS FAILURE VALUE 3044F HG A1C LEVEL LT 7.0% RECENT HEMOGLOBIN A1C LEVEL No Clearance Required < 7.0% 3046F HEMOGLOBIN A1C LEVEL >9.0% RECENT A1C LEVEL L09- required HEMOGLOBIN LEVEL >9 .0% RECENT A1C LEVEL L09 HEMOGLOBIN LEVEL Required. DL-C

3050F LDL-C >/= 130 MG/DL RECENT LDL-C >/SIG 130 No approval required MG/DL 3051F HG A1C>EQUAL 7.0% EQUAL S No approval required 7.0%&EQUAL 8.0% 8 .0% EQUAL. &/EQUAL 140 MM HG 3078F DIAST BP /= 90 MM HG RECENT DIASTOLIC BLOOD PRESSURE No approval required >/EQUAL 90 MM HG 3082F KT/V /= 1.7 No approval required 3085F REQUIRED IN SUICIDE RISK CODE Auth. 88F MDD MILD SEVERE DEPRESSIVE MESSAGE MILD No authorization required 3089F MDD MODERATE MAJOR DEPRESSIVE MESSAGE No authorization required MODERATE 3090F MDD severe U/O PSYCHIC MDD severe NO PSYCHOTIC No authorization required FUNCTION MJEVRESCH 3090F MDD SEVERE NON PSYCHOTIC MDD. ERE No approval required W/PSYCHOTIC FUNCTION 3092F MDD IN REMISSION MAJOR DEPRESSIVE DISORDER No approval required REMISSION 3093F DOC NEW DIAG 1ST/ADDL MDD DOC NEW DIAG DX INIT/REPEAT No approval required EPISODE MDD 3095F CENTRAL DEX CENTRAL Aquid . THYOMETRY DOCD 3096F CENTRAL DEXA ORDERED CENTRAL DUAL ENERGY No approval required ABSORPCIOMETRY ORDERED 3100F IMAGING EXAMINATION REF CAROT DIAM CAROTID IMAGNG REPORT DIR/INDIR No approval required GAUGE DIAM 3110F PRES/ABSN HMRHG/LESION DOCDLESHG/MACUMRI H FROC No DIROC. 111F CT/MRI BRAIN DONE WITHIN 24 HOURS CT OR MRI BRAIN DONE WITHIN 24 HOURS No authorization required ARRIVAL AT HOSP 3112F CT/MRI BRAIN DONE 24 HOURS CT/MRI BRAIN DONE 24 HOURS AFTER No authorization required ARRIVAL AT HOSP QUANTITY 5F KV . EVAL CURR LEVEL No approval required ACTIVITY CLIN SYMP 3117F HF ASSESSMENT TOOL FOR SPECIFIC HF DISEASE ASSESSMENT No approval required COMPLETED 3118F NEW HEART ASSOC CLASS DOCD NEW YORK HEART ASSOCIATION 1 EVAL CURR LEVEL NO. ACTIVITY CLIN SYMP NO EVAL ACTIVITY LEVEL OR No approval required CLINICAL SYMPTOMS 3120F 12-LEAD ECG DONE 12-LEAD ECG DONE No approval required 3126F ESOPH BX RPRT W/DYSPL INFO ESOPH BX RPRT W/DYSPLAS INFO GR0P 3126F ESOPH BX RPRT W/DYSPLAS INFO DYSPL INFO GI ENDOSCOPY PERFORMED UPPER GI ENDOSCOPY PERFORMED No Approval Required 3132F DOC REF UPPER GI ENDOSCOPY DOC INSTRUCTION FOR UPPER GI GI No Approval Required ENDOSCOPY 3140F UPPER GI ENDO VIEWS BARRTTS UPPER GI ENDO VIEWS REPORT Full Surgical POSSS Authorization from BSOTT Approval from 3140F UPPER GI ENDO 141F UPPER GI ENDO NO BARRTTS UPPER GI ENDO REPORT SHOWS NO AUTHORIZATION REQUIRED Gastrointestinal Surgery Full Clinical Exam SUSPECT BARRETT'S SYSTEM 3142F BARIUM PULSE TEST ORDERED BARIUM PULSE TEST ORDERED No Authorization Required 3150F TANG ESOPH BIOPSO ESOPSY WITHDRAWN FORCED Auth 5 F CYTOGEN TEST SKIN Marrow B/ 4 TX CYTOGEN TEST DONE SKIN MARGIN DIAGNOSIS No Clearance OR PREREQUISITE TXMNT 3160F DOC FE+ STORES B/4 EPO THX DOC IRON STORES BEFORE STARTING EPO No Clearance Required TREATMENT 3170F FLOW CYTO DONE B/4 TX FLOW CYTOMETRY REQ/00 F BARI UM IMPLICATION TEST NOT REQUIRED BARIUM IMPLICATION TEST NOT ORDERED No Authorization Required 3210F GRP A STREP TEST DONE GROUP A STREP TEST DONE No Authorization Required 3215F PT HEP IMMUNITY EN DOCD DOCUMENTED IMMUNITY A DOCD AUT 3215F PT DOCUMENTED IMMUNITY Auth CD DOCUMENTED IMMUNITY H HEPATITIS B No approval required 3218F RNA TSTNG HEP C DOCD DONE HEP C RNA TEST 6 MOS PRIOR No approval required ANTIVIRAL TX 3220F HEP C QUANT RNA TSTNG DOCD HEP C QUANT RNA TEST 12 WEEKS AFTER TXANT NOT REQUIRED 3IN TO 3IN HEV 3IN REQUIRED HEARING TEST 6 MEN 6 MOS BEFORE EAR EAR No approval required TUBE INSERTION 3250F NONPRIM LOC ANAT BX SITE TUM NONPRIM ANATOMIC LOCATION No approval required SPECIMEN SITE 3260F PT CAT/PN CAT/PN CAT/HIST Required/HIST USE/HIST DOCUMENTED

3265F RNA TSTNG HEPC VIR ORD/DOCD RNA HEP C VIREMIA TESTING No approval required ORDERED/DOCD 3266F HEPC GN TSTNG DOCD B/4TXMNT HEPATITIS C GENOTYPE PRIOR No approval required ANTIVIRAL TREATMENT/PN ANTIVIRAL TREATMENT 3266 C RPRT INCLUDES PT & PN CAT no Authorization Required GLEASON 3268F PSA/T/GLSC DOCD B/4 TXMNT PSA & TUMOR STAGE&GLEASON GRADE No Authorization Required BEFORE START 3269F BONE SCN B/4 TXMNT/AFTR DX BONE SCAN PREVIOUSLY Verified PREVIOUS CANCER 3270F NO BONE SCN B/4 TXMNT/AFTR AFTRDX BONE SCAN NOT PRIOR TO START TX/DX No approval required PROSTATE CA 3271F LOW RISK PROSTATE CANCER LOW RISK OF PROSTATE RECURRENCE No approval required CANCER MEDICAL RISK A PROSTARMICK RISK SA 327 uth required PROSTATE CANCER 3273F HIGH RISK PROSTATE CANCER HIGH RISK OF PROSTATE RECURRENCE A No approval required CANCER 3274F PROST CNCR RSK NOT LW/MD/HGH PROST CANCER RSK NOT RETURNED No approval required DETER/LOW/INTERMED/INTERMED 8/8 CALCUM PHOSPH SERUM LEVELS No approval required PARATHYR & LIPID PR 3279F HGB LVL >/= 13 G/DL HEMOGLOBIN LEVEL>/ LIG 13 G/DL No approval required 3280F HGB LVL 11-12.9 GDL 11-12.9 GDL/12.9 GDL/12.9 GDL. G/DL No approval required 3281F HGB LVL /LIG 15% 3285F IOP DOWN

3386F AJCC CLN CNCR STAGE 2 DOCD AJCC COLON CANCER STAGE II No approval required 3388F AJCC CLN CNCR STAGE 3 DOCD AJCC COLON CANCER STAGE III DOCD No approval required 3390F AJCC CLN STAGE CLN CCRDO uth Required 3394F QUANT HER2 IHC EVAL BRST CX QUANTITY HER2 IHC EVALUATION OF BRST Approval not required CANCER ASCO/CAP 3395F QUANT NONHER2 IHC BRST CX QUANT NON-HER2 IHC EVAL OF BRST Approval not required CANCER DONE 3450F DYSPNEA NO SCRYSP DYSPNEA NO SCRYSP DYSPNEA. Authorization required 3451F DYSPNEA SCRND MOD-HIGH DYSP DYSPNEA SCRND MOD-NORTH No authorization required DYSPNEA 3452F DYSPNEA NOT SCREEN DYSPNEA NOT SCREEN No authorization required 3455F TB SCRNG DONE-INTRPDCRD 6

3761F PT WITHOUT DYSPHAG/WT TAB/NUTR PT WO/DYSPHAG/WT TAB/SET No approval required EDUCATION 3762F PATIENT WITH DYSARTHRIC PATIENT IS DYSARTHRIC Approval not required 3763F NOT REQUIRED NOT REQUIRED PATIENT WITH DYSARTHRIC 7 EXAMINATION OF DETECTED ADENOMA DETECTED ADENOMAS/NEOPLASMS Approval not required SCRNG CLNSCPY 3776F ADENOMA NOT DETECTED ADENOMA(S)/NEOPLASMA SCREENING NOT Required Approval DETECTED SCRNG CLNSCPY 4000F TOBACCO USE TXUNCESSMANT COUNCIL IV. 4001F TOBACOO USE TXMNT PHARMACOL TOBACCO STOP IVNTJ No approval required PHARMACOLOGIC THER 4003F PT ED WRITE/ORAL PTS W/ HF PT EDUCATION WRTTN/ORAL HRT No approval required ERROR PTS PFRMD 4004F PT TOBACCO SCREEN RCVD TLKOBACPT SCREND REQUISITION TVDOBACPT SCRAND Tquis 4005F PHARM THX TO UP RXD PHARMACOLOGY Osteoporosis No approval required TREATMENT PRESCRIBED 4008F BETA BLOCKER THERAPY RXD/TKN BETA BLOCKER THERAPY No approval required. /CURRENTLY TAKING 4011F ORAL ANTIPROBIC THERAPY RX ORAL ANTIPROBIC THERAPY No Authorization Required PRESCRIBED 4012F WARFAR INTERTHERAPY RX WARFAR INTERTHERAPY PRESCRIBED No Authorization Required 4013F STATIN THERAPY/CURRENT TKN STATIN THERAPY/CURRENT TKN STAT. INTERAPHY R4FARINTERAPHY R4FTA NR0X DERIVE INSTR PRVD DSCHRG INSTRUCTIONS HRT ERROR No approval required fox XCP PTS 18 YR 4015F PERMANENT ASTHMA MEDICINE CTRL PERSISTENT ASTHMA LONG-TERM CTRL No approval required PRESCRIBED 4016F ANTI-INFLM/ANLGSC AGENT RX ANTI-INFLAMMATORY/ANALGESIC AGT No approval required PROPHLASKET PRESCRIBED FOR 4017 PRESCRI IPTION XIS NSAID USE PRESCRIBED No Approval Required 4018F JOINT RX THERAPY TRAINING EXERCISE THERAPY INCLUDED JTS No INST/PRESPRIBATION Approval Required 4019F DOC RECPT ADVICE VIT D/CALC+ DOCUMENT ADVICE No Approval Required CALCIUM & VITAMIN 4025F INHALER INHALER BRONCHODILATOR NO. PRESCRIBED 4030F OLT THERAPY RX LONG TERM OLT THERAPY No authorization required PRESCRIBED 4033F LUNG REHAB REC PULMONARY REHABILITATION No authorization required RECOMMENDED 4035F INFLUENZA IMM REC IMMUNIZATION AGAINST FLU No authorization required RECOMMENDED 4037F INFLUENZA FOR OR AUT. red OR ADMINISTERED 4040F PNEUMOC VAC/ADMIN/RCVD PNEUMOCOCCAL VACCINE ADMIN No RCVD Approval Required BEFORE 4041F DOC ORDER CEFAZOLIN/CEFUROX DOC ORDER CEFAZOLIN/CEFUROXIM No Approval Required ANTIMICRB PROPHYL 4042F DOC ANTIBIO NOT GIVEN ANTIBIO DOC ORDER CANCEL ANTIBIO W/ I 48 None approvals required HOURS SURG 4044F DOC ORDER VTE PROPHYLX DOC ORDER VTE PROFYL W/IN 24 HOURS No approval required PREDICTION 4045F EMPIRIC ANTIBIOTIC RX APPROPRIATE EMPIRIS ANTIBIO DAY B/4 SURG DOCD ANTIBIO W /IN 4 HOURS No approval required PRE/INTRAOP. SU RG INCIS 4047F DOC ANTIBIO DANA B/4 SURGICAL DOC ORDER ANTIBIO DANA W/INCIS 1 HOUR No approval required PRE SURGICAL/INC 4048F DOC ANTIBIO DANA DOC ANTIBIO DANA B/4 1 HOUR PREREQUISITE No approval required KURG/INCIS 4049F DOC DANA STOP ANTIBIO DOC ORDER GIVEN TO DISCONTINUE ANTIBIO No Approval Required W/IN 24 HOUR SURG 4050F HT CARE PLAN DOC HYPERTENSION PLAN REQUIRED 5 AUT REQUIRED 1 FISTULA RECOMMENDED FOR ARTERIO-VENOUS No Approval Required (AV) FISTULA 4052F HEMODIALYSIS BY AV FISTULA HEMODIAL V IA FUNCTIONAL AV FISTULA Br Authorization Required 4053F HEMODIALYSIS VIA AV GRAFT HEMODIALYSIS VIA Auth FUNCTION VIA Auth FUNCTION 5 TER HEMODIALYSIS VIA CATHETER No Authorization Required 4055F PT RCVNG PERITONEAL DIALYSIS PATIENT RECEIVING PERITONEAL No Authorization Required 4056 F APPROP ORAL REHYD RECOMMENDED APPROPRIATE ORAL REHYD SOLUTION None approvals for required RECOMMENDED 4058F PED GASTRO ED GIVES CAREGVR to C6 PUT. PSYCHOTHERAPY SERVICES PROVIDED No Approval Required 4062F PT REFERRAL PSYCH DOCD PATIENT REFERRAL FOR No Approval Required PSYCHOTHERAPY DOCUMENTED 4063F ANTIDEPRESSANT RXTHXPY NOT RXD ANTIDEPRESSANT RXTHXY CONSIDER & No Approval Required NOT PRESCRIBED 4064 F ANTIDEPRESSANT RX REQUIRED ANTIDEPRESSANT PHARMACIB 6 IC RX ANTIDEPRESSANT COTIC PHARMACOTHERAPY O healing is not required PRESCRIBED 4066F SUPPLIED ECT ELECTROCONVULSIVE THERAPY (ECT) Authorization not required SUPPLIED 4067F PT ECT REFERRAL DOCD PT ELECTROCONVULSIVE REFERRAL No authorization required THXPY (ECT) DOCD 4069F VTE PROPHYLAXIS RCVD VENOUS THROMBOEMBOLIC (VTE) No Reauthorization Requested 4069F VTE PROPHYLAXIS 2 DEEP PROPHYLAXIS G VENOUS THROMBUS RECVD OD No approval required HOSP DAY 2 4073F ORAL ANTIPLAT THX RX DISCHRG ORAL ANTIPLATELET THERAPY No approval required PRESCRIBED BY PRINT

4075F ANTICOAG THX RX AT DISCHRG ANTICOAGULANT THERAPY PRESCRIBED No Approval Required AT PRESS 4077F DOC T-PA ADMIN EMPLOYED DOC T-PA ADMIN WAS Approval No Required CONSIDERED 4079F RECOMMENDED DOCERE DOCERE DOCERE DOCERE DOCERE DOCERE DOCERE REQUIRED CONSIDERED 4084 F ASPIRIN RECVD W/IN 24 HRS. ASPIRIN RECVD W/IN 24 HOURS PRIOR ED No Authorization Required ARRIVAL/STAY 4086F ASPIRIN/CLOPIDOGREL RXD PRESCRIBED ASPIRIN OR CLOPIDOGREL No Authorization Required PY 4095F PT NOT RCVNG EPO THXPY PATIENT NOT RECEIVING No Authorization Required ERYTHORPOETINE THERAPY 4100F BIPHOS THXPY VENA ORD/RECVD BIPHOS THXPY VENØ p ORDERED OR Approval not required RECEIVED 4110F INT MAM ART USED FOR CABG SHEET GRAFT USED IN 1 ABS 1 ISO P5 USED IN 1. B1 ISO. LCKR ADMIN M/IN 24 HOURS BETA BLOCKER GIVEN M/IN 24 HOURS No Approval Required PRETEQUISITE SURG INC 4120F ANTIBIOTIC RXD/DAY ANTIBIOTIC PRESCRIBED OR DISPENSED No Approval Required 4124F ANTIBIOTIC NOT RXD/DAY ANTIBIOTIC NEITHER DISPENSED OR PRESCRIBED 3 RX AOE ACUTE OTITIS EXTERNAL LOCAL PREPARATIONS No authorization required Prescribed 4131F Syst Antimicrobial THX RX Systemic Antimicrobial TX No authorization required Prescribed 4132F NO SYST ANTIMICROBIAL THX RX SYSTEIMICROBIAL TX NO NO AUT. ANTIHISTAMINE/DECONGESTANT NO No Approval Required PRESCRIBED 4135F SYSTEMIC CORTICOSTEROIDS RX SYSTEMIC CORTICOSTEROIDS No Approval Required PRESCRIBED 4136F SYSTEMIC CORTICOSTEROIDS NO RX SYSTEMIC CORTICOSTEROIDS NO REQUIRED 4136F SYSTEM AL CORTICOSTEROIDS NO Authentic CORTICOSTEROIDS 0. STEROIDS RXD INHALED CORTICOSTEROIDS No Approval Required PRESCRIBED 4142F CORTICOSTER SPARNG THRPY RXD TREATMENT FOR CORTICOSTEROID SAVING No approval required PRESCRIBED 4144F ALL LONG TERM CONTROL WITH RXD ALTERNATIVE LONG TERM CONTROL No approval required ed. DRUGS RXD 4145F 2+ ANTI-HYPRTNSV TKN 2+ ANTI- HY PERTENSIVE AGENTS Authenta RXD AUT 4 AD14 X REQUIRED V8 ADMINISTERED MIN/RECVD HEPATITIS A VACCINE ADMINISTRATOR OR No approval required PRIOR RECVD 4149F HEP B VAC INJXN ADMIN/RECVD VACCINE ADMIN. HEPATITIS B OR No authorization required PREVIOUS RECCVD 4150F PT RECVNG ANTIVIR TXMNT HEPC CURRENT AUTHENT 5 F PT NOT RECVNG ANTIV HEP C NO CURRENT HEPATITIS C ANTIVIRAL No authorization required TREATMENT 4153F COMBO PEGINTF/RIB RX KAMM PEGINTERF/RIBAVIRIN TX No authorization required PRESCRIBED 4155F HEP A VAC SERIES PREV RECVD HEPATITIS A VACC INE SERIES PRE REQUEST B75 RECVD HEPATITIS B VACCINE SERIES REQUIRED No authorization required PRE RECEIVED 4158F PT EDU RE ALCOHOL DRINKING COMPLETED PATIENT WARNED OF RISKS No authorization required ALCOHOL USE 4159F CONTRCP CONVERSATION B/4 ANTIV TXMNT PREVENTIVE SAV JETOVATION BEFORE TX4 6 PROUNT 3 PROPT 4 6 PROUNT required ST PT COUNSELING TREATMENT OPTIONS Br approval required PROSTATE CANCER 4164F A DJV HRMNL THXPY RXD ADJUVANT HORMONAL THXPY No approval required RX/ADMIN 4165F 3D-CRT/IMRT RECEIVED 3D-CRT OR Not INTENSITY MODULE WORK approval required THXPY RECVD 1 BED-6YDENT HD 416 5F 3D-CRT/IMRT 30 -45° 1ST ST VENT Approval not required DAY ORDERED 4168F PT CARE ICU&VENT M/IN 24HRS PT RCVG CARE ICU & RCVNG MECH No approval required WAIT 24 HOURS/ < 4169F NO PT CARE ICU/WAIT 24 HOURS NOT REQUIRED IRCVG MECHL VENT 417 1F PT RCVNG ESA THXPY PATIENT RECEIVING (ESA) TREATMENT Approval not required 4172F PT NOT RCVNG ESA THXPY PATIENT NOT RECEIVING (ESA) TREATMENT Approval not required 4174F ADVISE POTENTIAL GLA/QUALT FL Approval Required PT /CRGVR 4175F VIS 20/40/> W/IN 90 DAYS CORRECT VIDUAL ACUIT 20/40/> W /IN No Approval Required 90 DAYS SURG 4176F TALK RE UV LIGHT PT/CRGVR ADVICE UV LITE PROTEC Auth Required PREV/PROGAT No DEVEL 4177F TALK PT/CRGVR RE AREDS PREV ADVICE BENEFITS/RISKS AREDS PREV AGE No Authorization Required RELATED AMD 4178F ANTID GLBLN RCVD W/IN 26WKS ANTI-D IMMUNOGLOBULIN RC0KS RC0KS Auth-26 Required AI PRESCRIBED TAMOXIFEN OR INHIBITOR AROMATASE No Authorization Required (AI) RXD 4180F ADJV THXP YRXD/RCVD COLON CA ADJVNT CHEMO RFRRD RXD/RCVD No Authorization Required STAGE III COLON CA 4181F CONFORMAL RADN THXPY RCVD REQUIRED CONFORMAL NO. RADN THXPY CONFORMAL RADIOTHERAPY NO No Approval Required RECEIVED 4185F CONTINUOUS PPI OR H2RA RCVD NONSTOP 12MON THXPY W/PPI OR H2 No Approval Required H2RA RCVD 4186F NO CONT PPI OR H2RA RCVD NO CONTIN 12MON TH XPY W/PPI 7 I DRUG FOR rheumatism. /PPI DIS MODFYRXD/GVN ANTI-RHEU drug THXPY No RX/GVN approval required

4188F Approp ACE/ARB TSTNG DONE APPROP ACE/ARB THXP MONIT TEST No approval needed Orrdd/Done 4189f Approp Digoxin Tstng Done Appord Digoxin Thxp Monit Tst No approval needed Appordrd/Done Tstng Iconvuls TSTNG APPROP ANTICONVUL THXP MONIT TST No approval needed ORDRD/DONE 4192F PT NOT RCVNG GLUCOCO THXPY PATIENT IS NOT RECEIVING No approval required GLUCOCORTICOID0 REQUIRED Auth Auth 0MG PREDNISONE 4195F PT RCVNG ANTI-RHEUMAT THXPY RA PT RCVNG 1ST BIOL ANTI-RHEUMA DRUG No approval required THXRP Y FOR RA 4196F PTNOT RCVNG ANTI-RHM THXPYRA PT NOT RCVNG 1 .BIOL ANTI-RHEUM No approval required DRUG THXPY RA 4200F BETTER TO REX 4200F FOR PRONL. ST No Approval Required W/WO NODAL IRRAD 4201F EXTRNL BEAM EXCEPT PLAIN EXTRNL BM RADIOTHXPY W/WO NODAL No Approval Required IRRAD AS ADJV 4210F ACE/ARB THXPY FOR MOS/> ACE/ARB DRUG TREATMENT 6 No Approval Required 422 INTH/>IG COIN. DIGOXIN DRUG THERAPY 6 No Authorization Required MONTHS/> 4221F DIURETIC THXPY FOR 6 MOS/> DIURETIC DRUG TREATMENT 6 No Authorization Required MOS/> 4230F ANTICONV THXPY FOR 6 MOS/> ANTICONV A4 MUS. RCZ BACK PAIN 12 WKS INSTR THER XRCS-DR FLLWUP PT EPSD No approval required BACK PN >12 WK 4242F SPRVSD XRCZ BACK PN >12 WKS TLK RE SPRVSD XRCS PROG TO PTS BACK No approval required PN >12WKS MLPTINST 4242F SPRVSD XRCZ BACK PN FOR HOLD/READMISSION Authorization not required NORMAL ACTIVITIES 4248F PT INSTR NO BD REST 4 DAYS/> ADVICE INIT BACK PAIN AGNST BED Authorization not required REST 4 DAYS/> 4250F WRMNG 4 SURG NORMOTHERMIA ACVIOPTV NORM 5 Auth Auth Auth 4 0 MIN /> AS DOCD DURATION GEN NEUR ANESTH 60 No approval required MIN./> DOC RECORD 4256F ANESTHE

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4480F PT RCVNG ACE/ARB B-BLOCKERTX PT RCVNG ACE/ARB BETA BLOCKER TX 3 No approval required MONS/LONGER 4481F PT RCVNG ACE/ARB BLKER =35.5CW/IN 30MIN 1MEDIUM 35MP-5C>=NJ AUT. Required MINS POST ANESTH 4560F ANESTH U/O GEN/NEURAX ANESTH ANESTH FAILED No Approval Required GENERAL/NEURAXIAL ANESTH 4561F PT W/ CORONARY ARTERY STENT PATIENT HAS CORONARY ARTERY STENT ARTERY PATIENT REQUIRED 452 STENTARY STAFF PATIENT WITH NO CORONARY DISEASE No ARTERY STENT Approval Required 4563F PT RECVD ASPIRIN W/IN 24 HOURS PT RECVD ASPIRIN W/IN 24 HOURS PRIOR Approval not required ANESTH START 5005F PT REVIEW ADVICE SEE MY ADVICE A NEX. 5010F MACULA RESULT PHY/QHP MNG DM DILATED MACULA/FUNDUS XM No approval required COMMUNJ TX PHYS/QHP 5015F DOC FX & TEST/TXMNT FOR OP DOCD CONTACT THAT FX EXISTED & PT 5010F TX PHYS/QHP 5015F DOC QHP OF 1 MONTH TX. SUM RPRT COMMON PHYS&PT 1 No approval required MO COMPLETE 5050F PLAN 2 MAIN DDR. FROM 1 MONTH TX COMMON PROVIDERS CONTINUATION No approval required CARE 3 DAYS INTERP 5062F MAMMO RESULT COM TO PT 5 DAYS DOC DIRECT COMM DIAG MAMMO No approval required FNDNGS PHONE/PERSON 5100F RSK FX REF W/N 24 HOUR X-ray FX RISK REF PHY S / Q2HP COMM. EVAL APPROS SURG THXPY EPI CONSID NEURO EVAL APPROP SURG Approval not required THXPY EPIL 3YRS 5250F ASTHMA PRINT PLAN PRESENT ASTHMA PRINT PLAN PRESENT Approval not required 6005F CARE LEVEL CARE LEVEL REQUIRED REVEL ED 6010F DYSPHAG TEST DONE B/4 DYSPHAGIA NUTRITION PREREQUISITE CHECK ORAL Br required approval ENTRY 6015F DYSPHAG TEST DONE B/4 EATING PATIENT OK FOR ORAL INTAKE No approval required (FOOD/DRUG) 6020F NPO (NO MOUTH) ORDERED NONE FILLED 0MAX 0MAX. E BARRIER FLWD ALL ELEM OF MAX STERILE BARRIER No approval required TECHNQ FLWD 6040F APPRO RAD DS DVCS TECHS DOCD USE APPROP RAD DOSE RDXN DEV/MAN No approval required TECHS DOCD 6045F RADXRT4F RADXRT4F INDIG FLURPXRPXD IND. No Approval Required PRXD DOCD 6070F PT ASKED/CNSLD AED EFFECTS WANTED PATIENT ADVICE ADVICE RE AED No Approval Required SIDE EFFECTS 6080F PT/CARER ASKED FALLS PATIENT ASKED ABOUT FALLS No Approval Required 6090F SAFETY ADVISOR NO. red STAGE APPROPRIATE 6100F CHECK PT SITE PXD DOCD CHECK CORRECT PT SITE PXD No approval required DOCUMENT 6101F DEMENTIA SAFETY ADVICE No approval required DEVELOPED 6102F SAFETY ADVICE DEM ORDER DEMENTIA SAFE ADVICE No approval required 6 10 2F SAFETY ADVICE DEM ORDER SAFETY ADVICE DEM ENTIA No approval required PROV RE RISKS DRIVING No approval required ALL FOR DRIVING 6150F PT NOTRCVNG1ST ANTITNF TXMNT PT NOT RCVNG 1ST COURSE ANTI- TNF THERAPY No approval required 7010F PT CALL SYSTEM INFORMATION PT INFORMATION ENTERED No approval required CALL SYSTEM 7020F MAMMO ASSESSMENT NOT REQUIRED DAMAT SCORE M B FOR TASTE 7025F PT INFOSYS ALARM 4 NXT MAMMO INFO SYSTEM ANALYSIS ABNORMAL No authorization required INTERPRATE 9001F AORTIC Aneurism CM MAX DIAM No authorization required CTRLN/AXIAL CT

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9005F ASYMPT CAROT/VRTBRBAS STONE ASYMPT CAROT STONE NO ISCHEM/STRK No Approval Required CAROT/VRTBROBAS 9006F SYMPT STEN-TIA/STRK A0425 COUNTRY KILLER DIRECTION PER. STATUTE OF THE ROUND MILE KIL. MERG TRNSPRT LVL 1 AMB SERVICE ALS NO EMERGENCY No authorization required TRANSPORT LEVEL 1 A0427 AMB SRVC ALS EMERG TRANSPORT LEVEL 1 AMB SERVICE ALS EMERGENCY No authorization required TRANSPORT LEVEL 1 A0428 AMB SERVICE BLS NONEMERG TRANSPORT AMBULANCE AMBANSPORT AMBULANCE A00 SERV ICE BLS EMERGENCY SERVICE AMBULANCE BLS EMERGENCY No. Authorization required TRANSPORT TRANSPORT A0430 AMB SRVC AIR TRNSPRT 1-WAY FIX WING AMB SERVICE CONVNTION AIR SRVC authorization required General medicine - other Full clinical examination TRANSPORT 1-WAY services and procedures A0431 AMB SRVC AIR TRNSPRTARY CONVNTION 1-WAY Medicine Required 1 WAY SERVICE e - other Full clinical review TRANSPORT 1-WAY services and procedures A0432 PARAMED INTRCPT RURL NO 3 PARTY PAY PARAMED INTRCPT RURL AMB NO BILL Approval not required 3 PART PAYER A0433 ADVANCED LIFE SUSTAINING LEVEL 2 SUPPORT ADVANCED L4 SP0 Required LIFE TRANSPORT SPECIAL CARE TRANSPORT PORT None authorization required A0435 FIX WING AIR MILEAGE-STATUTE MILEAGE FIXED WING AIR MILEAGE BY STATUTE Authorization required General Medicine - Other Full clinical examination MILE Services and procedures A0436 ROTARY WING AIR MILEAGE-STATUTE MILE ROTARY REQUIRED ROTARY WING ROTARY WING other Full clinical examination STATUTE MILE Services and procedures A0999 NON-CALL EMERGENCY SERVICES NON-CALL EMERGENCY SERVICES Authorization Required General Medicine - Other Complete Clinical Examination Services and Procedures A4206 SYRINGE W/ STERILE NEEDLE 1 CC/< EACH SYRINGE 1 OR ONE SYRINGE REQUIRED FOR PROCUREMENT. EACH A4207 SYRINGE WITH STERILE NEEDLE 2 CC EACH SYRINGE WITH STERILE NEEDLE 2 CC No Authorization Required EACH A4208 SYRINGE WITH STERILE NEEDLE 3 CC EACH SYRINGE WITH STERILE NEEDLE 3 CC Auth STERILE REQUIRED Br. 5 CC/> EA SYRINGE WITH NEEDLE STERILE 5 CC OR No Approval Required LARGER EACH A4211 SELF-ADMINISTRATION CONSUMABLES INJECTION CONSUMABLES SELF-ADMINISTRATION CONSUMABLES No Approval Required INJECTIONS A4212 NEEDLE/STYLE NEEDLE FOR USE WITHOUT CORING WITH USE NOT REQUIRED. CATHETER A4213 SYRINGE STERILE 20 CC/LARGER EACH SYRINGE STERILE 20 CC OR LARGER No Approval Required EACH A4215 NEEDLE STERILE ANY SIZE EACH NEEDLE STERILE ANY SIZE ANY SIZE EACH No Approval Required A4216 STERL H2O PHYSICAL PLANT STE RILE & OR DXT DXT NO. DILUTION/RINSE 10 ML A4217 STERILE WATER/PHYSICAL PLANT 500 ML STERILE WATER/PHYSICAL PLANT 500 ML No authorization required A4218 STERILE PHYSICAL PLANT/WATER METRD DOSE 10 ML STERILE PHYSICAL PLANT/STICK METERED DOSE No Auth REQUIRED Auth 210 DISPLANT REF. US IMPLANT INFUSION PUMP FILLING KIT No Approval Required PUMP A4221 SUPS MAINTENANCE SUPPLIES NON-INS RX INFUS CATH PW MAINTENANCE SUPPLIES NON-INS RX INFUS No Approval Required Supplies Drug Supplies CATH PER WK Administration A4222 INFUS SPL EXT RX INFUS PUMP CAS /BAG INFX NO. Auth Required CASSETTE/BAG A4223 INFUS SPL NO EXT INFUS PUMP CAS/BAG INFUS SPL NOT USED W/EXT INFUS No Auth Required PUMP CASSETTE/BAG A4224 SPL MAINTENANCE INSULIN INFUS CATH PR. MAINTENANCE WEEK A4 MAINTENANCE A2 MAINTENANCE INF. SPL EXT INS INF PMP SYR T CART ST E SPL EXT INSULIN INFUS PUMP SYR TYPE No Approval Required CART ST EA A4226 S MNT INS IP DR ADJ TX CNT G SNS PW SPL MAINTENANCE INS IP DR ADJUST USAGE TX No Approval Required CONT G230 WK A4 SENS WK INFUS SET EXT INSULIN PUMP NONNDLE INFUS SET EXT INSULIN PUMP NONNDLE Authorization not required CANNULE TYPE A4231 INFUS SET EXT INSULIN PUMP NEEDLE INFUSION SET EXTERNAL INSULIN PUMP Not required J A4 Auth REQUIRED J A4 Auth. MON REPL BATT ALKALINE NOT J CELL HOM No Authorization Required BG MON OWND PT A4234 REPL BATT ALK J CELL HOM BG MON REPL BATT ALKALINE J CELL HOM BG No Authorization Required MON OWN PT EA A4235 REPL BATT LITHIUM HOM BG MON OWN REPL Auth MON OWN PT EA A4236 REPL BATT SILVER OXIDE HOM BG MON REPL BATT SILVER OXIDE HOM BG MON No approval required OWN PT EA A4244 ALCOHOL OR PEROXIDE PR. POLYTER OF ALCOHOL OR PEROXIDE PER PINT AUT 4 Auth ALCO5 REQUIRED B PR. CASE No Auth Required A4246 BETADINE/PHISOHEX SOLUTION PR. PINT BETADINE OR PHISOHEX SOLUTION BY NO. Auth Required PINT A4247 BETADINE/IODINE/VITTERE PER. BOX BETADINE OR IODINE CARPET/WISSES No authorization required 4NING48 BETADINE/IODINE SPRING PER. ORHEXIDINE CONTAINS No approval required ANTISEPTIC 1 ML A4253 BLD GLU TST/REAGT TRAKE HOM MON-50 BLD GLU TEST/REAGT TRAKE HOME BLD No approval required GLU MON-50 A4255 PLATFORM HOM BLD GLU MON 50-BOX PLATFORM HOME BLEED FIRE EXTINGUISHER No approx. oval required 50 -BOX PLATFORMS 50 BOX PLATFORMS 5 OL /CHIPS NORMAL LOW AND HIGH CALIBRATOR No approval required SOLUTION/CHIPS A4257 REPL LENS SHIELD CARTRIDGE LASR SKN REPL LENS SHIELD CARTRIDGE LASR SKN No approval required PIERC DEVC A4258 SPRING DR IVE UNIT Equit EVICE-LANCET Equit Equit Equit LANCER 259 LANCER PER. BOX OF 100 LANCERS PER BOX OF 100 No Authorization Required A4262 TEMP ABSORB LAC DUCT IMPLANT EA TEMPORARY ABSORBABLE TEAR IMPLANT No Authorization Required EACH A4263 PERM NONDISSOLV LAC DUTBOL NO. red LAC DUCT IMPL EA

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A4265 PARAFFIN PER POUND PARAFFIN PER POUND No Approval Required A4270 DISPOSABLE ENDOSCOPIC SEAL EACH DISPOSABLE ENDOSCOPIC SEAL EACH No Approval Required A4280 ADHES SKN SUPP ATTCH BRST PROSTH US SUP ADHEX SKAT NO W/ EA A4281 REPLACEMENT BREAST PUMP HOSE BREAST PUMP HOSE None approvals Re required REPLACEMENT FOR A4282 CHEST PUMP ADAPTER BR EAST PUMP ADAPTER No Approval REQUIRED EXCHANGE REPLACEMENT A4283 ADDED PUMP BOTTLE ADDED PUMP BOTTLE AquiPLELD 8 BURNT 8 REPLACEMENT CHEST SHIRTS MP REPL CHEST SHIELD & SPLASH GUARD No Approval W /PUMP FOR BREAST REPLACEMENT A4285 POLYCARBATE BREAST PUMP BOTTLE REPL POLYCARBONATE BOTTLE USE No Approval Required M /BREAST PUMP REPL A4286 BREAST PUMP LOCK BREAST PUMP LOCK No Approval Required T4286 BREAST PUMP LOCK BREAST PUMP LOCK None Authorization REQUIRED SACR 0 ACH SACRAL NERVE STIMULATION TEST Authorization Required Spine care combined with a full clinical exam LEAD EA CH neck and back conditions including: A4300 IMPL ACSS CATHETER EXTERNAL ACCESS IMPLANTABLE ACCESS CATHETER No authorization required EXTERNAL ACCESS A4301 IMPL ACSS TOTAL CATH PORT/RESABLE ACCESS IMPLANT IMPLANT A4305 DISPBL RX DEL SYS RATE 50 ML/>-HR DISPBL DRUG DELIV SYSTEM FLOW No approval required 50 ML/>-TIME A4306 DISPOSABL RX DEL SYS FLW < 50 ML HR AVAILABLE Drug DEL SYS FLOW RATE No approval required

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A4364 LIQUID GLUE/AS ANY TYPE-OUNCE LIQUID GLUE OR ANY TYPE No Approval Required PR. UNCA A4366 STOMA VENT ANY TYPE EACH STOMA VENT ANY TYPE EACH No approval required EACHOST A436Y. 368 STOMY FILTER ANY TYPE EACH STOMY FILTER ANY TYPE EACH No Approval Required A4369 STOMY SKIN BARRIER FLUID PER OZ STOMY SKIN BARRIER FLUID PER. OL 4X4/EQUV STD EA OST SKIN BARR SOL 4X4/EQUV STD No Approval Required WEAR CONVXITY EA A4373 OST SKN BARR W/FLNGE BUILT IN CONVX OST SKN BARR W/FLNGE W/BUILT No Approval Required. EA STOMIPOSE DRINABLE No approval required W/FCEPLATE ATTCH PLSTC EA A4376 OST POUCH DRINABLE W/FCEPLAT RUBR OSTOMY POUCH DRINABLE No approval required EA W/FACEPLATE ATTCH RUBBER EA POUCEPLAT POUCE POUCHOM DRENABLE DRENABLE USE No approval required OVER SEE PLASTIC EA A4378 OST BAG FCEPLAT RELEASEABLE RUBR EA STOMIE POUCH FLEXIBLE USE No approval required FACE PLATE RUBBER EACH A4379 OST POUCH URINARY W/FCEPLAT PLSTC EA STOMIE POUCH URINARY No approval required 3 POINT 3 I W/FCEPLAT RUBR EA STOMIPOUSE URINARY No approval required W/FACEPLATE ATTCH RUBBER EA A4381 OST POUCH URINARY FCEPLAT PLSTC EA OSTOMY POUCH URINARY USE No approval required FACE TRAY PLASTIC EACH A4382 OST POUCH URINE PCETCAT EAUT. requested HEAVY PLSTC EA A4383 OST POUCH URINE USE FCEPLAT RUBR EA OSTOMIPOUCH URINE USE No approval required FACE SHET RUBBER EACH A4384 OST FCEPLAT EQUA SILICONING EA STOMY PAD EQUIVALENT No approval required SILICONING EACH 4384 SKIN/SK 438 SK CON V 438, 1/1 RIJER FULL 4X4 EXT U/U No Approval Required CONVXITY EA A4387 OST POUCH CLOS BARR BUILT CONVX OSTOMY POSE CLOSED W/BAR BUILT- No Approval Required I CONVXITY EA A4388 OST POUCH DRNABL W/EXT WEAR BARR OSTEAR POUCH ARRATTIER WEAR OSTEAR POUCH ARRAINBOW EA A4389 OST POUCH DRNBL BAR BUILT-IN CONVX OST POUCH DRNABLE W/BARR W/BUILT- No Authorization Required I CONVXITY EA A4390 OST POUCH DRNABLE EXT M/CONVXITY EA OST POUCH DRNABLE W/AuthXITY Required 3 OST POUCH URINE W/EXT WEAR STD W /CONVXITY EA OST POUCH URINE M /STD WEAR No Approval Required BARRIER ATTCH EA A4392 OST POUCH URINE STD W/CONVXITY EA OST POUCH URINE M/STD WEAR No Approval Required BARRIER W/STD 3/4 EXT M/CONVXITY EA OST POUCH URINE M/EXT WEAR No approval required. BARRIER W/CONVXITY EA A4394 OSTOMY DEODORANT W/WO LUB PER FL STOMY DEODORANT W/WO No approval required OZ LUBRICANT POUCH DE4OD39 FLOST SOLID POUCH PER 39 FLOST SOLID TAB STOMY DEODORANT USE STOMY No approval required BAG FAST PER FLADE A4396 STOMY SEALS W/ PERISTOMAL HERN SUP BELT FOR COMPLETE PERISTOMAL HERNIA No approval required A4397 IRRIGATION DEVICE; CRUSH EVERY STOCK OF WHEAT; SLEEVE EACH No approval required A4398 GASTRIC DISCHARGE; BEHIND EACH STOMACH PRESERVING A RECORD; REAR No approval required EACH A4399 OST IRRIG SPL; CONE/CATH W/WO BRUSH STOMY WIND SUPPLY; No Approval Required KEGEL/CATH W/WO BRUSH A4400 GASTRIC SCAN KIT GASTRIC WASH KIT No Approval Required A4402 LUBRICANT PR. LUBRICANT OUNCES PER STE-OZ STOMY SKIN BARRIER NONPECTIN- No Approval Required PASTE-OZ A4406 OST SKN BARRIER PECTIN PASTE-OZ OSTOMY SKIN BARRIER PECTIN BASED No Approval Required PASTE PER OUN A4407 OST SKN BARRIER W/CONVXITY 4X4 SKIN BARRIN NO WOST SKN IN/ - < Approval Required CONVXITY 4X4 IN/< EA A4408 OST SKN BARRIER W/CONVXITY > 4X4 IN OST SKN BARRIER W/BUILDED No Approval Required CONVXITY > 4X4 IN EA A4409 OST SKN BARR EXT U/O BARRX/< 4X4 SKN EXT U/ U BUILT-IN No Approval Required CONVXTY 4X4 IN/4X4 I OST SKN BARR EXT U/O BUILT-IN No Approval Required CONVXITY>4X4 IN EA A4411 OST SKN BARR SOLID 4X4/EQ W/CONVXTY OST SKN BARRIER SOLID /EQ No Approval Required W/BUILT-IN CONVXITY A4412 OST POUCH DRNBL BARR FLNGE U/O FLTR OST POUCH DRNABLE BARRIER No Approval Required W/FLNGE U/O FLTR EA A4413 OST POUCH DRNABL BARRIER DRNABLE POUCH OP HIGH No Approval Required M/ FLNGE/FLTR EA A4414 OST SKN BARRIER U/O CONVX 4X4 IN/< OST SKN BARRIER U/O EMBEDDED No Authorization Required CONVXITY 4X4 IN/4X4 IN OST SKN BARRIER U/O EMBEDDED No Authentication Required CONVXITY >4X4 I EA A4416 OST POUCH CLO BARR ATTCH W/FILTR EA OSTOMY POUCH CLOSED M /BARRIER No Approval Required ATTCH W/FILTER EA A4417 OST POUCH CLO BARR W/BLT-IN CONVXIT CATT WATT/BLT-IN CONVXIT CATT WOST/AUT. Needed W/BUILT-IN CONVXIT A4418 OST POUCH CLOS; U/O BARR W/FILTR EA STOMY BAG CLOSED; NO OBSTRUCTION No approval required CONNECTION W/FILTER EA A4419 OST POUCH CLOS; BARRIER W/NON-LOCKHEES POUCH CLOS; BARRIER W/NON- Approval not required LOCK FLNGE W/FLTR A4420 OST POUCH CLO; USE BARR LOCK FLNG EA OSTOMY POUCH CLO; BARRIER USE No approval required W/LOCK FLNGE EA A4421 OSTOMY ACCESSORIES; MISCELLANEOUS STOMA FILLING; MISCELLANEOUS Approval required Full clinical review A4422 OST ABSORB MATL THICKN LQD STOML OP OST ABSORBENT MATL POUCH THICKEN No approval required LQD STOMAL OP EA A4423 OST POUCH CLOS; BARR W/LOCK FLNG EA OST POUCH CLOS; BARRIER W/LOCK No Approval Required FLNGE W/FLTR EA A4424 OST POUCH DRNBL BARR ATTCH FILTER EA OSTOMY POUCH DENSIBL No Approval Required W/BARRIER ATTCH W/FLTR EA A4425 OST POUCH DRNBL; BARR NON-LOCK FLNG OST POUCH DRNABL; BARR NON-LOCK No approval required FLNGE W/FILTR EA

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A4426 CHEST BAG DRNBL;BAR W/LOCK FLNG EA CHEST BAG DETACHABLE; USE BARRIER No Approval Required W/LOCK FLNGE EA A4427 OST POUCH DRN;BARR LOCK FLNG FLTR OST POUCH DRNABLE; BARRIER LOCK No Authorization Required FLNGE W/FLTR EA A4428 OST POUCH URINE W/TAPE TAP OST POUCH URINE EXT BARR W/TAPE No Authorization Required W/VALVE TAP W/VALVE A4429 OST POUCH URINE W/BLT-IN BAG IN OSVX BLT-IN IN CONVXI No Approval Required W/TAC TAP VALVE A4430 OST POUCH URN BLT-IN CNVX FAUCT VLV OST POUCH URINE EXT BARR BLT-IN No Approval Required CNVX FAUCT VLV EA A4431 OST POUCH URINE; W/BAR W/TAPE No Approval Required TAP W/VALVE EA A4432 OST POUCH URN;NO-LCK FLNG FAUCT VLV OST POUCH URINE;BARR NON-LOCKING No Approval Required FLNG FAUCT TAP VALVE A4433 OST POUCH URINE; BARR W/LOCK FLNG EA OST POUCH URINE; FOR BARR No Approval Required W/LOCK FLANGE EA A4434 OST POUCH URN;LOCK FLNG FAUCT VLV OST POUCH URIN; BARR LOCK FLNG No Authorization Required FAUCET VALVE A4435 OST POUCH DRN HI OP EXT WR BARR EA OST POUCH DRAIN HI OP EXT WEAR No Authorization Required BARR W/WO FLTR EA A4450 TAPE NOT 18 SQUARE WATERPROOF 18 SQUARE Authority Required SQUARE INCHES A4452 TAPE WATERPROOF PR. 18 SQUARE IN TAPE WATERPROOF PO EA ADHESIVE REMOVER WIPES ANY TYPE No Authorization Required EACH A4458 ENEMA BAG WITH TUBING REUSABLE ENEMA SYSTEM WITH REUSABLE TUBING No Authorization Required A4459 MAN PUMP-OP ENEMA SYSTEM REUSABLE ANY WHICH HAND PUMPING ENEMA SYSTEM No authorization required REUSABLE TYPE 46 1ESSLE RGISK DRESS HOLDER NON - Approval not required EA REUSABLE EACH A4463 SURGICAL CORD HOLDER REUSABLE EA SURGICAL CORD HOLDER REUSABLE No approval required. LT STRAP REMEDY OR No Approval Required General Medical - COVERS ANY TYPE OF HEALTH AND BEHAVIORAL ASSESSMENT/INTERVENTION A4470 GRAVLEE JET WASHER GRAVLEE JET WASHER No Approval Required A4480 VABRA ASPIRATOR VABRA ASPIRATOR No Approval Required A4481 TRACH EOSTOMA FLTR TYPE ASITOME EZ Auth. A4483 MOISTR EXCHGR DISPBL W /INVASV VENT MOISTR EXCHGR DISPBL USE W/INVASV No approval required MECH VENT A4550 SURGICAL CADET SURGICAL BATHS No approval required A4553 NON-COMBAT USE PADS ALL SIZES NON-COMBAT CONTAINERS A456 no ELECTRODES required PO. PAR Approval not required A4557 WATER WIRES PO. PAIR OF LEADS PER PAIR No Approval Required A4558 CONDUCTVE GEL/PASTE USAGE W/ELEC DEVC CONDUCTIVE GEL/PASTA FOR USE No Approval Required W/ELECTRICAL DEVICE A4559 COUPLING GEL/PASTE W/US COSTEVC US PERELZPA OBS W/US No Approval Required DEVICE PER OZ A4561 PESSAR RUBBER ANY TYPE PESSAR RUBBER ANY TYPE No approval required A4562 PESSAR NOT RUBBER ANY TYPE PESSAR NOT RUBBER ANY TYPE No approval required A4563 SRCTL CNTRYS ERL AG INSRT LT USE No approval required ANY TYPE EA A4565 SAILS Not required approval. RS No approval required DEVC REPL EA A4601 LIB RECHARG NON-PROSTHETIC USE REPL LITHIUM ION BATT RECHARG NONPROS No approval required USE REPLACEMENT A4602 REPL BA EXT IP OWND PT LI 1.5 V EA REPL BA EXT INFUS PUMP EJ No approval required PATIENT LIUBEA 1.5 04 WINTHE 1,604 WINTHE 1,604 WINTHE 1. TUBE W/INTGR HEATING ELEM W/POS No approval required DEVC AIR WALL PRESS DEVC A4605 TRHEAL SUCTION CATH CLOS SYS EA TRHEAL SUCTION CATHETER CLOSED No approval required SYSTEM EACH A4606 O2 PROBE W/OXIMETER PROBE W/OXIMETER MUST USE APP/OXIMER USER ICE REPLACEMENT A4608 TRANSTRACHEAL ICTCATHETER TRANSTRACHEAL ICTCATHETER No approval required EACH A4614 PEAK EXPIRATORY FLOW METER MANUAL PEAK EXPIRATORY FLOW METER No approval required HAND CNULANASAL A4615 A4615 A4615 hose per. foot Hose by foot No approval required A4617 mouthpiece USTIK No approval required A4618 BREATHING CIRCUIT BREATHING CIRCUIT No approval required A4619 FACE TENT FACE TENT No approval required A4620 VARIABLE CONCENTRATION MASK VARIABLE CONCENTRATION MASK No authorization required INTRAAN CLAANER CLAANER C423NER C OST. NULL No approval required A4624 TRACHEAL SUCTN CATH NOT CLOSED SYS EA TRACHEAL SUCTN CATH TYPE OTH No approval required END CLOS SYS EA A4625 TRACHEOST CARE KIT NEW TRACHEOST TRACHEOST CARE KIT FOR NEW No approval required TRACHEOSTOMY A4626 TRACHEOSTOMY CLEANING B RUSH EACH TRACHEOSTOMY CLEANING A4626 TRACHEOSTOMY EVENING BRUSH APPLICATION A46 CLEANING A2 CATHETERS OROPHARYNGEAL SUCTION CATHETERS No approval required EACH A4629 TRACHEOSTOMY CARE KIT EST TRACHEOSTOMY CARE KIT ESTABLISHED No approval required TRACHEOSTOMY A4630 REPL BATTERY TRNSQ ELEC STIM OWN PT REPLCMT BATTERY S NECES TRNSQ No approval required ELEC STIM OWND A4 630 REPLVTX OWND APLV 4 LG REPLV4 CMT LAMP/ULLAVIOLET LAMP No Authorization Required LIGHT TX SYSTEM EA A4634 REPLCMT Bulb TX LGHT BOX TABOP MDL REPLCMT Bulb THERAPY LIGHT No Authorization Required BOX TABOP MODEL A4635 FOREARM CHRYKKE REPLACEMENT FOREARM PAD CUTCHA No Authorization Required

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A4636 REPLACEMENT HANDLE CAN CRUTCHES/WALKERS EA REPLACEMENT JACKET HANDLE No CRUTCHES OR WALKERS APPROVAL REQUIRED A4637 REPLACEMENT HANDLES CAN CRUTCHES WALKER EA REPLACEMENT JACKET WALKER NO APPROVAL REQUIRED WALKERS EACH A463SE REPLOW BATTEA P8-DOMENA BATTEA- REPLEMENT PT-OWNED EAR Approval Required for hearing aids Full clinical review PULSE GEN EA A4639 REPL PAD INFRARED HEATING PAD SYS EA REPLACEMENT PAD INFRARED HEATING No approval required PAD SYSTEM EACH A4640 REPL PAD W/ALTERNAT PRSS PAD OWN PAD W REPLACEMENT PAD TO REPLACE OWN PT A4641 RADIOPHARMACEUTICAL DIAGNOSTICS RADIOPHARMACEUTICAL DIAGNOSTICS Not required approval NOC NOC A4642 IN-111 SATUMOMB PENDETID DX TO 6MCI INDIUM IN-111 SATUMOMAB No approval required UP4642 IN-111 SATUMOMB PENDETID DX TO 6MCI INDIUM IN-111 SATUMOMAB No approval required UP4642 IN-111 SATUMOMB PENDETID DX TO 6MCI INDIUM IN-111 SATUMOMAB No approval required UP4642 IN-111 SATUMOMB PENDETID DX TO 6MCI INDIUM IN-111 SATUMOMAB No approval required UP4642 IN-111 MIX TYPE EA TISSUE MARKER FOR IMPLANTATION ALL No approval required TYPE EACH A4649 SURGICAL CONSUMER; MISCELLANEOUS SURGICAL SUPPLIES; MISCELLANEOUS approval required Full clinical examination A4650 IMBALANT RADIATION DOSIMETER EA IMBALANT RADIATION DOSIMETER No approval required. ALANT MICROCAPILLARY TUBE SEAL No approval required A4653 PERITONE DIALYSIS CATH ANCHR BELT EA PERITONE DIALYSIS CATHETER ANCHR No approval required UNIT BELT EA A4657 SYRINGE WITH OR WITHOUT NEEDLE EACH SYRINGE WITH OR WITHOUT NEEDLE No approval required. BLOOD PRESSURE CUFF ONLY BLOOD PRESSURE CUFF ONLY Art. Author Required A4671 DISPBL CYCLES SET USED WITH/DIALYSIS CYCLES DISPBL CYCLES SET USED W/CYCLES No authorization required DIALYSIS MACH EA A4672 DRAIN EXT LINE STERILE DIALYSIS EA DRAIN EXT ENSION Auth LINE STERILE REQUIRED W3 LOCK CNCTR DIALYSIS EXT LINE W/EASY LOCK CONNECTORS No approval required USED W/DIALYSIS A4674 KEMS/ANTISPTC SOL CLEAN/STERL 8OZ CHEMS/ANTISEPTIC SALT No approval required CLEAN/STERILIZER DIALY 8OZ A4680 CATIVE CARBODIAL ACTIVATED CARBODIALAUT Required HEMODIALYSIS EACH A4690 DIALYZER ALL TYPES SZS HEMODIAL EA DIALYZER ALL TYPES ALL SIZES No approval required HEMODIALYSIS EACH A4706 BICARBONATE CONC SOL HEMODIAL-GAL BICARBONATE CONCENTRATE SALT No approval required HEMODIAL ARBONATE BW7 ATE CONCENTRATE POWDER No approval required PCKET HEMODIAL PACK A4708 ACTAT CONC SOL HE MODIAL-GALLON ACTAT CONCENTRATE SOLUTION No approval required HEMODIAL PER GALLON A4709 ACID CONC SOL HEMODIAL GALLON ACID CONCENTRATE SOLUTION No Approval Required HEMODIAL PER GALLON A4714 TREATED HEMODIAL GALLON A4714 TREATED THROUGH H2O PERITONE. requested DIALYSIS PER GALLON A4719 Y PERITONEAL DIALYSIS TUBING SET Y PERITONEAL DIALYSIS TUBING SET No approval required A4720 DIALYZER FL>249249999999199919992999299939993999499949995999 999999599 9999999999 5999 red PD A4728 DIALYSAT SOL NO-DXTRS CNTAIN 500 ML DIALYSIS SOLUTION NON-DXTROS No approval required CONTAINS 500 ML A4730 Fist CANNULATE SET HEMODIALYSIS EA CANNULATION FISTULA SET FOR No authorization required HEMODIALYSIS EACH A4736 LOCAL AESTHETICS DIALYSIS PO G LOCAL AESTHETICS FOR DIALYSIS PO No authorization required G A4737 DIALECTIC AESTHETICS INJECTION ANESTHETIC ANESTHETICS. PR approval is NOT required. 10 ML A4740 SHUNT ACCESSORIES HEMODIAL ANY TYPE EA SHUNT ACCESSORIES HEMODIALYSIS ANY No approval required TYPE EACH A4750 BLD TYPE TUBING/VENOUS HEMODIAL EA BLOOD TUBING ARTERIAL/VENOUS No approval required HEMODIALYSIS EACH A4755 BLD T UBING TYPE AND TUBING AUT. requested COMBINED HEMODIALYSIS EA A4760 DIALYSAT SOL TST KIT PERITON EA DIALYSAT SOL TST KIT PERITON No approval required DIALYSIS TYPE EA A4765 DIALYSAT POWDER PERITON DIALYSAT DIALYSAT CONC POWDER ADD No approval required PERITON DIALYSIS-PCKET A4766 DIALYSAT SOLYSAT Aquid. IALYSIS-10 ML A4770 BLD COLLECTION TUBE VAC DIALYSIS-50 BLOOD COLLECTION TUBE DUST SUM No approval required FOR DIALYSIS PER 50 A4771 SERUM COROBEL TIME TUBE DIALYSIS-50 SERUM COOKING TIME TUBE FOR No approval required DIALYSIS PER. GOOD TEST STRIPS FOR GLUCOSE MEASUREMENT FOR Nr Auth required DIALYSIS PO. 50 A4773 OCCULT BLD TEST STRIPS DIALYSIS-50 OCCULT BLOOD TEST STRIPS FOR No approval required DIALYSIS PER. 50 A4774 AMMONIUM TEST STRIPS FOR DIALYSIS PER HEMODIAL-50 MG PROTAMINE SULFATE FOR No approval required HEMODIALYSIS PER. 50 MG A4860 DISPBL CATH TIP PERITONEAL DIALYSIS-10 DISPBL CATHETER TIPS PERITONEAL No approval required DIALYSIS PR. EQUIPMENT

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A4890 CONTRACTS REPR & MAINTENANCE HEMODIALYSIS EQUIPMENT CONTRACTS REPAIR & MAINTENANCE No Approval Required HEMODIALYSIS EQUIPMENT A4911 DRAINAGE BAG/DIALYSIS BOTTLE EACH DRAINAGE BAG/DIALYSIS BOTTLE EACH No Approval Required A4911 Dialysis Drainage Bag/VIAL REFERRAL Approval Required Full Clinical Examination NOS A4918 VENØ S PRESSURE CLAMP HEMODIAL EA VENOUS PRESSURE CLAMPS FOR No approval required HEMODIALYSIS EACH A4927 GLOVES NON-STERILE PO. 100 NON-STERILE GLOVES EACH 100 No approval required A4928 SURGICAL MASK EACH. 20 SURGICAL MASKS PER OURNIQUET FOR DIALYSIS EACH No approval required A4930 GLOVES STERILE PO. A PAIR OF STERILE GLOVES. PAIR No approval required A4931 ENT THERMOMETER REUSBL ANY TYPE EA ORAL THERMOMETER REUSABLE ALL No approval required TYPE EACH A4932 RECTAL THERMOMETER REUSBL REUSBL MULTI-USE THERMOMETER A5 RECTAL THERMOMETER MULTI-USE THERMOMETER EA5 51 OST POUCH CLOS; W/BARRIER ATTCH EA OSTOMY BAG CLOSED; NO approval required. BARRIER RAISED EACH A5052 CHEESE BAG CLOSED; WITHOUT CLOSE ADDS EA STOMY BAG CLOSED; NO No approval required ATTACHED OBSTRUCTION EA A5053 OSTOMY BAG CLOSED; USE TOP PAGE CLOSED POINT STOMY; FOR USE ON No approval required CAUTION EACH A5054 CHEST POUCH CLOSES; BARRIER W/FLNGE EA OSTOMY BAG CLOSED; USE BARRIER No Auth Required W/FLANGE ECH A5055 STOMA CAP STOMA CAP No Auth Required A5056 OST POUCH DRAIN EXT BARRIER FLTR EA OST POUCH FLEXIBLE EXT WEAR No Auth Required BARRIER W/FILTER EARRAIN BARREA POUCHRA CONTROUCH 7 BL EXT WE AR BARRIER No Auth Required CONVXTY FLTR EA A5061 CHEST BAG FOR DRYING; W/BARR ATTCH EA FLEXIBLE OSTOMY BAG; No Approval Required WITH BARRIER ATTACHED TO EACH A5062 DRNABL CHEST POUCH; NO BARRR ATTCH EA SEPARATOR OSTOMY BAG; NO No Approval Required BARRIER ATTCH EA A5063 OST POUCH DRNABLE; BARR W/FLNGE EA FLEXIBLE OSTOMY BAG; USE No approval required BARRIER W/FLANGE EA A5071 CHEST URINE BAG; W/BARRIER ATTCH EA URINARY OSTOMY BAG; NO approval required. BARRIER RAISED EACH A5072 CHEESE BAGS URINE; NO BARR ATTCH EA URINE OSTOMY POUCH; NO No Approval Required BARRIER ATTCH EA A5073 CHEST URINE BAG; BARRIER W/ FLNGE EA OSTOMY BAG URINARY; USES No Approval Required BARRIER W/BRACKET EACH A5081 STOMA PLUG OR SEAL ANY TYPE STOMA PLUG OR SEAL ANY TYPE No Approval Required A5082 CONTINENT DEVC;CATH CONTINENT CONTINENT DEVICE; CATHETER FOR No authorization required STOMA CONTINENT STOMA A5083 CONT. DEVICE STOMA ABSORBENT COVER CONTINENT DEVICE STOMA No approval required ABSORBENT STOMA COVER A5093 STOMA ACCESSORIES; CONVEX INSERT FOR STOMY ACCESSORIES; CONVEX INSERT No Approval Required A5102 DRN BOTTLE WITH NIGHT ASSIST W/WO TUBING EA DRAIN BOTTLE WITH NIGHT OBJECT W/WO TUBING No Approval Required RIGID/XPNDABLE EA A5105 URINE ASSIST LEG BAG W/WO WATER TUBING WITH EASP TUBING EACH A5112 URINE D RAIN BAG BEN/ABD LATEX EA LEG URINE DRAINAGE BAG OR No approval required DOWN. LATEX REPLCMT-SET LEG STRAP ONLY; LATEX REPLACEMENT ONLY No PR approval required. KIT A5114 BENZEM; FOAM/FABRIC REPL-SET LEG STRAP; FOAM/FABRIC No approval required EXCHANGE PO ONLY. SET. SOLID 6X6/EQUIVALENT EA SKIN BARRIER; SOLID 6 X 6 OR No approval required EQUIVALENT EACH A5122 SKN BARRIER; SOLID 8X8/EQUALENT EA SKIN BARRIER; SOLID 8 X 8 OR No approval required EQUIVALENT EACH A5126 ADHESIVE/NON-ADHESIVE; DISC/FOAM CUSHION ADHESIVE OR NON-ADHESIVE; DISC OR No approval required FOAM PAD A5131 APPLINC CLNR INCONT&OST APPLN-16 OZ APPLINC CLNR INCONT&OSTOMY No approval required APPLINCS PER 16 OZ A5200 PERQ CATH/TUBE ANCHR DEVCTH ADHICE Acquired SKN ADHES ADHES A5200 PERQ A5500 DM ONLY CSTM PREP SHO MX DNS INSRT ONLY DIAB FITS CSTM PREP&SPL SHOES No approval required MX DNSITY INSRT A5501 DM ONLY CSTM PREP SHOE FORM PTS FT DIAB FITS CSTM PREP&SPL SHOES ONLY No approval required DM 5 MOD SHOES DM 5 MOD SHOE 3 MODE LY MOD SHOES/ CSTM FORM No approval required ROLLER/ROCK emergency ROLLER /ROCKR BUND A5504 DM SHOES ONLY/CSTM W/KIL DIAB SHOES ONLY/CSTM FORM No approval required SHOES SHOES W/KILLES A5505 DM SHOE/CSTM SHOE ONLY. MOD SHOES/CSTM FORM ONLY No authorization required SHOES SHOES W/MT BAR SHOES A5506 DM ONLY MOLD SHOES/CSTM OFF SET HEELS ONLY DIJAB MOD SHOES/CSTM FORM No authorization required SHOES W/OFF SET HEELS A5507 DM ONLY MOLD DIAB ONLY NOSE MOD SHOE/CSTM Approval not required SHO MOLLD SHOES PR. SHOE A5508 DM DELUX FEATURES ONLY SHOE/CSTM DIAB DELUXE FEATURES ONLY No approval required MOLLD SHOE/CSTM MOLD SHOE A5508 MOD DIAB FORM DIRONLY FORM. RS FORM No Approval Required PTS FT U/O HEAT A5512 FOR DIAB MX DNSITY INSRT ONLY PRFAB ONLY FOR DIAB MX DNSITY INSRT DIR FORM No Approval Required. MDL PT FT CF EA A5514 DIA MX DEN INS DIR CARV CSTM FAB EA DIAB ONLY MX DEN INSRT DIRECT CARV No Approval Required CUSTOM FAB EA A6010 COLLEGEN WUND FILLR DRY SHAPE PR. 1 COLLAGEN WOUND FILLER GEL/PASTE PO G COLLAGEN BASED WOUND FILLER No approval required GEL/PASTE STERL PO G A6021 COLL DRESS PAD SIZE 16 SQ/SMALL EA COLLAGEN BANDAGE STERILE SIZE 16 No approval required SQ A60 SG2 ST62 STRL> SQ IN None approval required MEN/=48 SQ EA A6023 COLL DRSG STERILE SZ >48 SQ IN EA COLLAGEN DANDAGE STERILE VEL. >48 No SQ approval required IN EACH

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A6024 COLL DRESS WND FIL STERL PER 6 AND COLLAGEN DRESSING WOUND FILLER No approval required STERILE PER 6 I A6025 GEL SHEET FOR DERMAL/EPIDRAL APPLICATION EA GEL SHEET FOR DERMAL/EPIDERMAL APPLICATION No approval required WACHO P15 REQUIRED. ACH No Approval Required A6196 ALGINATE/OTHER FIBER GELL PAD 16 SQ/161648 SQ EA ALGINATE/OTHER FIBER GEL DRESS WND No Approval Required PAD > 48 SQ EA A6199 ALGINATE/OTHER FIBER GELL DRESS FIL-6IN ALGINATE/OTHER FIBER DRESS Item no. I A6203 COMPOS DRESS 16 SQ/< W/ADHESION BORDR COMPOS DRESS STERL PAD 16 SQ/< No approval required W/ADHES DRESS EA A6204 COMPOS DRESS >16 16SQ BUT 48SQ W/ADHESION BORDR 8 COMPOS ON No. EA W/ADHESIVE BOARD A6206 CNTCT LAYER STERL 16 KV IN/ 16 KV MALE 16 KV MALE 48 KV EACH COATING CONTACT LAYER STERL > 48 KV IN EACH No COATING Approval Required A6209 FOAM DRESS NO ADDRESS SQSTERL DRESS SQSTERL ADDRESS SQSTERL DRESS 6 SQ/ < NO No Approval Required ADHESIVE BORDER EA A6210 FOAM DRESS >16 16 MEN 48 SQ NO NICE FOAM DRESS STERL PAD >48 SQ NO No Approval Required ADHESIVE BORDER EA A6212 FOAM DRESS 16 SQAM BOARD TABLE W. PAD SZ 16 SQ/> No Approval Required approval M /ADHESIVE BORDR EA A6213 FOAM DRESS >16 16 KV MEN 48 KV W/ADHES BORDR EA FOAM DRESS STERL PAD SZ > 48 SQ No approval required W/ADHES ADDRESSO W/ADHES BORDESSO FORD25 STERL PO G FOAM FILLER BANDAGE FOR WOUNDS No approval required STERILE PO G A6216 GAUZE NEMPREG NONSTERL 16 SQ/< GAUZE NON-IMPREG NONSTERL 16 No approval required SQ/< U/O ADHES EA6 A6217 No. Required 48 SQ GAUZE NON-IMPREG NONSTERL > 48 SQ No Authorization Required U/O ADHESIVE EA A6219 GAUZE NON-IMPREG STERL 16 SQ/16 16 48 SQ W/ADHES GAUZE NON-IMPREG STERL/ Auth Required No. EA A6222 GAUZ IMPREG NOT H2O/HYDRGEL 16 GAUZE IMPREG NOT H2O NL No Authorization Required SQ/< SALINE/HYDROGEL 16 SQ/< A6223 GAUZ IMPREG NOT H2O/HYDRGL >1616 48 No H2O/HYDRGL Auth EL > 48 SQ A6228 GA UZ IMPREG WATR /NL SALINE > 16 SQ GAUZE IMPREG H2O/NL SALINE STERL No Authorization Required >16 SQ NO ADHES A6229 GAUZE IMPREG WATR/SALI >1616 BUT48 SQ Auth GAUZE IMPR. NO ADHESIVE A6231 GAUZE IMPREG HYDRGEL DIR WND 16 SQ/< GAUZE IMPREG HYDROGEL DIR WND No approval required CNTC STERL 16 SQ/< A6232 GAUZE IMPREG HYDRGEL DIR >16 16 16 48 CNTC STERL>48 SQ A6234 HYDRCID DRESS 16 SQ/< GAUGE NO. Hydrocolloid dressing Sterl 16 Sq/1616 Ali 48 SQ without glue Hydrocolloid no. A4 AUTH 237 Hydrocolloid dressing 16 Sq/16 16 M EN 48 SQ W/ ADHES HYDROCOLLOID DRESS STERLuth >48 SQ BORDR A6238 HYDROCOLLOID DRESS COOL FIL PAST- FL OZ HYDROCOLLOID DRESS WND FIL No approval required PASTE STERL PER OZ A6241 HYDROCOLLOID DRESS DRY FORM PER G HYDROCOLLOID DRESS WND FIL DRY No no approval required FORM STERL PER G A6242 HYDROCOLLOID DRESS /< 16 HYDROCOLLOID DRESSING WND FIL DRY. DRESS STERL PAD 16 SQ /< No approval required NO ADHESIONS BORDR A6243 HYDROGEL DRESS >16 16 SQ MEN 48 SQ U/O ADHESIVES EA HYDROGEL DRESS STERL PAD > 48 SQ No approval required NO ADHES BORDR A6245 HYDROGEL DRESS/HYDROGEL H YDROGEL STERL PAD 16 SQ/< No Approval Required ADHES BORDR A6246 HYDROGEL DRESS >16 16 SQ MEN 48 SQ ADHES HYDROGEL DRESS STERL PAD > 48 SQ No Approval Required ADHES BORDR A6248 HYDROGEL WDRESS WDRØGEL UND FILLER No Approval Required GEL PR FL OZ A6250 SKN SEALNT PRO TCT MOISTURIZE SKIN SEALNT PROTECT MOISTURIZER No Authorization Required OINTMNT OINTMNT TYPE SZ A6251 SPCLTY ABSORBENT DRESS 16SQ/< NEADHESIVE SPCLTY ABSORB DRESS STERL Required 16 SQ No Auth.

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A6252 SPCL ABSORB DRESS >1616 48 SQ NO ADHESIVE SPCLTY ABSORB DRESS STERL >48 SQ No Authorization Required NO ADHESIVE TRIM A6254 SPCLTY ABSORB DRESS 16 SQ/< W/ADHES SPCLTY ABSORB DRESS Authent A6 SQREA STERL 1 SPCLTY ABSORB DRESS CL ABSORB DRESS > 1616 48 SQ W/ADHES SPCLTY ABSORB DRESS STERL > 48 SQ No Authorization Required ADHES BORDR A6257 TRNSPRT FILM STERL 16 SQ/< EA DRESS CLEAR FILM STERL 16 SQ Auth RESS IN A2 SQ I OR 5 16 SQ MEN 16 SQ MEN 48 SQ EA DRESS TRANSPARENT FILM STERL > 48 SQ IN No approval required EA DRESSING A6260 WOUND CLEANER ANY TYPE ALL SIZES WOUND CLEANER ANY TYPE ANY SIZE No approval required WPA-FILLO F100/12000 ER GEL/PASTE PO FL OZ Not required approval NOS A6262 WOUND FILLING ERS DRY FORM PO G NO. WOUND FILLER DRY FORM BY G NO. Approval required SECOND SPEC. YD A6402 GAUZE NON-IMPREG STERL 16 SQ/< WITHOUT AD GAUZE NON-IMPREG STERL 16 SQ/< No approval required U/O ADHESIVE BOARD A6403 GAUZE NON-IMPREG STERL >16 16 48SQ WITHOUT GAUZE SQL NO. Auth Required ADHESIVE WITHOUT ADHESIVE BOARD A6407 TAPE PACKAGE NON-IMPREGNATED OP 2 IN TAPE PACKAGE NON-IMPREGNATED OP 2 IN No Approval Required WDTH-LINR YARD A6410 EYE PAD STERILE EACH EYE PAD A4 Auth1 Required EACH EYE PAD NON-STERILE EA CH Approval Not Required A6412 OCCLUSIVE OCCLUSION PADDED OCCLUSION PADDED OCCLUSION Any Approval A6441 PADD Tape No Elastic Bands No Padd Tape Non Elast No Woven Approval-2WDN WO6TTON/4 Matching Tape Matching Band No Elast Non Approved KTINT/ FABRIC NON-ST A6443 CONFORMED TAPE NON ELASTIC CONFORMED TAPE NON ELASTIC Not Required approval KNITTED/FABRIC NON-KNITTED/FABRIC NON-COMPLIANT B4443 -ELAST No approval required KNITTED/WOVEN NON-ST A6445 CONFORMING TAPE NON-ELASTIC COMPLIANT TAPE NON-ELASTIC No approval required KNITTED/FABRIC STERL A6446 CONFORMAL TAPE NON-ELASTIC CONFORMAL TAPE NON-ELASTIC REQUIRED KNITTED/FABRIC STERL A6446 A6447 COMPLIANT BAND NON ELASTIC COMPLIANT BAND NON ELASTIC No approval required KNIT/WO VEN STERL A644 8 LT COMPRS BAND ELASTIC WIDTH < 3 I LT COMPRS BANDGE ELAST WDTH < 3 I No approval required 64 BAND3 YARD = 64 BAND3 YARD & /= 3 No approval required & /= 5 IN LT COMPRS BANDGE ELAST WDTH >/= 5 No approval required IN PER YARD A6451 MOD COMPRS BANDGE WD >/= 3 & /= 3 & /= 3 & /= 3 & / = 5 No approval required And PR. YARD A6456 ZINC PAST BANDGE WD >/= 3 & /= 3 & 16 SI 16 SI MEN

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A6550 WND CARE SET NEG PRSS WND TX PUMP WND CARE SET NEG PRSS WND TX ELEC No Authorization Required PUMP SPL A7000 CANISTER DISPBL USED W/SUCTN PUMP DISPOSABLE CANISTER With None Auth Required CASITION A7 PUNISN SUP US NON-DISPOSABLE No Authorization Required PUMP W/ SUCTION PUMP EACH A7002 HOSE USED WITH SUCTION PUMP EACH HOSE USED WITH SUCTION PUMP No approval required. DISPBL A7004 SM VOL NONFILTR PNEUMATIC NEB DISPBL SMALL VOLUME NONFILTR PNEUMATIC No approval required NEBULIZER DISPBL A7005 ADMN SET SM VOL NONFLTR NEB ADMN SET W/SM VOL NONFILTR No approval required NONDISP NEBULIZR NEBULIZR NON-SET -WTR DISPSM A SET WITH SMALL VOLUME FILTER No authorization required PNEUMAT NEBULIZR A7007 LG VOL NEBULIZR DISPBL UNFIL COMPRS LG VOL NEBULIZR DISPBL UNFIL USED No authorization required W/AROSL COMPRS A7008 LG VOL NEBULIZR DISPBL PRFIL COMPRS LG VOL NEBULIZR COMPRESS USE No Auth Required RESRVOR BOTTLE LG VOL US NEBULIZR RESRVOR BOTTLE NE- DISPBL M/LG No Approval Required VOL US NEBULIZR A7010 CORUG TUBING DISPBL LG VOL NEB 100 FT CORUGATD TUBING DISPBL W/LG VOL No Approval Required NEBULIZR 100 DEFT A7 CORUGATD A7 EC DEV USE W/LG VOL NEB No Approval Required A7013 FILTER DISP M /AREO COMPRESS/US GEN FILTER DISPOSABLE W/AREOSOL No Approval Required KOMPRESS/US GENERATOR A7014 FLTR NON-DISPBL AROSL COMPRS/US GEN FILTER US NON-DISPOSBL. Authentication Required COMPRS/US GEN A7015 AREO MASK USED W/ DME NEB AREO MASK USED W/ DME NEB No Authentication Required A7016 DOME&MOUTHPECE W/SM VOL US DOME&MUTHYLCE USED W/LITTLE No Authentication Required NEBULIZR USES NEBULIZR VOLUME A7 NOTULIZR USCL7 W/O2 NEB GLASS/AUTOCLAVE NOT USED W/O2 No Approval Required A7018 H2O DIST USE W/LG VOL. NEB 1000 ML H2O DIST USE W/LG VOL. NEB 1000 ML No approval required A7020 INTERFACE COUGH STIM MOVE COUGH STIM DEPL. No Approval Required REPLACE ONLY A7025 HI FREQ CHST WALL OSCILLAT VEST REPL HI FREQ CHST WALL OSCILLAT SYS VEST DME Approval Required Full Clinical Review REPL PT OWND A7026 HI FREQ CHST WALL OSCILLAT TUBE REPL WALL Squirted isk Review REPL PT OWND A7027 KAMM ORAL/NASAL MASK W/CPAP EACH COMB ORAL/NASAL MASK USED No Approval Required M/CPAP UNIT EACH A7028 ORAL CUSHION ORAL/NASAL MASK REPL EA ORAL CUSHION COMB ORAL/NASAL COMB ORAL/NASAL MA RE AUT RE A7028 NASL CUSHION ORL/NASL MASK REPL PAIR NOSE PADS COMB ORAL/NASL No Approval Required MASK REPL PAIR ONLY A7030 FULL FCE MASK POS ARWAY PRSS DEV EA FULL FACE MASK USED W/POS ARWAY No Approval Required A7V3 REPRESS DERF31 MASK EA FACE MASK INTERFACE REPLCMT FULL No Approval Required FACE MASK EA A7032 CUSHN NASAL MASK INTF REPLACE ONLY EA CUSHN NASAL MASK INTERFACE No Authorization Required REPLACE EACH ONLY A7033 PILL NASL INDENTURE CANNUL Auth Required REPL PAIR ONLY A7034 NASL INTERFCE POS ARWAY PRSS DEVC NASL INTRFCE POS ARWAY PRSS DEVC No Authorization Required W/WO MAIN PLAIN A7035 MAIN USE BENDED W/POS ARWAY PRSS MAIN BEND USED W/POSITIVE AIRWAY No Approval PRESSURE SCREEN DEVICE W/6 VC CHINSTRAP USED W/POSITIVE AIRWAY No Approval Required PRESSURE DEVICE A7037 HOSE USED W/POS ARWAY PRESS DEVC HOSE USED WITH POSITIVE AIRWAY BY ROADS No Approval Required PRESSURE DEVICE A7038 FLTR DISPBL W/ POS DEVELOPMENT PRINT DO NOT SELECT. RE UNIT A7039 FLTR NOT DISPBL POS ARWAY PRSS DEVC FILTER NOT DISPBL USED W/POS No approval required ARWAY PRESS UNIT A7040 ONE WAY BREAST FLOW VALVE ONE WAY OUTLET BREAST VALVE No approval required A7041 REQUIRED A7041 WATER A7041 TREATMENT SEuth. TAINER & TUBING TUBE A7044 ORL INTERFCE W/POS ARWAY PRSS DEVC ORAL INTERFCE USED W/POS ARWAY No Approval Required PRESS UNIT EA A7045 EXHAUST CONNECTOR ONLY REPLACEMENT OF TRAINING HOLE WITH WO SWIVEL No Approval Required ONLY REPLACEMENT A7045 A7045 TRAIN ING PORT US R USED W /POS No Authorization Required ARWA ARWAY PRSS DEVC R A7047 ORAL INTF USED RESP SUCTION PUMP EA ORAL INTERFACE USED RESPIRATION No Authorization Required SUCTION PUMP EA A7048 VACUUM DRN CLCT U & TUBING SET EA VACUUM Auth Required EA VACUUM Auth 7501 TRACHEOSTOMY VALVE INCLUDING MEMBERS RE TRACHEOSTOM VALVE INCLUSIVE No Approval Required Diaphragm EA EACH A7 502 REPL Membrane/FCEPLAT TRACHEOSTOMA REPL Membrane/FCEPLATE No Approval Required VALVE TRACHEOSTOMA VALVE EATR A7503 REFLAPTR/REFLAC FLACUT Required TRACHEOSTOMA TRACHEOSTOMA EXCHG SYS EA A7504 FLTR USE TRACHEOSTOMA EXCH G SYS EA FLTR USING TRACHEOSTOMA No approval required HEAT&MOISTR EXCHG SYS EA A7505 HUS RECYCLE NO LIBE EXCHG SYS HOUSING REUSE NO LIP CHANGE No approval required SYS & 0 6 6 6 0 0 W/TRACHVALVE ADHESIVE DISC EXCHG SYS &/ No approval required W/TRACHEOSTOMY VALVE EA A7507 FLTR HLDR&INTGR FLTR TRACHEOSTOMA FLTR HLDR&INTGR FLTR U/ O ADHESIVE No authorization required TRACHEOSTOMA EXCHG A7508 HOUS&INTCHVAL SHOUS/EXCHVAL SHOUS/ No authorization required EXCHG SYS &/ VALV A7509 FLTR HLDR&INTGR FLTR HOUS&ADHES FLTR HLDR&INTGR FLTR HOUS&ADHES No authorization required TRACHEOSTOMA A752 0 TRACHEOST/LARYNGEKT TUBE NON- TRACHEOST/LARYNGEKT TUBE NON- No authorization required TRACHEOSTOMA A7520 TRACHEOST/LARYNGEKT TUBE NO- No authorization required CUFF VINYCUFFED 15 PVC TRACHEOST/LARYNGEKT TUBE MANCHENT No authorization required PVC SILICON/= EA

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A7522 TRACHEOST/LARYNGECT TUBE STNLESS ST TRACHEOST/LARYNGECT TUBE STNLESS No approval required STEEL/STRAIGHT EA A7523 TRACHEOSTOMY SHOWER SETS TRACHEOSTOMY SHOWER PROTECTION No approval required EACH A7524 STREET PROTECTION FOR EACH A7524 STUD. OUT/BUTTON No approval required EACH A7525 TRACHEOSTOMY MASK EACH TRACHEOSTOMY MASK EACH No approval required A7526 TRACHEOSTOMY TUBE HALF/HOLDER TRACHEOSTOMY TUBE HALF/HOLDER No approval required EA EACH A7527 TRACHEOST/LRYNGCT TUBE STOP/STOP LAUT. STOP EVERY A8000 PROTECTIVE SOFT PREFAB HELMET PROTECTIVE SOFT PREFAB No approval required COMPONENT ACCESSORIES A8001 PROTECTIVE HARD PREFAB HELMET PROTECTIVE HARD PREFAB No approval required COMPONENT ACCESSORIES. HOME PROTECTIVE HARD CUSTOM FAB HELMET PROTECTIVE HARD CUSTOM No. Authorization Required FAB COMP ACCSSRIES A8004 HELMET REPLACEMENT SOFT INTERFACE ONLY HELMET SOFT INTERFACE REPLACEMENT ONLY No Authorization Required A9150 NON-RESPECIFIED MEDICATION NON-RESPECIFIED MEDICATION No Authorization Required A9155 Authent 30 SLIVA 3 9284 SPIROMETER NO ELE CTRONIC INCLUDED SPIROMETER NO ELECTRONIC LOW INCLUDED YESTERDAY ALL No. Auth Required ACCESS ACCESSORIES A9285 INVERSION/EVERSION CORRECTION DEVC INVERSION/EVERSION CORRECTION No authorization required UNIT A9500 TC-99M SESTAMIBI DX PER STUDY DOSE TECHNETIUM TC-99M SESTAMIBI DX 1 NAME DX PER. TECHNETIUM TC -99M TEBOROXIME DX DOSING TRIAL No PR approval required. STUDIDOSIS A9502 TC-99M TETROFOSMIN DX - STUDIDOSIS TECHNETIUM TC-99M TETROFOSMIN No approval required DX PR. DOSAGE STUDY A9503 TC-9XCIM DRUG TEC-99M MTC-99M MED. ATE DX No Approval Required UP TO 30 MCI A9504 TC-99M APCITIDE DX UP TO 20 MCI TECHNETIUM TC-99M APCITIDE DX UP No Approval Required UP TO 20 MCI A9505 TL-201 PRECIPITATE CHLORIDE DX PR. A9507 IN -111 CAPROMB PENDETD DX UP TO 10 MCI INDIA IN-111 CAPROMAB PENDETID No Authorization Required DX UP TO 10 MCI A9508 I-131 IOBENGUAN SULFATE DX 0.5 MCI IODINE I-131 IOBENGUANE Auth. I-131 IOBENGUANE Auth. 123 SODIUM IODIDE DX MCI IODINE I-123 SODIUM IODIDE DX PER No authorization required MILLICURIE A9510 TC-99M DISOFENIN DX UP TO 15 MCI TECHNETIUM TC-99M DISOFENIN DX ABOVE No authorization required UP TO 15 MCI TECHNETIUM A95 TC-99M PERTCHNETATE No authorization required DX PER MILLICURIE A9513 LUTETIUM LU 177 DOTATATE THER 1 MCI LUTETIUM LU 177 DOTATATE No approval required THERAPEUTIC 1 MCI A9515 KOLIN C-11 DX STUDY MCI LUTETIUM LU 177 DOTATY Not required for 20 MCI A9516 I-123 SODIUM IODIDE DX TO 999 UCI IODINE I -123 SODIUM IODIDE DX PER No authorization required 99M TILMANOCEPT DX UP TO 0.5 MCI TECHNETIUM TC-99M TILMANOCEPT DX No authorization required UP TO 0.5 MCI A9521 TC-99M EXETAZIME DX UP TO 25 MCI TECHNETIUM TC-99M EXETAZIME 2 TD S ERUM ALB DX 5 UCI IODINE I-131 IODINATD SERUM No approval required ALBUMIN DX PER 5 UCI A9526 NITRO N-13 AMMONIA DX UP TO 40 MCI NITROGEN N-13 AMMONIA DX STDY No approval required. MCI IODINE I-125 SODIUM IODIDE SALT TX No Approval Required PER MCI A9528 I-131 SODIUM IODIDE CAPS DX PR. MCI IODINE I-131 SODIUM IODIDE CAPSULES No approval required 131 SODIUM IODIDE No approval required SOLIDINA I-131 SODIU A9530 I-131 SODIUM IODIDE SALT TX PO MCI IODINE I-131 SODIUM IODIDE SOLUTION No approval required TX PO MCI A9531 I-131 SODIUM IODIDE IODIDE I-131 SODIUM IODIDE I-131 IODIDE DX TO 100 No approval required MICROCURIE A9532 I-125 SERUM ALB DX PR. 5 MICROCURIES IODINE I-125 SERUM ALBUMIN DX PER. No Approval Required UP TO 35 MCI A9537 TC-99M MEBROFENIN DX UP TO 15 MCI TECHNETIUM TC-99M MEBROFENIN DX No Approval Required UP TO 15 MCI A9538 TC-99M PYROPHOSHATE DX UP TO 25 MCI TECHOSHATE 9 Obtained Not UP TO 25 MCI A9 539 TC- 99M PENTETATE DX UP TO 25 MCI TECHNETIUM TC-99M PENTETATE DX No approval required UP TO 25 MCI A9540 TC-99M MAA DX UP TO 10 MCI TECHNETIUM TC-99M MAA DX REQUIRED 5 -99M SULFUR COLL DX UP TO 20 MCI TECHNETIUM TC - 99M MAA DX REQUIRED SULFUR COLLOID No authorization required DX TO 20 MCI A9542 IN-111 IBRITUMAB TIUXTN DX TO 5 MCI INDIA IN-111 IBRITUMANX D-5 Auth. 90 IBRITUMOMB TIUXTN TX TO 40 MCI YTTRIUM Y-90 IBRITUMOMAB No approval required TIUXETAN TX TO 40 MCI A9546 CO-57/58 CYANOCOBALAMIN DX TO 1 UCI COBALT CO-57/58 DYX CYANOCOBALAMIN AUT. 11 OXYQUINOLINE DX 0.5 MILLICURE INDIUM IN-111 OXYQUINOLINE DX PR. No Approval Required 0.5 MILLICURIE A9548 INDIUM IN-111 PENTETATE DX 0.5 MCI INDIUM IN-111 PENTETATE DX PR. 25 MCI TECHNETIUM TC-99M SODIUM No Approval Required GLUCEPTATE DX UP TO 25 MCI A9551 TC-99M SUCCIMER DX UP TO 10 MCI TECHNETIUM TC-99M SUCCIMER DX ABOVE No Approval Required UP TO 10 MCI

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A9552 FDG F-18 FDG DX UP TO 45 MCI FLUORODEOXYGLUCOSE F-18 FDG DX No approval required UP TO 45 MCI A9553 CR-51 SODIUM CHROMATE DX UP TO 250 UCI CHROMIUM CR-51 SODIUM CHROMIUM CR-51 SODIUM REQUIREMENT UP TO 250 UCI CHROMIUM I - 125 SODIUM IOTALAMATE DX UP TO 10 UCI IODINE I-125 SODIUM IOTALAMATE No approval required DX UP TO 10 UCI A9555 RUBIDIUM RB-82 DX UP TO 60 MCI RUBIDIUM RB-82 DX BY TEST 5 AUT 5 A 6 TO GA -67 CITRATE DX PR . MCI GALLIUM GA-67 CITRATE DIAGNOSTICK No approval required PER MILLICURIE A9557 TC-99M BICISATE DX UP TO 25 MCI TECHNETIUM TC-99M BICISATE DX UP No approval required UP TO 35 MCION G95AS G3-50X15X3 0 MCI XENON XE-133 GAS DIAGNOSTIC PER 10 None required approval MILLICURIES A9559 CO-57 CYANOCOBALAMIN ORAL DX UP TO 1 UCI COBALT CO-57 CYANOCOBALAMIN No approval required ORAL DX UP TO 1 UCI A9560 UP TO 1 UCI A9560 3 MTC A9560 UM TC- 99M LABELED RBC DX No approval required UP TO 30 MCI A 9561 TC- 99M OXIDRONATE DX UP TO 30 MCI TECHNETIUM TC-99M OXIDRONATE DX No approval required UP TO 30 MCI A9562 TC-99M 99M TECHNETIUM 99M 99M MERTIATIDE DX No approval required UP TO 15 MCI A9563 SODIUM PHOSHAT P-32 TX PR. MCI SODIUM PHOSPHATE P-32 No approval required THERAPEUTIC ON MILLICOUR A9564 CHROMIUM PHOSPHATE P-32 SUSP TX MCI CHROMIUM PHOSPHATE A9 REQUIRED MCI CHROMIUM A9 PHOSHATE 5 6 TC -99M FANOLESOMAB DX TO 25 MCI TECHNETIUM TC-99M FANOLESOM AB No approval required DX UP UP TO 25 MCI A9567 TC-99M PENTETATE DX AROSL UP TO 75 MCI TECHNETIUM TC-99M Auth M ARCITUMOMAB DX UP TO 45 MCI TECHTM TC-99M ARCITUMOMAB DX No authorization required STDY DOSE UP TO 45 MCI A9569 TC-99M EXAMETAZIME AUTOLG WBC DX TECHNETIUM TC-99M EXAMETAZIME No approval required AUTOSE WBC D5100 INLG WBC D5100 INLG WBC D510 1 UM IN-111 AUTOLOG WBC DX No approval required PR. STUDY DOSAGE A9571 INDIUM IN-111 AUTOLG DRUM BROMDETTER DX INDIUM IN-111 AUTOLOG No approval required DRUM LEAFERS DX STUDY DOSAGE A9572 IN-111 PENTETREOTIDE INDIUM DX FOR 6 MCIET DX1 REquit DX1 M1 SE FOR 6 MCI A9575 INJ GADOTERAT MEGL UMINE 0.1 ML INJECTION GADOTERAT MEGLUMINE No approval required 0.1 ML A9576 INJECTION GADOTERIDOL PR. ENATE DIMEGLUMINE No approval required MULTIHANCE PER ML A9578 INJ GADOBENATE DIMEGLUMINE MXPACK INJ GADOBENATE DIMEGLUMINE No approval required ML MXHANCE MXPACK PER ML A9579 INJ GADOLINIUM MR CONTRAST NOS ML GADOLINIUM BASED INJECTION MR No approval required CONTRAST NOS ML A9580 NAF F-18 DOX STUDY SOX STUDY F8 No approval required DOSE FOR 30 MCI A9581 INJ GADOXETATE DINODIUM 1 ML INJECTION GADOXETATE DINODIUM 1 ML No approval required ML A9582 I-123 IOBENGUANE DX DOSE FOR 15 MCI IODINE I-123 IOBENGUANE Authen DX STUDY I N 8 OSVESETATE TRINADIUM 1 ML INJECTION GADOPHOSVESET TRISODIUM No Authorization Required 1 ML A9584 IODINE I-123 IOFLUPAN DX UP 5 MCI IODINE I-123 IOFLUPANE DX-STUDY No Authorization Required DOSE UP 5 MCI A9585 INJECTION GADOBUTROL 0.1 ML TRIAL NO Auth. TAPR F18 DX-STDY DS FOR 10 MCI FLORBETAPIR F18 DX PR. DOSE TEST No approval required UP TO 10 MCI A9587 GALLIUM GA-68 DOTATATE DX 0.1 MCI GALLIUM GA-68 DOTATATE No approval required DIAGNOSTIC 0.1 CLOVIC8 F195 MILLICURIE F195 MILLIC FLU LUCICLOVINE F-18 DIAGNOSIS 1 No approval required MILLICURIE A95 89 DROP HAL HCI 100 MG INSTALLATION HEXAMINOLEVULINATE No Approval Required HCI 100 MG A9590 IODINE I-131 IOBENGUANE 1 MCI IODINE I-131 IOBENGUANE Authority Required 1 NOC POSITRON EMISSION TOMOGRAPHY RP No Approval Required DX TUMOR ID NOC A9598 PET RADIOPHARM DX NENTUMOR ID POS ITRON EMISSION TOMOGRAPHY RP DX NON - No Approval Required NOC TUMOR ID NOC A9600 STRONTIUM SR-89 CHLORIDE TX PO MCI STRONTIUM SR-89 CHLORIDE SR-89 CHLORIDE NOC A9600 STRONTIUM SR-89 CHLORIDE TX PO MCI STRONTIUM SR-89 CHLORIDE SR-89 CHLORIDE NO 4 L A A59 L 3 EXIDRONAM TX FOR 150 MCI SAMARIUM SM-153 LEXIDRONAM TX No approval required DOSE FOR 150 MCI A9606 RADIUM RA-223 DICHLORIDE TX per RADIOACTV CONTRST IMAG No approval required NOC MATERIAL NOC PER STDY A9699 RADIOPHARMACEUTICAL THERAPY NOC approval required NOC A9700 SUP OF INJ CONTRST MAT-ECHO P/STUDY SUP OF INJ PUP/STUDY SUP OF INJ PUP/ MAT- ECHO LAKE D9 SRV COMPONENT /OTH DME SUP/ADGANG/SRV-COMPON/OTH No HCPCS approval required HCPCS A9901 DME DEL SET&/DSPNS SRVC ANOTH DME DEL SET UP&/DISPNS SRVC CMPNT No approval required Approval required Complete clinical examination NO. ACCESSORIES NO. B4034 ENTERAL FEED SPL KIT; ACCESSORIES FOR ENTERAL FOOD SYRYNE DAY; SYRINGE Required DME approval Full clinical examination FEED PER DAY B4035 ENTERAL FEED SPL KIT; PUMP FED-DAY SET FOR ENTERAL FOOD; PUMP No approval required FED PER DAY B4036 ENTERAL FD SPL KIT; KIT FOR ENTERAL FOOD FOR A DAY BY GRAVITY; GRAVITY DME approval required Full clinical examination DARE ON DAY B4081 NASOGASTRIC TUBES WITH STYLE NOSOGASTRIC TUBES WITH STYLE No approval required B4082 NOSOGASTRIC TUBES WITHOUT STYLE NOSAGASTRIC TUBES WITHOUT STYLES NASOGASTRIC TUBES AQUITH08 BEVOLTY WITHOUT NEJ08 PE GASTRONIC - LEVINE TYPE No approval required B40 87 GASTROSTOMA /J - TUBE STANDARD EACH GASTROSTOMY/J-TUBE STANDARD EACH No approval required MATERIAL/TYPE EA

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B4088 GASTROSTOMY/J-TUBE LOW PROFILE EA GASTROSTOMY/J-TUBE LOW-PROFILE No Approval Required ANY MAT/TYPE EACH B4102 ENTRAL F ADLT REPL FL&LYTES 500 ML ENTRAL FORMULA ADLT REPLY PERFORMANCE Full CMLTE Authorization 1 0 Authorization D5 B4103 Entral F Ped. Repl fl & lytes 500ml Entral Formula PED Repl fls & lytes Authorization Required DME Full Clinical Review 500ml = 1 U B4104 Enteral Formula Additive Enteral Formula Additive No Author CTG DIG ENZYME ENTERAL Authorization Required Home Health Services Full Clinical Review FEEDING EA B4149 ENTRAL F MANF BLNDRIZD NAT FOODS ENTRAL F MANF BLNDRIZD NAT FOODS Authorization Required DME Full Clinical Review W/NUTRIENTS B4150 COMPOSITION ENTRAL SUBMISSION NUTRIENT SUGGESTIONS DME Required Full Clinical Review W/INTACT NUTRIENTS B4152 ENTRAL F NUTRITIONS CMPL CAL DENSE ENT RAL F NUTRITION CMPL CAL DENSE DME Approval Required Full Clinical Review INTACT NUTRNTS B4153 ENTRL F NUTRTN CMPL HYDROLYZD PROTS FORMULATION REQUIRED Full Review HYDROLYZD PROTS FORMULATION REQUIRED. ZED PROTS B4154 ENTRAL F CMPL NR ARVET DZ METAB ENTRAL F NUTRITION CMPL NO Approval required DME Full Clinical Review ARVET DZ METAB B4155 ENTRAL F NUTRITN INCMPL/MOD ENTRAL F NUTRITION Approval Required DME Full Clinical Review NUTRNTS INCMPL/MODULAR ENTRA F4 NUTRIEND ENTRA EN TRA 15 L F NUTRITION CMPL LEGACY Approval Required DME Full Clinical Review DZ METAB B4158 ENTRAL F PED NUTRITN CMPL SOY BASD SOY ENTRAL F PED NUTRITN Full Review DME F PED NUTRITN Required DME Full Clinical Review W/INTACT NUTRNTS B4159 INTCT NUTRNTS B4160 ENTRAL F PED NUTRITN CMPL KAL DENSE ENTRAL F PED NUTRITION CMPL CAL Authorization Required DME Full Clinical Review DENSE NUTRNTS B4161 ENTRAL F PED HYDROLYZED/AA PROTEINI ENTRAL F PED CHAIN Full Review PED CHAADDY CROPTIDE PROTAIN. B4162 ENTRAL F PED ARVET DZ METAB ENTRAL F PED SPCL METAB REQUIRES DME Authorization Complete Clinical Review ARVET DZ METAB B4164 PARNTRAL NUT SOL; CARBOHYDRATES 50%/< HOM PARENTRAL NUTRITION SUN; Approval Required CARBS DME Full Clinical Review 50%/LESS - HOM MIX B4168 PARNTRAL NUT SALT; AMINO ACID 3.5% PARENTRAL NUTRITION SALT; Approval required for AMINO DME Full clinical review ACID 3.5% -HOM MIX B4172 PARNTRAL NUT SOL; AMINO ACIDS 5.5-7% PARENTRAL NUTS; AMINO ACIDS 5.5 DME Approval Required Full Clinical Review THROUGH 7%-HOM MIX B4176 PARNTRAL NUT SALT; AMINO ACIDS 7-8.5% PARENTRAL NUTS; AMINO ACID 7 DME Approval Required Full Clinical Review THROUGH 8.5%-HOM MIX B4178 PARNTRAL NUT SALT; AMINO ACIDS > 8.5% PARENTAL NUTRITIONAL SALT; AMINO ACIDS > DME Approval Required Full Clinical Review 85% - HOM MIX B4180 PARENTRAL NUT SALT; CARBOHYDRATES > 50% HOM PARENTRAL NUTRITION SUN; Carbohydrates > Approval required DME Full clinical review 50% - HOME MIX B4185 PARENTERAL NUTRITION SOL NOS 10 G LIPIDS PARENTERAL NUTRITION SOL NOS 10 Approval required DME Full clinical review GRAMS LIPIDS B4187 OMEGAVEN 10 GLIME G LIPIDS Author's review B4189 PARENTERAL NUT;AMINE O ACIDS CARBOHYDRATES 10 - PARENTRAL NUT SALT; Approval Required for AMINO DME Full Clinical Review 51GM ACID&CARB 10-51 GMS PROT B4193 PARNTRAL NUT; AMINOACID&CARB 52- PARENTRAL NUT SALT; Approval Required for AMINO DME Full Clinical Review 73GM ACID&CARB 52-73 GMS PROT B4197 PARNTRL NUT;AMINOACID&CARB 74- PARNTRAL NUT SOL; Approval Required for AMINO DME Full Clinical Review 100GM ACID&CARB 74-100 GM PROT B4199 PARENTRAL NUT;AMINO ACID&CARB PARENTRAL NUT SOL; Approval required for AMINO DME Full clinical review >100 GM ACIDS AND CARBOHYDRATES > 100 GMS PPAR B4216 PARNTRAL NUT; SUPPLEMENTS-HOM MIX-DAILY PARENTRAL NUTRITION; ADDITIVES - required DME approval Full clinical review HOME MIX PER DAY B4220 PARENTRAL NUTRIT SPL KIT; PREMIX-DAY KIT FOR PARENTERAL FOOD; Approval not required MOVE BY DAY B4222 PARNTRAL NUT SPL KIT; HOM MIX-DAY PARENTRAL NUTRITION KIT DELIVERY; No HOME MIX PR approval required. DAY B4224 PARENTERAL NUTRITION ADMIN KIT-DAY PARENTERAL NUTRITION Required DME Approval Complete Clinical Examination ADMIN KIT PR. DAN B5000 PARENTRAL FOOD; AMINO ACIDS AND CARBOHYDRATES PARNTRAL NUT SALT; AMINO DME Approval Required Full Clinical Review RENL ACID&CARBS RENL-AMIROSYN B5100 PARENTERL NUT SALT AMINO ACID & CARRB PARENTERAL NUT SALT AMINO ACID Approval Required DME Full Clinical Review AND CARBOHYDRATES B5200 SALT HYDRATE ACRN & A CAMINO PARNTRL ACCERNUT SALT B Application for Approval Issued by DME Full Clinical review STRSS -BR CHAIN B9002 ENTERAL INFUSION PUMP FOR NUTRITION ANY TYPE OF ENTERAL INFUSION PUMP FOR NUTRITION No approval required ANY TYPE B9004 PARENTAL INFUSION PUMP FOR NUTRITION PRTBLE PARENTAL INFUSION FOR NUTRITION 9 Auth. PUMP STATION PARENTERAL NUTRIENT INFUSION No approval required PUMP STATIONARY B9998 NOC FOR ENTERAL CONSUMABLES NOC FOR ENTERAL CONSUMABLES No approval required B9999 NOC FOR PARENTERAL CONSUMABLES NOC FOR PARENTERAL CONSUMABLES Approval required DME Full Clinical Review C1713 ANCHR/SCREW OPPOS BN -BN/SFTPOST- TISS - BNTO ANCHORING - BSCREW A Required BN/SOFT TISSUE-TO-BN C1714 CATH TRNSLUM ATHERECT DIRECTION CATHETER TRANSLUMINAL No approval required ATHERECTOMY DIRECTION C1715 BRACHYTHERAPY NEEDLE BRACHYTHERAPY NEEDLE No approval required C1716 BRACHYTHERAPY NEEDLE C1716 BRACHYTHERAPY UNSTRANDED GOLD - No approval required SRC 1 98 PR. SOURCE C1717 BRACHYTX NONSTRAND HD IRIDIUM-192 BRACHYTX NON-STRANDED HIGH DOSAGE No approval required IRIDIUM-192 PO SRC C1719 BRACHYTX NONSTRND NONHD IRIDIUM- BRACHYTX NON-STRANDED NON-HD No approval required 192 IRIDIUM-192 PO S RC 192 FOR 2 CARS CAR 192 CAR 192 CAR 192 -DEFIBRILLATOR DOUBLE No approval required CHAMBER C1722 CARDIOVERT-DEFIB SINGLE CHAMBER CARDIOVERTER-DEFIBRILLATOR SINGLE No approval required CHAMBER C1724 CATH TRNSLUM ATHERECT ROTARY CATHETER TRANSLUMINAL No approval required ATERECTOMY ROTARY C1725 NUMBER CATHETER TRANSLUMINAL ATERECTOMY ROTARY C1725 725 NO. required LASER ANGIOPLASTY NO LASER C1726 CATHETER BALLON DILAT NO CATHETER BALLOON DILATION NO- No approval required VASCULAR VASCULAR C1727 CATH BALLN TISS DISCTOR NON-VASCATETER BALLOON TISSUE DISCTOR No approval required NON-VASCULAR C1728 CAT. HETER BRACHYTHERAPY SEED ADMIN CATHETER REQUIRED ADMINISTRATION THERE

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C1729 CATHETER DRAINAGE CATHETER DRAINAGE No authorization required C1730 CATH EP DX EXCEPT 3D CARD 19/< CATH ELECTROPHYSIOLOGY DX OTH No authorization required EXCEPT 3D CARD 19/< C1731 CATH EP 2D 3D 3D 3D DX DX/O LOG> X OTH No authorization required NEGO 3D MAP 20/> C1732 CATH EP DX/ABLAT 3D/VECTOR MAP CATH ELEKTROPHYSIOLOGY DX/ABLAT No Approval Required 3D/VECTOR MAP C1733 CATH EP DX/ABLAT NOT MAP/COOL-TIP/CATH EP DX Approval Required MAP NOT COOL - TIP C1734 ORTHO/DEVC/DX MX OPP BTB/SFT T-TO B ORTHOPEDIC/DEVC/DX MATRIX OPP No approval required BTB/SFT TISS-TO BN C1749 ENDO RETRO IMAG/ILLUM COLONOSCOIMEND LIGHTING No approval required COLONOSCOPY UNIT C1750 CATH HEMODIAL /PERITON LONG TERM CATHETER HEMODIAL/PERITONEAL No approval required LONG TERM C1751 CATH INFUS INSRT PERIFH CNTRL/MIDLN CATHETERS PERIPHERAL INFUS INSTR. CATHETER HEMODIALYSIS SHORT-TERM CATHETER HEMODIALYSIS SHORT-TERM No approval required C1753 CATHETER INTRAVASCULAR ULTRASOUND CATHETER INTRAVASCULAR No approval required ULTRASOUND C1754 CATHETER INTRADISCAL CATHETER INTRADISCAL No approval required C1755 CATHETER INTRASPINAL C1755 CATHETER INTRASPINAL C17 ING TRANSESOPHAGEAL CATHETER PACING TRANSESOF AGEAL Not required approval C1757 CATHETER CATHETERS No approval required THROMBECTOMY/ EMBOLECTOMY THROMBECTOMY / EMBOLECTOMY C1758 CATHETER URETERAL CATHETER URETERAL No authorization required C1759 CATHETER INTRACARDIAC CATHETER INTRACARDIAC No authorization required ECHOCARDIGRAPHY ECHOCARDIGRAPHY ECHOCARDIGRAPHY A V None Required C1760 C1760 CATHETER Required C1762 CONNECTIVE TISSUE HUMAN CONNECTIVE TISSUE HUMAN No approval required C1763 CONNECTIVE TISSUE HUMAN CONNECTIVE TISSUE NO -HUMAN CONNECTIVE TISSUE NON-HUMAN No authorization required C1764 EVENT RECORDER CARDIAC EVENT RECORDER CARDIAC No authorization required C1765 ADHESION BARRIER ADHESION BARRIER No authorization required C1766 INTRDUCR/COVER EP NON-SEPARATED INTRDUCRAD A-7 Required 67 GENERATOR NEUROSTIM GENERATOR NEUROSTIMULATOR No authorization required NON -RECHARGEABLE NON-RECHARGEABLE C1 768 GRAFT VASCULAR GRAFT VASCULAR No approval required C1769 GUIDE WIRE GUIDE WIRE No approval required C1770 MAGNETIC RESONANCE IMAGING COIL M7 Authentic Required M1769 VICE URINE INCONT W/SLING GFT URINARY INCONTINENCE RE PAIR DEVICE No approval required W/SLING GRAFT C1772 INFUSION PUMP PROGRAMMABLE INFUSION PUMP PROGRAMMABLE No Approval Required C1773 PICKUP HAT INSERTABLE PULL-OUT UNIT INSERTABLE No Approval Required C1776 ARTICULATED DEVICE ARTICULATED DEVICE Complete View C7DFL Rev. ENDOCARD 1 WIRE DRAIN CARDIOVERT-DEFIB ENDOCARDIAC No authorization required SINGLE WIRE C1778 NEUROSTIMULATOR LEAD NEUROSTIMULATOR No authorization required C1779 LEAD PACEMKR TRNS VDD SINGLE CIRCLE DRAIN PACEMAKER TRANSVENOUS VDD No authorization required SINGLE PASS C1780 LENS INTRA OCULAR C1780 INTRAOCULAR LENS C1 Auth No pk fox Required C1782 MORCELLATOR MORCELLATOR No authorization required C1783 OCULAR IMPLANT AQUEOUS DRAINAGE ASST DEVC Ocular IMPLANT AQUEOUS DRAINAGE No authorization required ASSISTIVE DEVICE C1784 OCULR DEVC INTRAOP TEMPTED RETINA OCULAR DEVICE INTRAOPERATIVE No authorization required FREE RETINA C178 5 PACEMKER DOUBLE CHAM- Auth PONSIVE RESIVE C1784 6 PACEMKR 1 CHAMBER RATE- RESPONSIVE SINGLE CHAMBER PACEMAKER RATE- No approval required RESPONSIVE C1787 PATIENT PROGRAMS PATIENT PROGPATIENT PROGRAMS No approval required NEUROSTIMULATOR NEUROSTIMULATOR C1788 PORT INDWELLING PORT INDWELLING No approval required PROTHASTISTISHES Author C17STHISES Author review C1813 PROSTHESIS PENILATE EDIBLE PENILATE PROSTHESIS EDIBLE No approval required C1 814 MESH TAMPON NICU SILKON OIL RETINAL TAMPON SILICON No approval required OIL C1815 PROSTHESIS URINARY PLUG PROSTHESIS URINARY PUMP No approval required C1816 RECV &OR TRANSMITTER NEUROSTIM ELIMINATE SUBMISSION1816 RECV &OR TRANSMITTER NEUROSTIM AUTTAGERE1 SEPTAL DEFEC IMPL SYSTEM INTRA CARD SEPTAL DEFEC IMPLANT SYSTEM No approval required INTRACARDIAC C1818 INTEGRATED KERATO DENTURES ARE NOT ACCEPTED KERATOPROSTHESIS No approval required C1819 SURG TISSUE LOC & EXC SURGICAL TISSUE LOCATOR AND No approval required CUTTING DEVICE C1820 WRG GEN NEUROSTIM REG. SYS & CHARGE SYSTEM required C1821 INTERSPINOUS PRC DISTRACT DEVC IMPL INTERSPINOUS PROCESS DISTRACT authorization required Spinal care combined with a full clinical DEVICE IMPL neck and back condition including: C1822 GEN NEUROSTIM HI FREQ RECHARG BATT GEN NEUROSTIM HIGH FREQ RECHARG No authorization required BATT & CH ARG SYS C1823 SYS C1823 GEN NRECMOSTEUROGNER TV No Authorization Required LD RECHRGABL TV S&STIM LEADS C1824 GENERATOR CARDIAC CONTRACILITY GENERATOR CARDIAC CONTRACTILITY No Authorization Required MODULATION C1830 BONE MARROW BIOPSY NEEDLE REQUIRED RESTH CBIOPSY No 3 ATH PRORISTH I8NED ESIS No Auth Required C184 0 INTRAO CULAR LENS TELESCOPIC INTRAOCULAR TELESCOPIC LENSES No. Auth Required C1841 RETINAL PROSTH INCL INTRL&EXT CMPNT RETINAL PROSTH INCL ALL INTRL & No Auth Required EXTERNL CMPNT C1874 STENT COATED/COVR W/ DELIVERY STENT COATED/COVERED WITH No Authorization Required SYSTEM CODELIVED/5 ENT COATED /COVERED WITHOUT Authorization Required DELIVERY SYSTEM C1876 STNT NON-COATED/NON-COVR DELIV SYS STENT NON-COATED/NON-COVERED No approval required W/ DELIVERY SYSTEM C1877 STNT NON-COAT/NON-COVR W/O DEL SYS -COATED/NON-COVR No approval required WITHOUT DELIV SYSTEM

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C1878 MATL VOCAL ELEAD SYNTH VOCAL LEAD MATERIAL No Authorization Required MEDIATION SYNTHETIC C1880 VENA CAVA FILTER VENA CAVA FILTER No Authorization Required C1881 DIALYSIS ACCESS SYSTEM DIALYSIS ACCESS SYSTEM/DI C1OV821 CAR 1 Auth CAR Required DIOVERT-DEFIB OTHER THAN No Authorization Required CHAMB SINGLE/DUAL CHAMB C188 3 ADAPTER /EXT PACE LEAD/NEUROSTIM ADAPTER/EXT PACING No approval required LEAD LEAD/NEUROSTIMULATOR LEAD C1884 EMBOLIZATION PROTECTION SYSTEM EMBOLIZATION PROTECTION SYSTEM EMBOLIZATION PROTECTION SYSTEM CSL1 LASER CATHETER TRANSLUMINAL No approval required ANG IOPLASTY LASER C1886 CATH EXTRAVASCULAR TISSUE ABLAT MODAL CATH EXTRA VASCULAR TISSUE ABLAT No approval required MODAL INSERTED C1887 CATHETER GUIDANCE CATHETER GUIDANCE No approval required C1888 CATHETER ABLATION NON-HARDIAN ENDOVASC ENDOVASC CATHETER- Obtained. DEVICE FOR INSTALLATION/INSERT NO. Auth Required OTRW CLASS C1890 NO IMPL/INSRT DEVC IN DEVC-INT PROC NO IMPLANT/INSERTABLE DEVC USED No Auth Required W/DEVC-INT PROC C1891 INFUS PUMP NON-PROGRAMMABLE INFUSION PUMP NON-PROGRAMMING DESCRIPTION NO. Auth. EP CURVE PEELING INTRDUCR/SHETH INTRCARD EP FIX- No Approval Required CURVE PEEL-AWAY C1893 INTRDUCR/SHETH EP CURVE NOT PEEL INTRDUCR/SHETH INRCARD EP No Approval Required CURVE NOT PEL-AWAY NOTDUCRGUSHON INLA-N /SHEATH NOT GUID No Approval INTRACARD EP NON-LASR C1895 LEAD CARDIOVRT-DFIB ENDOCARD DUL LEAD CARDIOVERT-DEFIB ENDOCARDIAL No approval required DUAL COIL C1896 LEAD CARDIOVRT-DFIB ENDOCARD NOT Aquid CARDIOVRT-DFIBAD ENDOCARD NO Aquid DUL COIL C1897 LEAD NEUROSTIMU LATOR TEST KIT LEAD NEUROSTIMULATOR TEST KIT No approval required C189 8 LEAD PACEMKR NOT TRNS VDD 1 PASS LEAD PACEMKR OTHERS ENTER TRNS VDD NO ADDITION Required Simple pass C1899 LEAD PACEDEMKR/CARDI COMBADEMKR/CARDICO UTH Combination required C1900 Lead Lt Ventricular Coron Venus Sys Lead Left Ventricular Coronar No Acceptance /W-VAL VE INTRMIT OCCL CATHETER PRESSURE GENERATED ONE WAY VALVE No approval required INTERMIT GUOCCL C25TCAGE PROC. GUIDED ROBOTICS No approval required WATER JET ABLATION C2613 LUNG BIOPSY PROBE WITH INSTALLATION SYSTEM LUNG BIOPSY PROBE WITH DELIVERY No approval required SYSTEM C2614 PERCUT LUMBAR DISCECTOMA PROBE PERCUTAN LUMBAR PROBE No approval required C2614 SOMDE PERCUTA LUMBAR DIS CECTOMY PROBE PERCUTA LUMBAR No approval C261 ANT LUNG FLUID No Authorization Required C2616 BRACHYTX NON-STRAND YTTRIUM-90 SRC BRACHYTHERAPY NON-STRANDED No Authorization Required YTTRIUM-90 PR. SOURCE C2617 STENT NON-COR TEMP U/O DELIV SYSTEM STENT NON-COR TEMPORARY NO Approval Required DELIVERY SYSTEM C2618 PROBE/NEEDLE CRYOBLATION PROBE/NEEDLES CRYOBLATION NERVE C2618 NEEDLE CRYOBLATION NEEDLE D-9 MAKER DUAL CHAMBER NOT RATE- Approval Not Required RESPONDS C2620 PACEMKR 1 CHAMBER NOT RATE- PACEMAKER SINGLE CHAMBER NO Authorization Required RESPONDS RATE RESPONDS C2621 PACEMKR EXCEPT CHAMBER WITH SINGLE/DUAL PACEMAKER OTHER CHAMBER/DUAL PACEMAKER Auth 22 PROSTHESIS PENILATE INFLATABLE FOAM PROSTHESIS LATE NON-INFLATE No Authorization Required C2623 CAT ETER TA MEDICAL BELT NON-LASER CATHETER TRNSLUM ANGPLASTY DRUG- No approval required COATED NON-LASER C2624 IMPL WL WL PULM SRART NO. Approval required SENSOR DEL CATH C2625 STENT NON-COR TEMP W/ DELIV SYSTEM STENT NON-CORONARY TEMPORARY No approval required W/ DELIVERY SYSTEM C2626 INFUS PUMP NON-PROGRAMMABLE INFUSION PUMP NON-PROGRAMABLE No approval required TEMPORARY C2/27 SUPPORIC C26 26 INFUS PUMP NON-PROGRAMMABLE INFUSION PUMP NAME SE SUPRAPUBIC/CYSTOSCOPIC No approval required C2628 CATHETEROCLUSION CATHETEROCLUSION No approval required C2629 INTRDCR/SHTH NOT GUID NO IC EEG LSR INTRDUCR/SHTH OTHER THAN GUID OTHER No approval required EXCEPT IC EEG NOT LASR C2630 CATHATX EP CATHAP/ABLAD /Vector no author SRC C2635 BRACHYTX NONSTRAND PD-103 >2.2 MCI BRACHYTX NONSTRND PALLADIUM-103 No approval required >2.2 MCI PO SRC C2636 BRACHYTX LIN NONSTRAND PD-103 1 MM BRACHYTX LINEAR LINEAR PALLADIUM-103 Auth NONSTRAND 3MM Auth N ONSTRAND10 7MM BRACHYTX NONSTRAND YTTERBIUM-169 BRACHYTX NENS TRANDED YTTERBIUM- No approval required 169 PR. SOURCE C2638 BRACHYTX STRANDED IODINE-125 SOURCE BRACHYTHERAPY STRANDED IODINE- No approval required 125 PR. ODINE-125 PER SOURCE C2640 BRACHYTX STRANDED PALLADIUM-103 BRACHYTHERAPY STRANDED No approval required SRC PALLADIUM-103 PR. SOURCE C2641 BRACHYTX NONSTRND PALLADIUM-103 BRACHYTHERAPY NON-STRANDED No approval required SRC PALLADIUM-103 PO SRC C2642 SRCUM-103 PO SRC C2642 STRAND 3ND BRACHYCEPY STRACHY 1 UM- No approval required 131 PR. SOURCE C2643 BRACHYTX NON-STRANDED CESIUM- 131 BRACHYTHERAPY NON-STRANDED No approval required SRC CESIUM-131 PR. SOURCE C2644 BT SRC CAESIUM-131 CHLORINE SALT PR. MCI BRACHYTERAPY SRC CESIUM-131 No approval required CHLORIDE SOL PR. MCI C20 THERAPY PLANAR SRC No approval required PALLADIUM-103 PR. SQ ML C2698 BRACHYTX STRANDED NOSE PR. SOURCE BRACHYTHERAPY SOURCE STRANDED No approval required NOS PR. SOURCE

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C2699 BRACHYTX NO. PR. BRACHYTHERAPY SOURCE No approval required SOURCE NON-DRAINED NO. PR. 1ST 25 CM/< C5272 APPL SG T-A-L A 100 CM;EA ADD 25 CM APPL SG TRNK ARM LEG AREA 100 No CM approval required; EA ADD 25 CM C5273 APPL SG T-A- L>/=100 CM;1ST 100 CM APPL SG TRUNK ARM BEN AREA >/=100 No approval required CM;1ST 100 CM C5274 APP SG T-A-L>/0EA; CM APPL SG TRNK ARM BEN AREA>/=100 No Approval Required CM;EA ADD 100 CM C5275 APP SG F-N-HF-G 100 CM;1ST 25 CM/< APPL SG F-S-N-H-F-G-M-D A TO 100; No approval required 1ST 25 CM/< C5276 APP SG F-S-N-HF-G 100 CM;EA A 25 CM APPL SG F-S-N-H-F-G-M-D A TO 100 No approval required CM;EA ADD 25 CMHF/ SGG FN/> =100;1ST 100/1 % CH APP SG F/N/HF/G A >/=100 CM;1ST 100 No approval required CM/1% A CHLD C5278 APP SG F/N/HF/G>/=100; ADD 100/1% CH APP SG F/N/HF/G A >/=100 CM;EA ADD No authorization required 100 CM/1% CHL C8900 MR ANGIOGRAPHY WITH/CONTRAST MR ANGIOGRAPHY WITH CONTRAST Authorization required Radiology - Diagnostic full clinical examination ABDOMEN ABDOMEN Radiology C8901 MR ANGIOGRAPHY WITHOUT CONTRAST MR ANGIOGRAPHY WITHOUT Authorization Required Radiology - Diagnostics Full Clinical Review ABD CONTRAST ABDOMEN Radiology C8902 MR ANGIO U/O CONTRAST W/CONTRST Authorization MR ANGIO WITH CONTRAST REQUIRED MR ANGIO WITH CONTROL INSTRUCTIONS USED CONTR. CONTRAST ABD radiology C8903 MR IMAGING WITH/CONTRAST BREAST; UNI MR BREAST IMAGING WITH CONTRAST; Authorization required Radiology - diagnostics Full clinical examination ONE-SIDED radiology Valid Jan. 2021 Temporary Change: Network Validation Review C8905 MR NO CONTRST FLW W/CNTRST MR IMAG U/O CONTRST FLWED Authorization Required Radiology - Diagnostic Full Clinical Review BRST; BROWN/ ; UNI Radiology Applies Jan. Interim Change 2021: Network Validation Review C8906 MR IMAGING WITH BREAST CONTROL; AUTO MR IMAGING WITH BREAST CONTRAST; Authorization required Radiology - diagnostics Full clinical examination BILATERAL radiology Valid Jan. Interim change 2021: network validation review C8908 MR NO CONTRST FLW CNTRST BRST; BIL MR IMAG W/O CONTRST FLWED Authorization Required Radiology - Diagnostic Full Clinical Exam W/CONTRST BRST; BIL radiology Valid Jan. 2021 Temporary Change: Network Validation Review C8909 MR ANGIOGRAPHY WITH CONTRAST MR ANGIOGRAPHY WITH CONTRAST Authorization Required Radiology - Diagnostic Complete Clinical Examination BREAST CHEST RADIOLOGY Effective Jan. 2021 Interim Review C8 CONTRAST ANGIOGRAPHY Authorization REQUIRED. GRAPH WITHOUT Authorization Required Radiology - Diagnostic Full Clinical Review CONTRAST CHEST radiology C8911 MR ANGIO NO CONTRST FLW CNTRST MR ANGIO WITHOUT CONTRST Authorization Required Radiology - Diagnostic Full Clinical Review CHST FOLLOWED W/CONTRST CHST Radiology C8912 MRCON TRANG WITH CONTRYG LOMR Authorization required Radiology - diagnosis Complete clinical examination of the EXTREMITIES OF THE LOWER EXTREMITIES radiology C8913 MR ANGIO WITHOUT CONTRAST LOW MR ANGIOGRAPHY WITHOUT authorization Required Radiology - diagnostics Complete clinical examination of the EXTREMITIES OF THE LOWER EXTREMITIES CONTRAST radiology 8914 LOW MR ANGIOGRAPHY NO. ST FLWED Authorization Required Radiology - Diagnostic Full Clinical Exam EXTRM WITH/LOW CONTRAST EXTREME Radiology C8918 MR ANGIOGRAPHY WITH CONTRAST MR ANGIOGRAPHY WITH CONTRAST Authorization Required Radiology - Diagnostic Full Clinical Exam PELVIS PELVIS Radiology C8919 MRA ANGIOGRAPHY ANTI CONTRAST Full Radiology ANTI CONTRAST WITHOUT CONTRAST PELVIS Radiology PELVIC linear review CONTRAST Radiology PELVIC C8920 MRA WITHOUT CONTRAST IS CONTRAST W/CONTRST MRA NO CONTRAST FOLLOWED Authorization required Radiology - Diagnostic Complete Clinical Examination PELV W/PELVIC CONTRAST Radiology C8921 TTE CONG CARDIAC ANOMAL; FULL TTE W/CONTRAST OR W/O FLW No clearance required W/CONTRAST; COMPLETE C8922 TTE CONG CARDIAC ANOMALY; RESTRICTED TTE W/CONTRAST OR U/U FLW No clearance required W/CONTRAST; F/U OR LTD C8923 TTE R-T DOC 2D INCL M-MODE REC CMPL TTE FLW M/CNTRST R-T DOC 2D INCL M- No approval required MODE REC CMPL C8924 TTE R-T 2D INCL M-MODE REC FU/LTD/ TCNTRST FLW R-T 2D INCL M- No Approval Required MODE REC FU/LTD C8925 TEE REAL TIME 2D; PROBE PLCMT I&R TEE W OR U/O FLW W/CNTRST REAL Approval not required TIME 2D; ACQ I&R C8926 TEE CONG CARDIAC ANOMALOUS; PROBE I&R TEE W OR U/O FLW W/CNTRST; PROBE No approval required PLCMT ACQ I&R C8927 TEE MON ASSESSMENT HEART PUMP FUNCTION TEE ASSESSMENT CARD PUMP FUNCT&TX No approval required MSR IMMED TM BASIS C8928 TTE M-MODE REC REST & CV ST W/I&R INCL RECL MCN Approval required & CV ST W/I&R C8929 TTE CMPL SPC & COLR FLOW DPPLR ECHO TTE CMPL SPEC DOPPLER & COLOR No Authorization Required FLOW DOPPLER ECHO C8930 TTE CMPL DURING REST & CVST I&R PHYS SUP WIRR TTE /PHYS SUP C8931 MRA W/CONTRAST SPINAL CANAL MR ANGIOGRAPHY W /CONTRAST Authorization Required Radiology - Diagnostic Complete clinical examination CONTENTS SPINAL CANAL CONTENTS radiology C8932 MRA WITHOUT CONTRAST SP CANAL CONTENTS Authorization MR ANGIOGRAPHIC CONSULTATION WITHOUT Complete REQUIREMENTS Diagnostic Examination Spinal Canal Contents Radiology C8933 MRA Without Contrast SP Canal Control Hr. Angio No permission required FLW for contrast Radiology - Diagnostic full clinical exam CNT w/contrast SP channel CNTN Radiology C8934 MRA with contrast Upper extremity Mgr. Contrast Authorization Angiography Required Radiology - Diagnostic Full Clinical Full Clinical C8934 Contrast-enhanced MRA Upper Extremity Mr. Contrast Angiography Authorization Radiology - Diagnostic Full Clinical Full Clinical Full Clinical Full Clinical Review Radiology UPPER EXTREMITY C8935 MRA NO CONTRAST UPPER MR ANGIOGRAPHY NO Clearance Required Radiology - Diagnostic Full Clinical Review EXTREMITY CONTRAST UPPER EXTREMITY Radiology C8936 MRA NO CONTRAST FLW W/ CONTRAST UPPER W/ CONTRAST GORE diagnostic authorized - Full KNONTR. linical Review EXT M/CONTRST UP EXT Radiology C8937 CAD INCL CMP ALG ANALYZE BRST MRI ID CMP-AID DETN INCL CMP ALG ANALYSIS Authorization Required Radiology - Diagnostic Full Clinical Review BR MRI IMG DATA Radiology C8957 IV INFUS TX/DX; /DX; INIT PROLNG RQR No Approval Required PORT/IMPL PUMP C9035 INJECTION ARIPIPRAZOLE LAUROXIL 1 MG INJECTION ARIPIPRAZOLE LAUROXIL 1 No Approval Required MG C9036 INJECTION PATISIRAN 0.1 MG INJECTION A7 MG INJECTION A7 REQUIRED PATIRISAN. Peridone 0.5mg Injection Risperidone 0.5mg No Approval Required c9038 Injection Mogamulizumab-kpkc 1mg Injection Mogamulizumab-kpkc 1mg No Approval Required Mg C9039 Injection 5mg Injection PLAZOMININ 5mg.

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C9040 INJECTION FREMANEZUMAB-VFRM 1 MG INJECTION FREMANEZUMAB-VFRM 1 Approval Required Full Clinical Review MG C9042 INJECTION BENDAMUSTINE HCL 1 MG INJECTION BENDAMUSTINE HCL 1 MG Approval Required Full Clinical Review INJECABTION-4CEMI C9042 INJECTION BENDAMUSTINE HCL 1 MG CEMIPLIMAB-RWLC 1 MG Approval Required Full Clinical Review C9045 INJ MOXTUMOMB PASUDOTX-TDFK 0.01 INJECTION MOXETUMOMAB requires authorization Full Clinical Review MG PASUDOTOX-TDFK 0.01 MG C9046 COCAINE HCI NASAL SALT TOP ADMN 1 MG COCAINE HYDROCHLORIDE ADMINISTRATION Full Review C9046 MG C90 47 INJECTION CAPLACIZUMAB-YHDP 1 MG INJECTION CAPLACIZUMAB- YHDP 1 MG Full clinical review required C9048 DEXAMETHASONE LAC OPHTH INSR 0.1 DEXAMETHASONE LACRIMAL Full clinical review required MG OPHTHALMIC INSERT 0.1 MG C9049 INJEXOFCXTA MCGERZOFCXTA OFUSP-ERZS 10 MCG approval Full clinical review required C9 050 INJECTION EMAPALUMAB -LZSG 1 MG IN EJECTION EMAPALUMAB-LZSG 1 MG Approval Needs Full Clinical Review C9051 INJECTION OMADACYCLINE 1 MG INJECTION OMADACYCLINE 1 MG Approval Needs Full Clinical Review C9052 INJECTION OMADACYCLINE 1 MG INJECTION OMADACYCLINE 1 MG Approval Needs Full Clinical Review C9052 INJECTION OMADACYCLINE 1 MG WVZ 10 MG Approval Needs Full Clinical review C9054 INJECTION LEFAMULIN XENLETA 1 MG INJECTION LEFAMULIN XENLETA 1 MG No approval required C9055 INJECTION BREXANOLONE 1 MG INJECTION BREXANOLONE 1 MG Approval required Full clinical review C9113 INJECTION PANTOPRAZOLOPE INJECTION NO. IAL C9132 PRT CC KCENTRA PO I.U. FCT IX ACTV PROTHROMBIN CMPLX CONC KCENTRA No approval required I.U. FCT IX ACTV C9141 Inje factor VIII PEGYILIDED-AUCL 1 IU Injectable factor VIII PEGylated- Authorization requires full clinical review AUCL 1 IU C9248 Injection injection Clevidipine Butyrate 1 mg inject clevidipine 1 mg inject, alir-sirida MA FIBRIN SEALING AGENT 2ML HUMAN PLASMA FIBRIN SEAL no. Authority Required STEAM HEATED SD 2ML C9254 LACOSAMIDE INJECTION 1 MG LACOSAMIDE INJECTION 1 MG No Authority Required C9257 BEVACIZUMAB INJECTION 0.25 MG BEVACIZUMAB INJECTION 0.25 MGLI CD O 285CA PKR. ATCH LIDOCAIN 70 MG/TETRACAIN 70 MG No PR approval required. PATCHES C9290 INJECTION BUPIVACAINE LIPOSOME 1 MG INJECTION BUPIVACAINE LIPOSOME 1 No authorization required MG C9293 INJECTION GLUCARPIDASE 10 UNITS. IDASE 10 UNITS No approval required C92 93 INJECTION GLUCARPIDASE LAGEN No approval required CM INSTALLATION PIPE PR . CM LEN C9353 MICROPOROUS COLL IMPL SLIT TUBE CM MICROPOROUS COLLAGEN No approval required IMPLANTABIL SLIT TUBE CM C9354 ACCELLULR PERICARDIAL TISSUE NH SQ CM ACELLULAR PERICARDIAL TISSUE MATRIX No approval required NONHUMAN SQ CM C9355 COLLAGEN NERVE CUFF CM 0TH 5 CUFF CMUNKT. Approval Required CENTIMETER LENGTH C9356 TENDON MATRIX COLLAGEN & GAG SQ CM TENDON POROUS MATRIX COLLAGEN & No Approval Required GAG PER SQ CM C9358 DERM SUB NATV FET BOV PER. IX bones FILLER No approval required KIT PR. 0.5 CC C9360 DERM SUBST NEONAT BOV ORIG 0.5 CM DERM SUBST NAT NONDNTRD COL NEO No Authorization Required BOV ORIG 0.5 CM C9361 COLL MATRIX NRV WRAP AT 0.5 CM. required 0.5 CM LENGTH C9362 POROUS COLL BN FILLER TAPE 0.5 CC POROUS COLL MATRIX BONE FILLER No approval required TAPE PER. 0.5 CC C9363 LEATHER SUB INTEGRA DOUBLE LAYER PO. RCINE IMPLANT PERMACOL PR No authorization required SQUARE CM C9399 UNCLASSIFIED DRUG OR BIOLOGICAL UNCLASSIFIED DRUG OR BIOLOGICAL Authorization required Drug administration Full clinical examination Always by physician C9447 INJ PHENYLEPHRIN & KET 4 ML CAP PROTECTION INJECTOR 4 ML C INJECTION REQUIRED AP 4 9460 INJECTION CANGRELOR 1 MG INJECTION CANGRELOR 1 MG No approval required C9462 INJECTION DELAFLOXACIN 1 MG INJECTION DELAFLOXACIN 1 MG No approval required C9482 INJECTION SOTALOL HYDROCHLORIDE 1 MG INJECTION SOTALOL HYDROCHLORIDE 1 No approval required IN 9482 INJECTION SOTALOL HYDROCHLORIDE DE 1 MG INJECTION SOTALOL HYDROCHLORIDE 1 No approval required IN 9482 INJECTION TION SOTALOL HYDROCHLORIDE TION CONIVAPTAN Approval Required Drug Administration Full Clinical Review HYDROCHLORIDE 1 MG C9600 PERQ TRANSCATH PLCMT; MAY 1 CA/BR PC TRNSCTH PLCMT RX ELUT IC Stents; No Approval Required MAY 1 CA/BR C9601 PC TRNSCATH PLCMT; EA ADD BR MAJ CA PC TRNSCTH PLCMT RX-ELUT IC STNT;EA No approval required ADD BR MCA C9602 PERQ TL CORONAR ATHERECT; 1 MCA/BR PC TL COR ATHERECT W/RX ELUT IC No STENT approval required; 1 MCA/BR C9603 PERQ TL COR ATHERECT;EA ADD BR MCA PERQ TL COR ATHERECT; EA ADD BR No approval required MAJ CORONARY ART C9604 PERQ TL REVISION/THRU CABG;1 VES PC TL REV OF/THRU CABG KOMB DE IC No approval required STNT; 1 VES C9605 PERQ TL REV OF/THRU CABG;EA ADD BR PC TL REV OF/THRU CABG; EA ADD BR No approval required SUBTEND BP GFT C9606 PC TL REV AC TOT/SUBTOT OCCL 1 VES PERQ TL REV AC TOTAL/SUBTTOTAL No approval required OCCLUSION 1 VES C9607 PERQ TL REV CHRN TOT OCCL; 1 VESSEL PC TL REV CHRN TOT OCCL CA CA No BR/CABG approval required; 1 VES C9608 PC TL REV CHRN TOT OCCL; EA ADD BR PC TL REV CHRN TOT OCCL; EA ADD CA No approval required CA BR/BP GFT C9725 PLCMT ENDORECTAL APPLICATION BRACHYTX PLCMT ENDORECT INTRACAV APPLIC HI No approval required INTNS BRACHYTX C9726 PLCMT&REMV AA BR IORT ADD BR PLCMT- I REMV A BRUT AUT. PROC C9727 INSRT IMPL SOFT PALATE; MIN 3 IMPL INSERT IMPL FOR SOFT PALATE; Authorization Required Respiratory Surgery Full Clinical Examination MINIMUM 3 IMPL System C9728 PLCMT INTERSTIT DEV NOT ABD PROS RP PLCMT INTERSTICIAL DEV NOT ABD PELV Authorization Required PROS RP THOR C9733 NONOPHTALMIC FLUOR VASCULAR VASCULAR NO FLUPHANGIC VASCULAR NOT IOGRAPHY C9734 FOCUSED U/S ABL / TX INT OTHER EXCEPT UL FOCUSED U/S ABL/TX INT OTHER EXCEPT UT Approval Required Female Reproductive System Surgery Complete Clinical Review LEIOMYOMATA System C9739 CYSTOSCPY INSRT TRNSPRSTAT IMPL;1-3 CYSTURETHRSCPY INSRT No Approval Required; 1-3 IMP

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C9740 CYSTOSCPY INSRT TRNSPRSTAT IMPL;4/> CYSTURETHRSCPY INSRT No approval required TRANSPROSTAT IMPL; 4/> IMPL C9745 NASAL ENDO SURGERY; BALLN DILAT EU T NASAL ENDO SURGERY; BALLON DILAT Authorization Required Surgery Full Clinical Review EUSTCHIAN TUBE C9746 TRNSPRNL IMPL PRM ADJ BALLN CNT DVC TRANSPERINL IMPL PERM ADJ BALLON Authorization Required Surgery Full Clinical Review CONT DEVICE C9747 ABLATION INCBLATION PROS TRRECY Authorization Required Full Clinical Review HIFU INCL I GUID C9749 REPAIR NAS PRSLUK LAT WALL STONE IMPL REPAIR NASAL VEST LATERAL WALL Authorization Required Surgery Full Clinical Examination STONE W/IMPLANT C9751 BRONCH RIGID/FLEX TRANSBRON ABL LES BRONCHOSCOPY RIGID/FLEXIBLE Authorization TR25 DESTRC IO BASIVA N 1ST 2 VERT B L/S DESTRUC IO BASIVERTEB NERV 1ST 2 Authorization Required Surgery Complete Clinical Review VERT B LUMB/SAC C9753 DSTRC IO BASIVA N EA ADD VA BDY L/S DESTRUC IO BASIVERTEB VERY NERV ADD EADD. L/S C9756 IO NIR FLUOR LM OF LYM W/ADMIN ICG INTRAOPERATIVE NIR FLUOR LM OF LYM Complete clinical exam required W/ADMIN ICG C9757 LAMINOTOMY DECOMP NRV RT;1 ISP LAMINOTOMY DECOMPNERV; 1 Approval Required Full Clinical Review LUMB INTERSPACE LUMB C9758 BI PRC NYHA 3/4 HF;TRNSCTH I IAS/PC BI PROC NYHA CL III/IV HF;TRNSCATH Approval Required Surgery Full Clinical Review IMPL IAS/PC C9762 DCMFRI; STR CMRI MORPHOL & FUNC QUAN SEG Authorization Required Network Validation IMAG DYSFUNC;STRAIN IMAG C9763 CMRI MRPHOL&FNC Q SEG DYSF;STS IMAG CMRI MORPHOL & FUNC QUAN SEG Authorization Required Network Validation C9763 CMRI MRPHOL&FNC Q SEG DYSF;STS IMAG CMRI MORPHOL&FNC Q SEG DYSF;STS SEG Authorization Required Network Validation C9RES FUNCAD R 9RES FUNC; AY RADIO MARKET PROD PROV UNDER A No Approval Required HOSPITAL IP STAY C9899 IMPL PROS DEVC PAYBL IP NO IP COV IMPL PROS DEVC PAYBLE IP WHO WORKS No Approval Required NO IP COV E0100 STICK ALL MATL ADJUSTABLE/FIXED WITH STICK ON TOP INCLUDING STICKS CUSTOMIZE ALL REQUIRED/. FIX W/TIP E0105 CRE QUAD/3-PRONG ALL MATL W/TIPS CNE QUAD/3-PRONG ALL MATL No Auth Required ADJUSTBL/FIX W/TIPS E0110 CRTCHES FOREARM MISCELLANEOUS MATL PAIR CRTCHES FOREARM MISCELLANEOUS MATL PAIR WRIPS/No Auth E0111 CRTCHES FOREARM MISCELLANEOUS MATL EA CRTCH FOREARM MISCELLANEOUS MATL EA No Approval Required W/TIP&HNDGRIP E0112 CRTCHS FOREARM WOOD PAIR CRTCHS FOREARM WOOD PAIR No Approval Required ADJSTBL/FIX W/PADS TIPS/HANDJFOOD CBLEADS TIPS & HNDJF3 RTCH UNARMT WOOD EA ADJSTBL/ FIX No Approval Required PAD TIP&HANDGRIP E0114 KPULL FOREARM EXCEPT WOOD PAR FOREARM SETTING EXCEPT WOOD No Approval Required PAR PAD TIP&HANDGRIP E0116 CRTCH FOREARM EXCEPT PULL FOREARM NOT WOOD ADJUSTMENT E/F1 Required 7 CRTCH FOREARM ITEM SPRING ASSTD CRUTCHES SEE FOREARM ARTICULATION No Approval Required EA SPRING ASSISTED EA E011 8 CRUTCHES REPLACEMENT LW CRUTCHES LEG PLATFORM SUBST LOWER LEG PLATFORM No Authorization Required W/WO WHEELS EAKER E0130 ADJALX RIGALID ADJALIGHT R. PORTABLE OR FIXED No Approval Required HEIGHT E0135 FOLDING WALKER ADJUSTABLE/FIXED HEIGHT WALKING F OLD ADJUSTABLE OR No Approval FIXED HEIGHT E0135 40 WALKS M /TRNK SUPP ADJUSTBL/FIX HT WALK WITH/COMBAT SUPPORT No approval required ADJUSTABLE AUTO/FIXED HT ANY TYPE OF WHEEL/TRNK SUPP R14 WHEEL ADJUSTABLE No. Authority required OR FIXED HEIGHT E0143 WALKER FOLDING WHEEL ADJUSTABLE/FIX HT WALKER FOLDING WHEEL ELED no approval required ADJUSTABLE/FIXED HEIGHT E0144 WALKER ENVIRONMENT 4 SIDE WHL POST WALKER SEAT REQUIRED FR 4S WALDER WALKR HEAVY DUTY MX BREMS VARIBL WHL WALKER HEAVY DUTY MX BRAKE SYS No Approval Required VARIBLE WHL RSIST E0148 WALK HEAVY DUTY NO WHLS RIGID/FOLD EA WALK HEAVY DUTY U/ O WHLS No Approval RIGID/FOLDING ANY TYPE WHYPE 149 EA WALKER HEAVY DUTY WHEEL No Approval RIGID/FOLDING ANY TYPE EA E0153 PLATFORM MOUNT CRUTCHES EA PLATFORM ATTACHMENT FOREARM No approval Re required CRUTCHES EACH E0154 PLATFORM MOUNT WALKERS EACH PLATFORM ATTACHMENT EACH ACCESSORY W5-5 LK- PAIR SEAT WHL ATTCH RIGD PICK-UP WALK-PAIR Not required approval SEAT ATTCH WALK E0156 SEAT ATTACH WALKER SEAT EXTRA WALK No approval required E0157 CRUTCHES FIXED WALKERS EACH CRUTCHES WALKERS EA CH No approval EXTOUR LEGTONS 8 EXTOUR LEGTONS E0157 FOR WARKER PR. SET No Authorization Required OF FOUR E0159 BRAKE SETTING WHEELS IDE REPLCMT BRAKE SETTING WHEELS No Authorization Required EA WALKER REPLACEMENT EACH E0160 BATH SEAT/EQP PRTBLE W/WO COMFORT TYPE SEAT BATH/EQP BATH/EQP PRTBLE USED E0160 BATH SEAT / EQP PRTBLE USED WITH FAUCET SEAT TYPE BATH/EQP PRTBLE USED No Authorization Required W/TAIL CONNECTIONS E0162 BATH SEAT CHAIR SEAT BATH CHAIR Item no. Auth Required E0163 DRESSER WITH FIXED ARMS DRESSER CHAIR MOBILE OR No Authorization Required DRESSER FABRIC CHAIR 5 TANKABLE DRESSER MO BALL/STATIONARY No Authorization Required ARMS W/ REMOVABLE ARMS E0167 USE OF COMFORT/PANEL W/ CHAIR REPLACEMENT OR CHAIR REPLACEMENT ONLY EXCHANGE FOR COMMODE E0168 COMMO DE CHAIR XTRA WIDE/WIDE/WIDE/WIDE Author required WORKSTATION/MOBILE E0170 COMMO DE CHAIR SEAT LIFT MECH ELEC COMMO DE CHAIR INTGR SEAT LIFT No approval required MECH ELEC ANY TYPE E0171 COMMO DE CHAIR SEAT LIFT MCH COMMO DE CHAIR INTGR SEAT LIFT MECH ELEC COMMO DE CHAIR INTGR SEAT LIFT E1C Auth Required No E1C REST USE W/ DRESSING FOOTSTOOL No authorization required. EACH CHAIR EACH E0181 PWR PRESS RED MATTRESS BASE W/ PUMP PWR PRESSURE RELIEF MATTRESS No OVERLY/PAD PUMP approval required

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E0182 PUMP ALTERNATING PRESSURE PAD REPLACE PUMP ALTERNATING PRESSURE PAD No Authorization required REPLACEMENT ONLY E0184 DRY MATTRESS DRY PRESSURE MATTRESS No authorization required E0185 GEL/GEL-LIQUID STRSS PRESS ST PAD- PADS GEL- LIQUID STRSS ST PAD- PAD- uth Re requested LEN&WDTH E0186 AIR PRESS THE MATTRESS No authorization required E0187 WATER PRESSURE MATTRESS WATER PRESSURE MATTRESS No authorization required E0188 SYNTHETIC SHEEP SKIN PILLOW SYNTHETIC SHEEP SKIN PILLOW No authority required E018 SWEPLASKIN SMBOOL SWEPLASKIN PAD SKI N PILLOW ANY SIZE No authorization required E0190 PSTN CUSHION/CUSHION/ EDGE ALL POSITIONING CUSHION/CUSHION/WEDGE Approval not required COMPONENT INCLUDES ALL COMPONENTS E0191 HEEL OR ELBOW PROTECTION EACH HEEL OR ELBOW PROTECTION EACH No approval required E0193 POWERED AIR BED POWERED AIR BED FLOTATION AIR Required LU IDIZED BED No approval required E0196 GEL PRESS MATTRESS GEL PRESS MATTRESS No approval required E0197 AIR PRSS PAD MATRSS STD LONG &WDTH AIR PRESS PAD MATRSS STD MATRSS No approval required LENGTH&WIDTH E0198 WATER PRSS PAD MATTRESS PRESS STD. SS LENGTH&WIDTH E0199 DRY PRSS BASE MATRSS STD LENGTH&VALUE. DRY PRESS PAD MATRSS STD MATRSS No approval required LENGTH&WIDTH E0200 HEATER LAMP WITHOUT STAND W/INFRARED ELEMENT HEATER LAMP W/INFRARED STAND INCLUDED No approval required Bulb/INFRARED ELEMENT E0202 PHOTOTHERAPY LIGHT SECOND PHOTOTHERAPY LIGHT WITH AUT. OMETAR E0205 HEAT LAMP W/STANDARD W/INFRARED ELEMENT HEAT LAMP W/STANDAL INCLUDED No authorization required BULB/INFRARED ELEMENT E0210 ELECTRIC HEATER STANDARD ELECTRIC HEATER STANDARD No authorization required E0215 ELECTRIC HEATER E0215 ELECTRIC HEAT PAD E02 ELECTRIC HEAT ELECTRIC Auth 1 ATING HEATING PILLOW W / PUMP WATER CIRCULATION HEATER CUSHION NO Authorization Required PUMP E0218 FLUID CIRCULATION COLD CUSHION W/ PUMP ANY TYPE OF FLUID CIRCULATION COLD CUSHION NO Authorization Required PUMP ANY TYPE E0221 INFRARED HEATING SYSTEM P2 Equir issue no. P2 5 HYDROCOLATOR UNITS INCLUDES PAD HYDROCOLATOR UNITS INCLUDES PADS Approval not required E 0235 PARAFFIN BATH UNIT PORTABLE PARAFFIN BATH UNIT PORTABLE No approval required E0236 WATER CIRCULATION PUMP PAD WATER CIRCULATION PUMP PAD No approval required E0239 HYDROC UNITOR E0239 No approval required E 0246 ORIES PORT RAIL ACCESS No approval required E0247 TRNSF BENCH /TOILET W/WO PORTABLE BENCH/TOILET W/WO No approval required DRESSER DRESS HOLE E0248 TRNSF BENCH HEAVY DUTY BENCH/TOILET TRNSF BENCH Authentic/WO required E0249 PAD H2O CIRCULAR HEATER REPLACEMENT ONLY PAD WATER CIRCULATING HEATER No approval required EXCHANGE ONLY E0250 AT BED FIX HT W/BARS W/MATTRESS HOSP BED FIX HT M /ANY TYPE OF SIDE RAILS B2 REQUIRED Euth 2 W/BARS NO MATTRESS HOSP BED FIX HT W/ANY TYPE OF SIDE RAILS FENCES No approval required W/O MATR. E0255 NEAR BED VARIABLE HT W/WIDTH W/MAT AT SED VARIABLE HT W/ANY TYPE OF SIDE RAIL No Approval Required MATRSS FOR FENCE E0256 FOR BED VARIABLE HT W/STICK NO MATTRESS ON BED VARIABLE HT ANY TYPE OF SIDE RAIL No Approval Required IN /O MATR. E0260 AT BED SEMI-ELEC W/RAIL W/MATRS AT BED SEMI-ELEC REquip W/ANY DME Complete Clinical Examination RAIL W/MATTRSE E0261 AT BED SEMI-ELEC W/RAIL NO MATRS AT SED SEMI-ELEC ANY TYPE OF SIDE RAIL Authorization Required DME Full Clinical Examination U/O MATTRESS E0271 MATTRESS INNER SPRING MATTRESS E02 Auth INNER2RING FOAM RUBBER MATTRESS FOAM RUBBER No approval required E0275 BED STANDARD METAL OR PLASTIC BED BED STANDARD METAL OR PLASTIC No approval required E0276 BED BED TOP METAL OR PLASTIC BED CONTAINER REQUIRED PLATE E7 METAL E7 ING AIR POWERED EDUCATIONAL AIR No approval required MATTRESS MATTRESS E0280 BED CRADLE ANY TYPE BED CRADLE ANY TYPE No approval required E0290 IN BED FIX HT U/O BAR W/MATTRESS NURSE FIX HT BED WITHOUT SIDES No Auth U/MATTRAISS0 REQUIRED B/MATTRESS0 O-BAR U/U MATTRESS HOSPITAL BED FIX HT U/U SIDE RAILS No Auth U/U MATTRESS E0292 ON BED VARIBL HT NO BAR W/MATTRESS HOSP BED VARIBL HT HI-LO U/O SIDE No approval required BED MATTRESS E0293 BED CODE VARIABLE HT NO BONNET/MATTRESS ON SENG VARIABLE HT HI-LO U/O SIDE No approval required BAR NO MATTRESS E0294 BED CODE SEMI-ELECTRO NO BAR W/MATRS HOSPITAL BED SEMI-ELEC U/O SIDE required DME full clinical exam RAIL W/MATRSS E0295 AT BED SEMI-ELEC U/O RAIL/MATRSS HOSP BED SEMI-ELEC U/O SIDE RAILS required DME approval full clinical exam U/O MATRSS E0300 PED CRIIB AT GRADE ENC W/WO ENC PED CRIB AT GRADE FULL ENC W/WO Authorization Required DME Full Clinical Examination TOP ENC E0301 AT BED HEVY DUTY W/WT CAP >350 PDS AT BED HEVY DUTY XTRA WIDE W/WT Authorization Required DME Full Clinical Review CAPY>33502DS AT BED WT CAP>600 U/O MATTRESS AT BED XTRA HEVY DUTY WT CAP>600 Authorization Required DME Full Clinical Review PDS U/O MTTRSS E0303 AT BED HEVY DUTY WT CAP >350350 Authorization Required DME Full Clinical HEX 60 B HEAVY DUTY WT DME Authorization Required Full Clinical Examination CAP>600 PDS MATRSS E0305 HALF LENGTH BED RAIL HALF LENGTH BED RAIL No approval required E0310 FULL LENGTH BED RAIL BED STRAPS - REQUIRED E0310 BED RAIL FULL LENGTH STRAPS FOR BED - EFR-EN FULL EFR/6 CANOLISE W/ HOSP BED SFTY INCLUDING FRME/CANOPY USE No Approval Required W/HOSP BED ANY TYPE E0325 URINAL; HAND POT TYPE ANY MATERIAL URINAL; ALL MATERIAL GLASS No approval required E0326 URINAL; FE JUG URINARY OF ANY MATERIAL; Women's Pot Type of Any Nursery Material E0328 HOSP Bed Ped Manual including Madras Hospital Beds Pediatric Manual Required DME DME Clinical Review including Mattress E0329 HOSP Bed Ped Electric including Mattress Clume Author Complete Clinical Review de Madras E0350 CNTRL U ELE C BOWEL IRRRIG / EVAC SYSTEM HOSE CONTROL UNIT No approval required IRRIGATION SYSTEM/EVAC

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E0352 DISPBL PACKAGE W/ELEC BOWEL IRRIG/EVAC DISPBL PACKAGE USE WITH ELEC BOWEL No approval required IRRIG/EVAC SYS E0370 HEEL AIR PRESSURE HEEL AIR PRESSURE HEEL No approval required E0370 HEEL AIR PRESSURE HEEL AIR PRESSURE No approval required required E0352 NO PROVSS0RLAY SS RDUC OVRLAY No approval required STD MATRSS STD WAIST&WDTH E0372 PWR AIR OVRLAY MATRSS STD PWR AIR OVRLAY MATRSS STD No approval required LENGTH&WDTH MATRSS LENGTH&WIDTH E0373 NONPWR ADVD PRESS REDUCTION NO REQUIRED ADDRESS. 0424 GASEOUS O2 SYSTEM BEARING STATION COMPRS; GAS SYSTEM O2 COMPRESS. FLAT No approval required RENT;FLWMTR HUMIDFR E0425 GAS SYSTEM COMPRESS. IT BECOME A PURCHASE; STATION COMPRS GAS SYS KUPA; Approval not required FLWMTR HUMIDFR NEB E0430 PRTBLE GASEOUS O2 SYSTEM PURCHASE; PRTBLE GASEOUS O2 SYS BUY; DME Approval Required Full Clinical Examination FLWMTR HUMIDFR&MASK E0431 PRTBLE GASEOUS O2 SYS BEARING; PRTBLE GAS O2 SYSTEM BEARING; DME approval required Full clinical examination FLWMTR HUMIDFR&MASK E0433 PORTBL LIQ O2 SYS RENT; HOME LIQUIF PORTABL LIQUID OXYGEN SYSTEM RENT; DME approval required Full clinical review HOME LIQUEFIER E0434 PRTBLE LIQUID O2 SYS BEARING; PRTBLE LQD O2 SYS BEARING; RESRVOR Approval Required DME Full Clinical Review HUMIDFR FLWMTR E0435 PRTBLE LIQUID O2 SYS PURCHASE; PRTBLE LQD O2 SYS BUY; TANK No Approval Required FLWMTR HUMIDFR E0439 STATION LIQUID O2 SYSTEM BEARING; STATION LQD O2 SYS BEARING; FLWMTR Approval not required HUMIDFR NEBULIZR E0440 STATION LIQUID O2 SYS PURCHASE; STATION LQD O2 SYS PURCHASE;RESRVOR No Approval Required HUMIDFR NEBULZR E0441 STATIONARY O2 CONT. GAS 1 MO SPL=1 IN STATIONARY CONTENTS O2 GAS 1 MO No Approval Required PURCHASE=1 UNIT E0442 STATIONARY LQD 02 CONT. LQD 1 MO No approval required PURCHASE = 1 UNIT E0443 PORTBL O2 CONTENT GAS 1 MO SPL= 1 U PORTABLE O2 CONTENT GASEOUS 1 No approval required MO PURCHASE=1 UNIT E0444 PORTBL O2 CONTENT LIQUID 1 MO UPORT 1 MO SPL. MO No approval required PURCHASE =1 UNIT E0445 OXIMETER MSR BLD O2 LEVEL NON-INVASIVE OXIMETER UNIT MSR BLD O2 LEVEL No approval required NON-INVASV E0446 LOCAL OXYGEN DELIVERY SYSTEM NO. E0447 P O C L 1M SPL=1U PRSC R/N XCD 4LPM PRTB O C LQD 1 MO SPL=1 U PRSC AMT No approval required R/N EXCD 4LPM E0455 O2 TENT EXCLUSIVE CRUPID/PEDIATRIC TENTS OXYGEN EXCLUDING CRUPIC OR PEDIATRIC TENTS 04 /WO SIDE RAILS ROCKING BED WITH OR WITHOUT SIDES REQUIRED Approval not required FENCES E0465 HOME VENT ANY TYPE USED INVASV INTF HOME VENTILATOR ANY TYPE USED Approval Required DME Full Clinical Exam W/INVASIVE INTF E0466 HOME VENTILATOR INVASIVE VENT PE USED Approval Required DME Full Clinical Exam W /NON - INVASV INTF E0467 HOME VENTILATOR MULTI FUNCTION RESP HOME VENTILATOR MULTI FUNCTION No approval required DVC RESPIRATORY DEVC E0470 RESP ASST DEVC BI-LEVL PRSS REQUIREMENTS FOR PREV. CAPABILITY W/BACK-UP E0471 RESP ASSST DEVC BI-LEVL PRSS POSSIBLE RESP ASSST DEVC BI-LEVL PRSS No approval required CAPABILITY W/BACK-UP E0472 RESP ASSST DEVC BI-LEVL PRSS POSSIBLE RESP ASSST DEVC PRESS CAPABILITY REQUIRED PR. W/BACKUP E0480 PERCUSSIONS ELECTRIC/PNEUMATIC HOME PERCUSSIONS ELECTRIC OR PNEUMATIC No Approval Required MODEL HOME MODEL E0482 COUGH EXAMINATION DEVC ALTERNATE POS&NEG STIM UNIT COUGH ALTERNATIVE No Approval Required POS WARSCAY & NEG 3 ACH HIGH FREQUENCY CH Approval Required EST WALL DME Full Clinical Review OSCILLATION SYSTEM EA E048 4 OSCILLAT POS EXPIRY PRSS NO-ELEC OSCILLATOR POS EXPIRY PRSS No Authorization Required DEVC NON-ELEC EA E0485 ORL DEVC/APPL RDUC UA COLAPS PRFAB OR EXPIRY BUY WRITE Author SIBILITY PRFAB E0486 ORL DEVC/APPL RDUC UA COLAPS CS TM ORL DEVC/ APPL RDUC UP AIRWAY Approval Required DME Full Clinical Examination COMPARISON CSTM E0487 SPIROMETER ELECTRONIC INCLUDING ACCESS SPIROMETER ELECTRONIC ACCESSORIES REQUIRED MACHT No. EBULZ;VALVES;PWR IPPB MACH W/INSTALLED SPRAY; No VALVE approval is required; PWR E0550 HUMDIFR EXT SUPLMNTL DUR IPPB TX/O2 HUMDIFIR DURBLE EXT SUPLMNTL DUR No approval required IPPB TX/O2 PART E0555 HUMDIFR GLASS/AUTOCLVBL PLSTC BOTTL HUMDIFIR DURABLE HUMDIFIR DURABLE DURING 5. Auth. HUMDIFIR SUPLMNTL DUR IPPB TX/O2 HUMDIFIR DURABLE SUPLMNTL DUR No Approval Required IPPB TX/O2 PART E0561 NON-HEATED HUMIDIFIER USED W/POS NON-HEATED HUMIDIFIER USED W/POS No Approval Required AIR WALL AIRWAY PRESS DEVC E0562 HUMDIFIR HEAT USED W/POS AIR STYLE OUT NO AIR AIR WALL. Required PRSS ARWAY PRESSURE DEVICE E0565 COMPRS AIR PWR EQP NOT SLF COMPRS AIR PWR EQP NOT SLF- No approval required CONTAIND/CYL DRIVE E0570 NEBULISER WITH COMPRESSOR NEBULISER WITH ABL COMPRESSOR A5 COMPRESSOR A5 2 ADPRESOR SL COMPRS ADJSTBL PRSS LGHT Br. Auth Required DUTY INTERMITTENT USE E0574 US/ELEC AROSL GEN M/SM VOLUME NEB ULTRASONIC/ELEC AROSL GEN No Approval Required W/SMALL VOLUME NEB E0575 NEBULIZER ULTRASONIC NEBULIZER LARGE VOLUME ULTRASONIC NEBULIZER ULTRASONIC 8 ASS/AUTOCLVBL PLST BOTTL NEBULIZER DURABLE No Approval Required GLASS /AUTOCLAVIERbar PLSTC BOTTLE E0585 NEBULISER WITH COMPRESSOR AND HEATER NEBULISER WITH COMPRESSOR AND No authorization required HEATER E0600 RESP SUCTN PUMP HOME MODEL ELEC RESP SUCTN PUMP E0 REQUIRED Auth. OUS POS AIRWAY PRESSURE CONTINUOUS POSITIVE AIRWAY No approval required DEVC PRESSURE DEVICE E0602 CHEST PUMP MANUAL ANY TYPE CHEST PUMP MANUAL ANY TYPE No approval required E0603 CHEST PUMP ELECTRIC ANY TYPE ELECTRIC CHEST PUMP ANY TYPE No authorization required E0604 B EVASTY PUMP HEVY DUTY HOSP GRADE No authorization required STAMP UP

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E0605 Vaporizer room type Vaporizer No approval E0606 Pumping plates No approval E0607 Blood dubcosis E0606 Monitoring plate for postural drainage No approval E0370 required Home Monitor BLOOD GLUCOSE POSTURAL DRAINAGE MONITOR E0607 MALE CHECKS BATTERY DEPLET No Authorization Required AUDBL&VISBL W/AUDIBL&VISIBL E0615 PACEMKR MON CHCK BATTRY DIGTL/VISBL PACEMKR MON CHECKS BATTRY DEPLET Authorization Required DME Full Clinical Exam W/DIGTL/VISIBL E0616 IMPL CARD EVNT REC MEM IMPL CARD EVENT RECORDR W/MEM No authorization required ACMERTVTR&6B PROGRAM ACMERTITR&6B7PROG D ECG ANALYSIS EXTERNAL DEFIB W/INTEGRATED ECG No authorization required ANALYSIS E0618 APNEA MONITOR NO RECORDING APNEA MONITOR NO No authorization required RECORDING FUNCTION FUNCTION E0619 APNEA MONITOR W/RECORDING FUNCTION APNEA MONITOR NO required APNEA MONITOR F0N DEVC CLCT CAPLRY BLD LASR SKIN PUNCTURE DEVICE CLCT CAPILLARY No approval required BLD LASER EA E0621 SLING/SEAT PT LIFT CANVAS/NYLON SLING OR CANVAS FOR PATIENT SEAT LIFT No approval required OR NYLON E0627 SEAT LIFT MECH COMB LIFT MECHANISM FOR CHAIR LIFT Aquinity No Auth 9 SEAT LIFT MECH MECH MECH No n-Electric Any type of seat lift mechanism Non-Electric No Author ELECTRIC WITH SEAT OR Authorization Required DME Full Clinical Review SLING E0636 MX PSTN PT SUPP SYS LIFT PT CNTRL MX PSTN PT SUPP SYS INTGR LIFT PT Authorization DME Full Clinical Review AVAILABLE CNTRL E0639 Rev. required DISASSMBL&REASSMBL W/DISASSMBL&REASSMBL E0640 PT LIFT FIX SYSTEM ALL CMPNTS/ACCESS PATIENT LIFT FIX SYSTEM INCLUDING ALL No Authorization Required CMPNTS/ACCESS E0650 PNEUMATIC COMPRESSOR NONSEG HOME PNEUMATIC COMPRESSOR Authorization Required MODEL COMPRESSOR MODEL NO NO CALBRT GRDNT PNEUMAT COMPRS SEG HOM MDL NO Authorization Required DME Complete Clinical Review PRSS CALBRTD GRDNT PRSS E0652 PNEUMAT COMPRS W/CALBRT GRADNT PNEUMAT COMPRS SEG HOM MDL Authorization Required DME Complete Clinical Review PRSS W/CALBRTD GRADNT PRSS E0655 NONSEGLI NONSEUPN APP NE red W /PNEUMAT COMPRS HALF ARM E0656 SEG PNEUMAT APPLINC W/ COMPRS SEG PNEUMAT APPLIANCE USE No Authorization Required TRUNK W/PNEUMAT COMPRS TRUNK E0657 SEG PNEUMAT APPLINC W/COMPRS SEG PNEUMAT APPLIANCE REPNEUMAT APPLIANCE REPNEUMAT APPLIANCE REPNEUMAT CH6 EPNEURS USE NE Authen MAT APPLINC FULL BEN NONSEG PNEUMAT APPLINC No Authorization Required W/PNEUMAT COMPRS FULL LEG E0665 NONSEG PNEUMAT APPLINC FULL ARM NONSEG PNEUMAT APPLINC No Approval Required W/PNEUMAT COMPRS FULL ARM E0666 NONSEG PNEUMAT APPLINC NonEG PNEUMAT APPLINC. EUMAT COMPRS HALF LEG E0667 SEG PNEUMAT APL. COMPRS FULL LEG SEG PNEUMAT APPLINC W/PNEUMAT No Approval Required COMPRS FULL LEG E0668 SEG PNEUMAT APPLINC COMPRS FULL SEG PNEUMAT APPLINC W/PNEUMAT No Approval Required ARM COMPRS KOMPRES 6APP ARM E0668 APPLIC W/PNEUMAT No Approval Required LEG COMPRS HALF LEG E06 70 SEG PNEU APPL P C INT 2 F LEG TRNK SEG PNEU APPLINC PNEU COMPRS IN 2 Approval Required DME Full Clinical Examination FULL LEGS TRNK E0671 SEG GRAD PRSS PNUMAT SEARCH PRÄV FULL LEGENT REAPP. LL BEN E0672 SEG GRAD PRSS PNUMAT APPLNC FULL SEGMENTAL GRADENT PRESS PNEUMAT No authorization required ARM APPLINC FULL ARM E0673 SEG GRAD PRSS PNUMAT APPLNC HLF BEN SEGMENTAL GRADENT PRESS PNEULF No authorization required APPLINC APPLINC APPLINC APPLINC APPLNC R67 EUMAT COMPRS DEVC HI PRSS RAPID No authorization required INFLATION/DEFL E0676 INTERMITTENT LIMB COMPRESSION DEVC NOS INTERMITTENT LIMB COMPRESSION No Authorization required UNIT NOS E0691 UV LIGHT TX lamp/LAMP; TX 2 SQ FT/< UV LIGHT TX SYS BULB/LAMP TIMER; Authorization Required TX DME Full Clinical Exam 2 SQ FT/LESS E0692 UV LT TX SYS PANEL W/LAMP 4 FT PANEL UV LT TX SYS PANL W/BULB/LAMP Authorization Required DME Full Clinical Exam TIMER 4 FT PANEL PANEL E0693 UVNL W/ LAMP 6 FT PANEL UV LT TX SYS PANL W/BULBS/LAMPS DME Approval Required Full Clinical Exam TIMER 6 FT PANEL E0694 UV MX DIR LT TX SYS 6 FT CABINET UV MX DIR LT TX SYS 6 C FT CABINET DME Authorization Exam Required W/ BULB /LAMP TMR E0700 SAFETY EQUIPMENT ANY TYPE SAFETY EQUIPMENT ANY TYPE SAFETY EQUIPMENT UNIT OR No Approval Required ACCESSORIES ANY TYPE E0705 TRANSFER UNIT ANY TYPE EACH TRANSFER UNIT ANY TYPE ANY TYPE REQUIRED ANY TYPE REQUIRED ANY NO. Approval required E0720 TENS DEVICE 2 LEADS LOCALIZED STIM TENS DEVICE TWO LEADS LOCALIZED No approval required STIMULATION E0730 TENS DEVICE 4/> LEAD MX NERVE STIM TENS DEVICE 4/MULTI LEAD MULTI No approval required NERVE CONDUCTION FORM E0730 TENS DEVICE 4/> LEADS MX NERVE STIM TENS UNIT 4/MULTI LEADS MULTI No approval required NERVE CONDUTION-FORM E0731 DUCTIVE CLOTHING No approval required DELIV TENS/NMES E0740 N-IMPL PELV FLR ELEC STIM CMPL SYS NON-IMPL PELV FLR ELECTRICAL No approval required STIMULATOR CMPL SYS E07 44 NEUROMUSCULAR STIMULATOR NEUROMUSCULAR STIMULATOR NEUROMUSCULAR STIMULATOR NEUROMUSCULAR STIMULATOR FOR no. SCO S05 STIM ELECTROSHOCK DEVICE NEUROMUSCULAR STIMULATOR No authorization required ELECTRONIC SHOCK DEVICE E0746 ELECTROMYOGRAPHY BIOFEEDBACK ELECTROMYOGRAPHY BIOFEE DBACK No authorization required DEVICE DEVICE E0747 OSTOGNS STIM NONINVASV NOT SP APPLC OSTOGNS STIM ELEC NONINVASABLE ELEC NONINVASABLE OTH- Group Full OTH review required Relate to all codes within specific group E0748 OSTOGNS Stim non-invasive SP app Ostogns Stimulator Elec Wound care PA authorization required for code in group Full clinical examination Non-invasive spinal application Applies to all codes within specific group E0749 Ostogns Stim Elec surgical impl osteogenesis stimulator Elec Authorization required for wound care PA for code in group Full clinical review SURGICAL IMPL Refers to all codes within a specific group

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E0755 ELEC SALIVARY REFLEX STIMULATOR ELECTRONIC SALIVARY REFLEX No authorization required STIMULATOR E0760 OSTOGNS STIM LW INTENS US NONINVASV OSTOGNS STIM LOW INTENS Approval required Wound therapy PA for code in group Full clinical examination N ULTRA-INVASOUNDSV Applies specifically to NULTRA-INVASOUNDSV codes N ULTRA- IN VASOUNDSV. THRML PULS RADIOWAVE NON-THRML PULS RADIOWAVE authorization required General medicine - other Full clinical examination ELECMAGNET ELECMAGNET ENRGY TX DEVC Services and procedures E0762 TRANSCUT ELEC JOINT STIM DEVC SYS TRANSCUT ELEC JOINT STIM DEVC SYS TRANSCUT ELEC JOINT STIM DEVC SYS 6 IM CMPT SC INJ FUNC NEUROMUSC STIM MUSC AMBUL Approval Required DME Full Clinical Review CMPT CNTRL SC INJ E0765 FDA APPRVD NRV STIM TX NAUSA&VEMING FDA APPRVD NRV STIM W/REPL BATTRY Approval Not Required TX NAUSA&CAACCELEC STYCALL IM DVC U CANCER TX INCL ALL No Approval Required ACC ANY TYPE E0769 EVALUATION /ELECTROMAGNETIC WOUNDS TX DEVC ESTIM/ELECTROMAGNETIC WOUNDS DME Authorization Required Full Clinical Examination NOC TREATMENT DEVC NOC E0770 FES TRANSQ STIM NERV&/MUSC TRANS STIM NERV&/MUSC CMPL/MUSC CMPLUT PL SYS NOS E0776 IV POLE IV POLE No Authorization Required E0779 AMB INFUS PUMP MECH INFUS 8 HR/> AMB INFUS PUMP MECH REUSABLE No Authorization Required INFUS 8 HOURS/GT E0780 AMB INFUS PUMP MECH INFUS MECH Acquired No INFUS Auth INFUS < 8 HOURS E0781 AMB INFUS PUMP 1/MX CHANNEL AMB INFUS PUMP 1 /MX KANNL Approval not required W/ADMIN W/ADMN EQP CARRY PT E0782 INFUS PUMP IMPL UNPROGRAMMED INFUSION Clin. PROGRAMMABLE E0783 INFUSION PUMP SYSTEM IMPL PROGRAMMABLE INFUSION PUMP SYSTEM IMPLANTABLE DME Approval Required Full Clinical Review PROGRAMMABLE E0784 EXTERNAL AMB INFUSION PUMP INSULIN EXTERNAL AMBULATORY INFUSION EPLIN 5 ANT INTRASPINL CATH PUMP-REPL FOR INSTALLATION IN TRASPINL CATHETER DME Approval Required Full Clinical Review USED WITH/ PUMP- REPL E0786 IMPLNT -PROGRAM INFUSION PUMP REPL IMPLANTABLE PROGRAMMABLE DME approval required Full clinical exam INFUSION PUMP REPL E0787 EXT AMB INFUS PUMP INSULIN D R ADJ EXTERNAL AMB INFUS REQUIRED D0 D0 EXTERNAL AMB INFOS. 1 PAIR INFUS PUMPS STAT SINGLE/MXCHANEL PARNTRAL INFUS PUMP STATIONARY No approval required SINGLE/MULTICANEL E0830 AMB TRACTION DEVICE ALL TYPES EACH AMBULATORY TRACTION DEVICE ALL No approval required TYPES EACH E0840 TRACTION FRAME CAD HEAD REQUIRED BOARD CERV TR ACTION E0849 TRAC EQP CERV FREESTND FRME TRACTION EQP CERV FREESTAND No Approval Required PNEUMAT STAND/FRME PNEUMATIC E0850 TRACT STAND FREESTAND CERV TRACT TRACTION STAND FREESTANDING No Approval Required CERVICAL TRACTION E0855 CERV TRACT EQUIP NO ADD STAND/FRAME REQUIRED E0856 CERVICAL TRAC DEVC INFL AIR BLADE CERVICAL TRACTION DEVICE No Approval Required OPPOSITE AIR BUDDLE E0860 OVER DOOR PULL EQUIPMENT CERV DOOR OVER PULL EQUIPMENT No approval required CERVICAL E0870 TRACT FRAME FOOT REQUIRED Part no. ARD EXTREM TRACTN E0880 TRACT STAND FREESTAND EXTREM TRACT TRACT STAND FREESTANDING No approval required EXTREMITY TRACTION E0890 TRAC FRAME ATTCH FOOTBRD PELV TRAC TRACTION FRAME ATTCH FOBOARD No approval required PELVIC TRACTION E0900 TRACT STAND FREESTANDING BELVTRA CT TRACTION STAND FREESTANDING No approval required PELVIC TRACTION B9 GRIP EZ BAR KNOWN AS PT HLPR ATTCH No approval required BED W/GRIP BAR E0911 TRAPEZ BAR PT WT >250 LBS BED GRAB TRAPEZ BAR HEVY DUTY PT WT >250 No approval required LBS BED GRAB BAR E0912 TRAPEZ BAR PT WT BDUPT HEVRY DUTY TREBTY FREE WT >250 No Approval Required LBS FREESTANDING E0920 FX FRAME ATTACHED BED INCLUDING WEIGHT USE FRAME ATTACHED TO BED No Approval Required INCLUDING WEIGHT E0930 FX FRAME FREESTANDING INCLUDING WEIGHT INCLUDING FRACTURE FRACTURE5. CONTINUATION PSV MOT EXER DEVC KNEE ONLY CONTINUOUS PASSIVE COUNTER EXERCISE No authorization required DEVC KNEE ONLY E0940 TRAPEZE BAR FREE CMPL W/GRAB TRAPEZE BAR FREE STANDING No authorization required BAR COMPLETE WITH HILL E0941 GRAVITY ASSTD TRAC DEVICE ANY TYPE GRASS. ITY requires A0941 AUT. CERVICAL HEAD APPLES/HALTER No approval required E0944 PELVIC BELT/ PELVIC BELT/ PISMA PELVIC BELT/ SUPPORT No approval required E0945 EXTREME BELT/ HARNESS EXTREME BELT/ HARNESS No approval required E0946 CACHRO FRAM BACRAL DU AL S BARS Approval not required ATTACHED TO BED E0947 FX FRAME ATTCH CMPLX PELV TRAC FRACTURE FRAME ATTCH COMPLEX DME authorization required Full clinical examination BELVIC TRACTION E0948 FX FRAME ATTCH CMPLX CERV TRAC FRACTURE CLINIC E0950 WHEELCHAIR ACCESSORY TRAY EACH WHEELCHAIR ACCESSORY TRAY EACH No Approval Required E0951 HEEL ATTACHMENT/HOLDER ANY TYPE EACH HEEL/HOLDER TYPE W/WO ANKLE No Approval Required EACH E0952 LOOP/TOE HOLDER ANY TYPE EACH LOOP/HOLDER ANY L0C REQUIRED ANY L0C Thigh/Knee ANY WHEELCHAIR AC THIGH END/KNEE REQUIRED Authorization General Medicine - Full Clinical Exam ANY TYPE EA Health & Behavioral Assessment/Intervention E0954 WHEELCHAIR AC FOOT BOX ANY TY EA FT ROOM CHAIR ACCESSORIES Complete Medicine APPENDIX Clinical Exam ANY TYPE EACH FOOT Medical and Behavioral Assessment/Intervention E0955 WC ACSS CUSHND HARDWARE WC ACSS CUSHND HARDWARE WC ACSS CSHNED FIX No EA approval required EA MOUNTING HARDWARE E0956 WC ACSS LAT TRNK/HIP HARDWARE L EA W required Acquired EA MOUNTING HARDWARE

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E0957 TOILET ACCESS WITH THIS SUPP HARDWARE EA TOILET ACCESS WITH THIS SUPP FIX MOUNTER No approval required HARDWARE EA E0958 MNL TOILET ACCESS 1-HAND DRIVE ATTACHMENT EA MANUAL WHLSTOL ACCESS 1-HAND No approval required DREANL DRIVE WAMP 95SS9 ANNUAL WHEELCHAIR ACCESS No application roval required EA ADAPTER FOR AMPUTES EA E0960 WC ACSS SHLDR HRNSS/STRAPS/CHST STR WC ACSS SHLDR HRNSS/STRAPS/CHST No approval required STRAP M/TIP MOU E0961 MNL WC ACCESS WHL approval LOCK BRAKE EXT EA E0966 MNL WC ACCESS NEAR CARRIER EXTENSION EA WHEELCHAIR ACCESS MANUAL Approval not required HEADREST EXTENSION EA E0967 MNL WC AC HND RIM PROJ REPL ONL EA MNL WHLCHR REQUEST AC HND AIM 9 COMFORT SEAT REQUIRED WHEELCHAIR COMFORT SEAT No approval required E0969 WHEELCHAIR PROTECTION UNIT WHEEL PROTECTION UNIT IĆ AIR Authorization not required E0971 MNL WC ACSS ANTI -TIP PING DEVC EA MNL WHEELCHAIR ACCESSORY ANTI- NO Auth Required 9 ARMRST EA WC ACCSS ADJUSTBL HT DTACH Authorization not required ARMRST CMPL ASSMBL EA E0974 MNL WC ACCESS ANTI-ROLLBACK DEVC EA MANUAL WHEELCHAIR ACCESS ANTI- No authorization required RETURN DEVICE EA E0978 WC ACSS PSTN/SFTY BELT/PELVTROLLER STRP/ BELT REQUIRED EA E0980 WHEELCHAIR SAFETY VEST WHEELCHAIR SAFETY VEST No authorization required E0981 WC ACSS SEAT ART REPLACEMENT EA ACCESS ONLY WHEELCHAIR SEAT OPPHLSTR No Authorization Required REPLCMT ONLY EA E0982 TOILET ACCESS RE SET NO. uth Required ONLY REPLCMT EA E0983 MNL WC ACSS PWR ADD-ON CNVRT MNL MNL WC ACSS PWR ADD-ON CONVRT No approval required WC MNL WC MOTRIZD WC E0984 MNL WC ACSS PWR ADD-ON CNVRT MNL MNL WC ACSS PWR ADD-ON CONVRT None authorization required WC8IZ MNL WC MOTR9 Wheelchair Access Seat Lift Mech Wheelchair Accessories Seat Lift No Autht Mechanism Required E0986 MNL WC ACSS PSH-RM ACT PWR ASST SYS MNL Wheelchair ACSS Push-Rim Act Authorization Required DME Full Clinical Review PWR Assist SYN MANUAL WC ACCESSORI ES LEVR - No authorization required ACTIVATD WHL DRIVE PAIR E0990 WC ACCSS STUDENT FOOTREST CMPL ASSMBL WHEELCHAIR ACCESS STUDENT FOOTREST No authorization required CMPL ASSMBL EA E0992 MNL ACCESS SUPPORT CHAIR AUT. SOLID SEAT INSERTS Required E0994 ARMREST EACH ARMREST EACH No approval required E0995 WC AC CALF ROLLER/CUSHION REPLACEMENT EA ONLY WHEELCHAIR ACCESSORIES CALF No approval required RETS/CUSHION REPL EA ONLY E1002 WC ACSS PWR SEATING SYS TILT SYS ONLY WHEELCHAIR ACCESS REQUIRES ADDITIONAL EQUIPMENT WITH ELECTRIC SEAT. LINE ONLY NO SHREAR RDUC WC ACSS PWR SEAT SYS RECLINE U/O No approval required HEAR RDUC E1004 WC ACSS RECLINE W/MECH HEAR RDUC WC ACSS PWR SEAT SYS RECLINE No approval required M/MECH SHER RDUC E1005 WC RECLINE WCRC RECLINE ACSS PWR SEAT SYS RECLINE Authorization Required DME Full Clinical Examination W/PWR SHRINK RDUC E1006 WC ACSS TILT&RECLINE NO SHEAR RDUC WC ACSS PWR SEAT SYS TILT&RECLINE Authorization Required DME Full Clinical Examination NO SHEAR RDUC E1007 ACCLIN TILT WRECL ADD Authorization Required DME Full Clinical Examination MECH SHEAR RDUC E1008 WC ACSS TILT&RECLINE PWR SHEAR RDUC WC ACSS PWR SEAT TILT&RECLINE Authorization Required DME Full Clinical Exam W/PWR SHEAR RDUC E1009 WC ACCSS MECH LINKE LINK SELEVAT AquiDD AquiDD Aquid WEG PWR BEN ELEV SYS EA E1010 WC ACCSS PWR BEN ELEV SYS PAR WC ACCSS ADD PWR SEAT SYSTEM PWR LEG No approval required HEIGHT SYSTEM PAIR E1011 MOD PED SIZE TOILET WIDTH ADJ. PEDIATRIC SIZE PACKAGING TOILET PACK CUSTOMIZE 10C. YS CNTR MNT EA WC ACCSS PWR SEAT SYS CNTR MNT Authorization required DME Full clinical examination PWR LEG HEIGHT EA E1014 RECLIN BACK ADD PED SIZE WHLCHOLICA RECLIN BACK ADDIT PEDIATRIC SIZE No approval required WHEELCHAIR ABSOREL MANUBERL ABSOREL MANUBSOREL MANUBERL ABSOR EL MANUBERL No approval required EA WHEELCHAIR EACH E 1016 ELECTRIC WHEELCHAIR SHOCK ABSORBER POWER WHEELCHAIR SHOCK ABSORBER No EA approval required WHEELCHAIR EACH E1017 HEAVY DUTY SHOCK ABSORBER AUT. ORBR PWR WC EA HEVY DUTY BUMPERS No approval required HEVY/XTRA HEVY PWR WC EA E1020 RES LIMB SUP SYS WHEELCHAIR ANY TYPE LIMB SUPPORT SYSTEM ANY TYPE WHEELCHAIR ANY TYPE No approval required E1028 WC ACCSS MAN SINGAWAY OTHER CNTRL NO CNTRL. /PSTN E1029 WHEELCHAIR ACCESS VENTILATION TRAY FIX WHEELCHAIR ACCESSORIES FAN No approval required TRAY FIX E1030 WHEELCHAIR ACCESS FAN TRAY GIMBALED WHEELCHAIR ACCESSORIES FAN No approval required TRAY GIMBALED E1031 RULLABOUT CHAIR AND CHAIRS WITH CHAIRS Auth. W/WHEELS 5 IN/GT E1035 MX-PSTN PT TRNSF SYS PT 300 LBS E1037 TRANSPORT CHAIR PEDIATRIC SIZE TRANSPORT CHAIR PEDIATRIC SIZE No Approval Required E1038 TRNSPRT CHAIR PT WT CAP TO&= 300 LB TRNSPRT CHAIR ADLT TOSZ&IN Auth PT WT 30RT No T90 Rquid. C30R CHAIR ADLT PT WT CAP>300 LB TRNSPRT CHAIR ADLT SZ HEVY DUTY PT No Authorization Required WT CAP>300 LB E1050 FULL RECLINE WC FIXED ARMREST FULL RECLINE WHL CHAIR; FIX FULL-LEN Required DME Approval Full Clinical Examination ARMS LEG REST E1060 FULL RECLN WHLCHAR;DTACH ARM FULL RECLIN WHLCHAIR; DTACHBLE DME Approval Required Full Clinical Examination LEGRST ARMS LEG SUPER E1070 FULL RECLN WHLCHR; DTACHBLE authorization required DME Full clinical examination FOOTRST ARMS FOOT SUPORTS

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E1083 HEMI-W/C; FIXED LEG REMOVING ARM HEMI-W/C; FIXED ARMS WITH FULL LEATHER DME approval required Full clinical examination DETACHABLE FOOT CHAIR E1084 HEMI-WHEELCHAIR; HEMI WHL CHAIR WITH ARMS FOR PREGNANT WOMEN; DTACHBLE ARMS Required DME Approval Full Clinical Examination LEGRST DESK/FULL LEGRETS E1087 TALL RIGID WHEELCHAIR; FIX ARMS LEGRST HI-STRGTH LGHTWT WHEELCHAIR; REPAIR Authorization Required DME Full Clinical Examination ARMS DTACH LEGRST E1088 HI-STRGTH WHLCHAIR;DTACH ARM HI-STRGTH LGHTWT WHLCHAIR; DME approval required Full clinical examination LEGMRST DTACHBL ARMS LEG SUPER E1092 WIDE HEVY-DUT WHLCHR; DTACH ARM WIDE HEAVY WHL CHAIR; DME approval required Full clinical examination BEN LEG SPACER WITH DETACHABLE ARMS E1093 WIDE HEAVY DUTY WHLCHR; ASSIGNABLE HEAVY HAND CART; DME approval required Full clinical examination of the FEET ASSIGNABLE ARMS FOOT RESTS E1100 SEMI-RECLINE WHLCHR;FIXED ARM DTAČ LEG SEMI-RECINE TROLLEY; FIX ARMS Required DME approval Full clinical examination DTACHBLE LEG SUPPORT E1110 SEMI-CLIN WHLCHR; DTACH ARM SEMI-RECLIN WHL CHAIR; DTACHBLE DME approval required Full clinical examination ARM HEIGHT FOOTREST E1150 WHEELCHAIR; FOOTREST WITH ARMCHAIR; DTACHBLE ARMS DTACHBLE DME Authorization Required Full Clinical Examination STUDENT LEG SUPPORT E1160 WHEELCHAIR; FIX ARMS DTACHBL LEG SUPER WHLSTOOL; FIX FULL-LEN ARMS Required DME Approval Full Clinical Review DTACHBL EVIS LEGRSTS E1161 MANUAL ADLT SZ WC INCL TILT SPACE MANUAL ADULT SIZE WHEELCHAIR Required DME Approval Full Clinical Review INCL TILT SPACE E1170 AMP WHLAIR; FIX ARM DTACH LEG CHAIR AMPUTATE; FIX FULL ARMS Required DME Approval Full Clinical Examination DTACHBL LEGRESTS E1171 AMP WHLCHAIR; FIX ARM NO AMPUTATE STROLLER; FIX FULL ARMS Required DME Approval Full Clinical Examination FOOT/LEG U/O FOOT/LEG SUPER E1172 AMP WHLCHR; DTACHBL ARMS Required DME Approval Full Clinical Examination FOOT/LEG WHEELCHAIR WITHOUT FOOT/LEG REST E1180 AMP WHEELCHAIR; DTACHBL ARMS AMPUTATE WHLSTOL; DTACHBL ARMS Required DME Approval Full Clinical Examination FOOTWEAR DTACHBL FOOTBARS E1190 AMP WHEELCHAIR; DTACHBL ARMS AMPUTATE WHLSTOL; DTACHBL ARMS Required DME Approval Full Clinical Examination FOOT RESTS DTACHBL FOOT REST E1195 HVY DUT WHLCHR;FIX ARM DTACH LEGRST HEVY DUTY WHLCHAIR; FIX FULL ARMS Required DME Approval Full Clinical Examination DTACHBL LEGMRST E1200 AMP WHEELCHAIR; FIX ARM DTACH AMPUTATE WHLSTOL; FIX FULL ARMS Required DME Approval Full Clinical Examination FOOTRST DTACHBL FOOTRSTS E1220 DRIVER'S CHAIR; SPCL SIZE/BUILDER WHEELCHAIR; SPECIAL SIZE OR Authorization required DME Full Clinical Review CONSTRUCTED E1221 WHEELCHAIR WITH FIXED ARM DME Approval Required Full Clinical Review FOOT RESTS FOOT RESTS E1222 WHEELCHAIR WITH FIXED ARM LIFTING ARM ARM LIFT Authorization Full Clinical Examination LEG LIFT TS E1223 WHEELCHAIR W / DETACHABLE ARM WHEELCHAIR WITH DETACHABLE ARMS Requires DME Approval Full Clinical Review FOOT RESTS FOOT RESTS E1224 WHLSTAIR W/DTACHBL ARMS STUDENT WHEELCHAIR W/DETACHABLE ARMS Requires DME Approval Full Clinical Review LEAT1224 CLINICAL DEVELOPMENT 1224 WHLSTAIR W/DTACHBL ARMS STUDENT DISABILITY WHEELCHAIR W/DETACHABLE HANDLES DME Approval Required Full Clinical Review E1224 FOOT CHAIR W/DTACHBL ARMS STUDENT WHEELCHAIR W/DETACHABLE HANDLES DME Approval Required Full Clinical Review E1224 FOOT CHAIR W/DTACHBL ARMS STUDENT WHEELCHAIR W/DETACHABLE HANDLES DME Approval Required Full Clinical Review SELV2 PAD BEHIND EA WHEELCHAIR ACCESS INSTRUCTIONS TIONS Approval not required SEMI-RECLINE BACK EACH E1226 WC ACCESS MNL FULL BACK RECLINE EA WHEELCHAIR ACCESS MANUAL FULL No clearance REQUIRED BACK SUCCESS EACH E1227 SPECIAL ARM HEIGHTS FOR WHEELCHAIRS SPECIAL ARM HEIGHTS FOR None Auth Required WHEELCHAIR SPECIAL FOR WHEELCHAIR SPECIAL E128 RE AR. No Approval Required WHEELCHAIR E1229 WHEELCHAIR PEDIATRIC SIZE NO SZ TILT-IN-SPACE RIGID Authorization Required DME Full Clinical Exam ADJUSTBL W/SEAT SYS E1232 WC PED SZ TILT-IN-SPACE FOLD W/SEAT WC PED SZ TILT-IN-SPACE FOLD Approval Required DME Full Clinical Exam ADJUSTBL W/SEAT SYS E1233 WC PED SZ TILT-I-SPCE RIGD NO SEAT WC PED SZ TILT-IN-SPACE RIGD Authorization Required DME Full Clinical Exam ADJUSTBL U/O SEAT E1234 WC PED SZ TILT-IN-SPACE RIGD I - SPCE Folding NO SEAT WC PED SZ TILT- IN-SPACE FOLD Authorization Required DME Full Clinical Exam ADJUSTBL U/O SEAT E1235 WC PED SZ KRIV ADJUSTBL W/SEAT SYS WHLCHAIR PED SIZE PED SIZE ADJUSTBL Authorization Required DME Full Clinical Exam W/ SEAT SYSTEM E1236 WFOC PEDJUSTER SSZ WHLSTOL PED SIZE FOLD ADJUSTBL Authorization Required DME Full Clinical Exam W/SEAT SYSTEM E1237 WC PED SZ RIGID ADJUSTBL NO SEAT SYS WHLSTOL PED SZ RIGID ADJUSTBL U/O Authorization Required DME Full Clinical Exam WHLSTOL PED SZ KRUT ADJUSTBL NO SEAT SYS S WHL CHAIR PED SZ RIGD ADJUSTBL U/O Approval Required DME Full Clinical Review WHLSTOL PED SYSTEM SEATHLYSCHAIR E12 PED SZ FOLD ADJUSTBL U/O No Approval Required SEAT SYSTEM E1239 ELECTRIC WHEELCHAIR PEDIATRIC SIZE NO ELECTRIC WHEELCHAIR PEDIATRIC SIZE Authorization Required D ME Full Clinical Review NOS E1240 LGHTWT WHEELCHAIR; DTACH ARMS LGHTWT WHEELCHAIR; DTACHBLE ARMS Required DME Approval Full Clinical Examination BEN DTACHBLE ARMS E1270 LGHTWT WHLCHR; FIX ARM DTACH LGHTWT WHEELCHAIR; FIX ARMS Required DME Approval Full Clinical Examination LEGRST DTACHBLE EVIS LEG SUPPORT E1280 HEVY-DUTY WHLCHR; DTACH ARMS HEAVY DUTY WHL CHAIR; DTACHBLE DME approval required Full clinical examination LEGRST ARMS ELEV LEG SUPER E1295 HEAVY DUTY WHEELCHAIR; FIX ARMS LEGRST HEAVY WHEELCHAIR; FIX FULL ARMS Needs DME approval Full clinical exam FOOTREST STUDENT E1296 SPECIAL WHEELCHAIR SEAT HT FROM FLR SPECIAL WHEELCHAIR SEAT HEIGHT Needs DME approval Full clinical exam FROM FLOOR E1297 SPECIAL WHEELCHAIR SEAT DEEP HELP DEPTH UPH. Clinical Review MOLSTER E1298 SPCL WHEELCHAIR SEAT DPTH&/WDTH SPECIAL WHEELCHAIR SEAT DEPTH & OR Required DME Approval Full Clinical Review CNSTR WIDTH CONSTRUCTION E1310 WHIRLPOOL NON-PORTABLE WHIRLPOOL NON-PORTABLE Required DME Approval Full Clinical Review E1352 FLPOSWYGEN PRGEN FLO XYGEN REG FL OXYGEN PRGEN. POS No approval required INSPIRATIONAL PRESS E1353 REGULATOR REGULATOR No approval required E1354 O2 ACCESS CART PRTBLE CYL/CONC REPL O2 ACCESS WHEEL PRTBLE No approval required CYL/CONC REPL EA E1355 RACK/SHELF RACK/CARRIER No authorization required BACCESS2 PAK/NOS OPLESS TR6 E13CRD RY PACKAGE /CRTRDGE No approval required PRTBLE CONC REPLACEMENT EA E1357 O2 ACCESS BATTERY CHARGER REPLACEMENT EA O2 ACCESS BATTERY CHARGER PRTBLE No approval required CONC REPL EA E1358 O2 ACCESS DC POWER ADAPTER EA O2 ACCESS REPLACEMENT DC POWER ADAPTER AFTER REPLACEMENT DC POWER ADAPTER 1 EMM EXTERNAL HEATER NEBULIZER Immersion EXTERNAL HEATER FOR No approval required NEBULIZER

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E1390 O2 CONC 85%/>02 CONC PRSC FLW RATE O2 CONC 1 PART 85%/>02 CONC AT No approval required PRSC FLW RATE E1391 02 CONC 2 PART 85%/>02 CONC FLW RATE O2 CONC 2 />O2 CONC No approval required PRSC FLW RATE EA E1392 PORTABLE OXYGEN CONCENTRATOR PORTABLE OXYGEN CONCENTRATOR No approval required RENTAL RENTAL E1399 DME MISCELLANEOUS DURABLE MEDICAL EQUIPMENT Approval required MISCEL0H&O Complete C4H2002 YS W/HEAT PART OXYGEN & STEAM ENRICHMENT No approval required SYS W/HEATED DELIVERY E 1406 O2&W ATER VAPR WORSE SYS NO HEATING DEL OXYGEN&WATER VAPOR ENRICHMENT SYS No Authorization Required U/U HEATED DELIVERY E1500 DIALYSIS CENTRIFUGE DIALYSIS CENTRIFUGE DIALYSIS E150 KEYNED REQUIRED NEY DIALIZATO DEL SYS KIDNEY No Authorization Required MACH PU MP RECIRC E1520 HEPARIN INFUSION PUMP HEMODIALYSIS HEPARIN INFUSION PUMP FOR No approval required HEMODIALYSIS E1530 AIR BUBBLE DETECTOR HEMODIAL EA REPLACEMENT AIR BUBBLE DETECTOR HEMODIALYSIS 1 RE4 REPLEA REPLEA1 RE4 REPLEA REPL HEMODIALYSIS PRESSURE ALARM No approval required. EACH REPLACEMENT E1550 BATH CONDUCTIVITY METER HEMODIAL BATH CONDUCTIVITY METER FOR No EA approval required HEMODIALYSIS EACH E1560 BLD LEAK DETECTOR HEMODIAL EA REPL BLOOD LEAK DETECTOR HEMODIALYSIS No approval required EA REPLACEMENT E1570 ADJUSTABLE CHAIR FOR EXHIBITOR CHAIR red E1575 TRNSDUCR PRTCTR/ BARR HEMODIAL SZ- TRANSDUCER PROTECTORS/FL No authorization required 10 BARRIER HEMODIAL SZ-10 E1580 UNIPUNCTURE CONTROL SYSTEM UNIPUNCTURE CONTROL SYSTEM FOR No authorization required HEMODIAL HEMODIALYSIS E1590 HEMODIALYSIS APPARATUS HEMODIALYSISUTISISE HEMODIALYSISUTISISE APPARATUS Required 592 AUTO INTERMITTENT PERITONEAL PERITONEAL no. Authorization required for dialysis, hemodialysis and peritoneal dialysis E1594 CYCLR DIALYSIS MACH PERITON DIALYS CYCLER DIALYSIS MACHINE FOR No authorization required Dialysis, hemodialysis PERITONEAL DIALYSIS and peritoneal dialysis and peritoneal dialysis E160 DELIV. INSTL STORAGE HEMODIAL No authorization required EQUIPMENT E1610 RVRS OSMOSIS H2O PURIF SYS HEMODIAL RVRS OSMOSIS H2O PURIFICATION No authorization required SYSTEM HEMODIAL E1615 DEIONIZATOR H2O PURIF SYS HEMODIAL DEIONIZER WATER PURIFICATION No authorization required SYSTEM HEMODIAL SIS E1620 BLOOD DIAGNOSE PUMPS Acquired REPLACEMENT REPLACEMENT E16 2 5 REPLACEMENT SYSTEM WATERS WATER REPLACEMENT SYSTEM FOR No Authorization Required HEMODIALYSIS HEMODIALYSIS E1630 RECIPROCATE PERITONEAL DIALYSIS SYSTEM RECIPROCATIVE PERITONEAL DIALYSIS No Authorization Required Dialysis, HEMODIALYSIS SYSTEM and Peritoneal Dialysis E1632 FERTILE ARTIFICIAL KIDNEY EACH WORN Lysis and Peritoneal Dialysis E1634 PERITONEAL DIALYSIS CLAMPS EACH CLA MPS FOR PERITONEAL DIALYSIS EACH No authorization required E163 5 COMPACT TRAVEL HEMODIALYZER COMPACT TRAVEL HEMODIALYZER No authorization required Dialysis, hemodialysis SYSTEM SYSTEM and peritoneal dialysis E1636 SORBENT CARTRIDGES HEMODIAL PR. HEMOSTATS EACH No approval required E1639 SCALE EACH SCALE EACH No approval required E1699 DIALYSIS EQUIPMENT NO. DIALYSIS EQUIPMENT NOT OTHER No Authorization Required STATED E1700 JAW MOTION REHABILITATION SYSTEM JAW MOTION REHABILITATION SYSTEM Authorization Required Temporomandibular Full Clinical Examination Treatment of Joint Dysfunction E170B REGYS PLOT 6 JAW MOTION REHABILITATION SYSTEM 6 JA W MOTION REHAB Authorization Required Temporomandibular Full Clinical Examination SU PARAGRAPH PKG SIX Joint Dysfunction Treatment E170 2 REPL MSR SCLS JAW MOT REHAB SYS 200 REPL MSR SCLS JAW MOTION REHAB Authorization Required Temporomandibular Full Clinical Examination SYSTEM PKG 200 Joint Dysfunction Treatment E1800 DYNBX DUSTABLE/DEFLX ADJUSTABLE/DEFLX ADJUSTABLE Auth Required M/SFT INTRFCE MA TL E1801 STATIC PROGRESS STRETCH ALBUE DEVC STATIC PROGRESSIVE STRETCH ELBOW No Authent Required UNIT E1802 DYN ADJUSTBL FORARM PRON/SUPIN DYN ADJUSTBL FORARM PRON/SUPUSTIN DEVC ADTL Equired Equired DYN ADJUSTBL FORARM PRON/SUPIN DEVC Authent 5 IST EXT/FLX DEVC DYN ADJUSTBL WRIST EXT/ FLX DEVC No authorization required M /INTERFCE MATL E1806 STATIC PROGRESSV STRETCH WRIST DEVC STATIC PROGRESSIVE STRETCH WRIST No authorization required UNIT E1810 DYN ADJUSTABLE KNEE EXT/FLX DEVC DYN EquitE ADJUSTBL KW 1. 811 STATIC PROGRESSV STRETCH KNEEE DEVC STATIC PROGRESSIVE STRET CH KNEE No authorization required required UNIT E1812 DYN KNEE EXT/ FLEX DEVC RESIST CNTRL DYN KNEE EXT/FLEX DEVC W/ACTV No approval required RESISTANCE CONTROL E1815 DYN ADFLX A DYN/ADFLX A DYN/ADFLX MANK EXT/FLEX DEVC INCL No approval required SOFT INTF MATL E1816 STATIC PROGRESSV STRETCHING ANKLE DEVC STATIC PROG. ANKLE RESEARCH STRETCH No approval required UNIT E1818 STATIC PROGRSV FOREARM STRETCH STATIC PROGRESSIVE STRETCH DEVC NR EPL0 REQUIRED DEVC18 DEVC STRETCH REQUIRED E1818 DYN EXT/FLX REPL SFT INTERFCE MATL DYN No approval required ADJUSTBL EXT/FLX DEVC E1821 REPL SFT INTERFCE MATL/MANCHET BI - DIR REPL SFT INTERFCE MATL/MANCHET BI -DIR No approval required STAT DEVC E1825 DYN ADJUSTABLE TOE EXT/FLX DEGR DYN No approval required W/SFT INTRFCE MAT E1830 DYN ADJUSTABLE TOE EXT/FLX DEVC DYN ADJUSTABLE TOE EXT/FLX DEVC No approval required W/ SFT INTRFCE MATL E1831 STATIC PROGRESSIVE STRETCH TOE DEVC STATIC PROGRESSIVE DEVELOPMENT AUT. DR FLX /ABDUCT/ROT DVC DYN ADJUSTBL SHLDR FLX/ABDCT/ROT No Approval Required DEVC SFT MATL

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E1841 STATIC PROGRS STRETCH SHOULDER DEVC STATIC PROGRESSIVE STRETCH Authorization required DME Full clinical examination SHOULDER DEVICE E1902 CMNCT BD NON-ELEC AUG/ALTERNTV CMNCT BD NON-ELEC AUG/ALTERNATV Medical clearance required Full clinical medical clearance required EVCT2. 000 GASTR SUCTN PUMP HOME MODEL ELEC GASTR SUCTN PUMP HOM MODEL No Approval Required PRTBLE/STATION ELEC E2100 BLD GLU MON INTEGRATED VOICE SYNTHESZR BLD GLU MONITOR W/INTEGRATED Approval Required DME Full Clinical Exam INDG200MON VOICE SLU C2010 MONTGV 10 00 VOICE 1. D BLD GLU MONITOR M /INTEGRATED No Authorization Required SAMPLE LANCING/BLD SAMPLE E2120 PULSE GEN SYS TYMPANIC TX INNR EAR PULSE GEN SYS TYMPANIC TX INNR EAR Authorization Required Hearing Aids Full Clinical Review ENDOLYMPH FL E220C SE MNL W201=No. Auth Required 20 IN & < 24 IN E2202 MNL WC ACSS SEAT WIDTH 24-27 IN MANUAL WC ACSS NONSTD SEAT FRME None Auth Required WIDTH 24-27 IN E2203 MNL WC ACSS SEAT DEPTH 20 < 11 ACSS NONSD MANUAL W Auth Required DEPTH 20 < 22 IN E2204 MNL TOILET ACSS SEAT DEPTH 22-25 IN MANUAL TOILET ACSS NOT TD SEAT FRME Approval Required DME Full Clinical Exam DEPTH 22-25 IN E2205 MNL TOILET HANDLE NO PROJ REPLACE WDRC MASK. No approval required PROJ REPL EACH E2206 MANL WC AC WL ASM CMPL REPL ONLY MANUAL WHEELCHAIR AC WL ASM No approval required EA CMPL REPL EA ONLY E2207 WHEELCHAIR ACCESS CRUTCHES & CANES HLDR WHEELCHAIR Equit CHAIR CHAIR Equit 2208 WHEELCHAIR ACCESS CYLTANK CARR EA ADDITIONAL CYLINDER FOR WHEELCHAIR No Approval Required TANK CARRIER EACH E2209 ARM CARD W/WO HAND HOLDER WITH OR WITHOUT Approval No Approval Required. ONLY TYPE REPL EA E2211 MNL WC ACCESS PNEUMATIC DRIVE TIRE MNL WHL CHAIR ACSS PNEUMATIC No approval required DRIVE TIRE ANY SZ E2212 MNL WC PIPE PNEUMATIC PROPULSION MNL WC ACCESS PIPE PNEUMATIC No approval required TIRE APPLICATION 3 LSN TIRE RES MNL WC ACSS INSRT PNEUMATIC Nr Required authorization DRIVE TIRES ALL SZ E2214 MNL TOILET ACCESS PNEUMATIC HOLLOW TIRE MNL WHL CHAIR ACCESS PNEUMATIC No approval required HOLLOW TIRES ALL SIZES E2215 MNL TOILET ACSS TUBE PNEUMATIC CASTR TIRE MNL WTUBECHAIR Acquired 2216 MNL TOILET ACSS FOAM FILLED DRIVE TIRE MNL TOILET ACCESS FOAM FILLED POSCA None approvals Required TIRES K ALL SZ E2217 MNL WC ACCSS FOAM FILLING HOLLOW TIRE MNL CROLLEY ACCESS ACCSS FOAM FILLING No approval required CASTR TIRES ALL SIZES E2218 MACSSION WNLFOAM WNL No approval required TIRE PROCEDURE ALL SIZES E2219 MNL WC ACSS FOAM HOLE TIRES RE ANY SZ MNL FOAM WHEELCHAIR ACCESS No approval required TIRES ALL SIZES ETC E2220 MNL WC AC SLD PROP T SZ RPL ONLY EA MNL WC ACSS SOLD PROPULSION REQUIRED 2C REPLØV E2C REPULS. AC SLD C TIR SZ REPL EA ONLY MNL WC AC SLD CSTER TIRES ALL SZ No approval required REPL EA ONLY E2222 MNL WC AC SLD C TIRES IN WHL SZ RPL E MNL WC AC SLD C TIRES IN WHL SZ RPL E No approval required MNL E2224 WC AC P WHL EXCL T SZ RPL E MNL ONLY WC ACSS PROP WHL EXCLD TIRES SZ No Approval Required REPL EA E2225 MNL ONLY WC CASTR WHL EXCLD TIRE REPL. CASTR FORK REPLACEMENT MNL ONLY WHL ACCESS CHAIRS CASTR FORK EVENTUAL No approval required SZ REPL EA ONLY E2227 MNL WC GEAR RED DRIVE WHEEL EACH MANUAL WC ACCESS REDUCTION GEAR No approval required DRIVE WHEEL EACH E2228 BNL WCEL WHEEL MACCYS WECLES BRAKE No approval required SYS&LOCK COMPLETE EA E2230 MNL WHEELCHAIR ACCESS MNL STAND HAND WHEELCHAIR ACCESSORIES No approval required SYS HAND STANDING SYS E2231 MNL WC ACCESS SOLID SEAT BASE MNL WC ACCESS ACCESSORIES SOLID E2W REQUIRED REQUIRED B2 LANR PED WC FIX ATTCH HARDWARE BAG PLANAR PED SZ WC INCL FIX No Approval Required ATTACH HARDWARE E2292 SEAT PLAN R PED WC FIX ATTCH SEAT HARDWARE PLANAR PED SZ WC INCL FIX No Approval Required ATTACH HARDWARE E2293 BACK CONTR PED WC PED WC PATTCED REQUIRED Full Clinical Review ATTACH HARDWARE E2294 SEAT CONTR PED WC ATTCH SEAT HARDWARE CONTOUR PED WC INCL FIX Authorization Required DME Full Clinical Exam ATTCH HARDWARE E2295 MNL WC ACCESS PED SIZE WC SEAT FRME MNLAMEC ACCESS DYNAMSIZEIC No W0C ACCESS PED Required ACC PWR SEAT EV. 01 WHEELCHAIR ACC PWR STND SYSTEM ALL TYPES WHEELCHAIR ACCESSORIES POWER No approval required STANDING SYSTEM ANY TYPE E2310 PTWEC ACC WCN ACCESS BETWEEN N WC No approval required CNTR CNTRLLER&ONE PWR E2311 PWR WC ACSS ELEC CNCT BETWN WC PWR WC ACSS ELEC CNCT BETWN WC No authorization required CNTR CNTRLLER&TWO/MORE E2312 POWER WC HAND /HOOK CONTROL POWER WC ACCESS HAND CONTROL 3 INTERFACE HAND COOLER 3 REQUIRED INTERFACE 3 RNESS UPGRADE EXP POWER WC ACCESS UPGRADE COMMUNICATION No authorization required CONTRLLR EXP CONTROLLR EA E2321 PWR WC ACSS HND CNTRL NO PRPRTNL PWR WC ACSS HND CNTRL REMOTE CONTROL No Authorization Required JOYSTCK NO PRPRTNL E2322 PWR WC ACTSCHMX No CRL WC ACTSCHMX ARL REQUIRED NOPPRRTNL SWTCH NO PRPRTNL E2323 PWR WC ACSS SPCLTY JOYSTCK HND PRFB PWR WC ACSS SPCLTY JOYSTCK HNDLE No Authorization Required PRFAB E2324 PWR W C ACSS CHIN CUP CHIN CNTRL INT POWER WHLCHAIR ACNT CHIN CHIN CHIN REQUIRED SS SIP&PUFF NENPRPRTNAL PWR WC ACSS SIP&PUFF INTERFCE No authorization required NEPROPRTNAL

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E2326 PWR WC ACSS BREATHER TUBE KIT SIP&PUF PWR WC ACSS BREATHER TUBE KIT SIP&PUFF INTERFCE No approval required E2327 PWR WC ACSS HEAD CNTRL MECH PWR WC ACSS HEAD CNTRL INTERFCE No approval required PWRC2 PROPRTNAL MERCH/8 PRPRTNL PWR WC ACSS HEAD CNTRL/EXT CNTRL None authorization required ELEC PRPRTNL E2329 PWR WC ACSS CNTC SWTCH NOPPRRTNL PWR WC ACSS HEAD CNTRL CNTC No authorization required SWTCH MECH NOPPRRTNL E2330 PWR WC ACCSS CNTC SWTCH NOPRPRTNL PRTNL MECH NONPPRRTNL E2331 PWR WC ACSS ATD ANT CNTRL PROPRTNAL PWR WC ACSS ACCESS CONTROL No authorization required PROPRO TIONAL E2340 POWER WC NONSTAND SEAT WD 20-23 IN POWER WC ACCESS NONSTAND SEAT No authorization required FRAME WD 20-23 IN E2340 NO PWR-2C PWR2C ACSS NONSTD SEAT FRME Authorization required DME full clinical examination WIDTH 24-27 IN E2342 PWR WC NONSTD SEAT DEPTH 20 /21 IN PWR WC ACSS NONSTD SEAT FRME No Approval Required DEPTH 20/21 IN E2343 PWRAT WCEPNSTH PWR WC WC ACSS NONSTD SEAT FRME Approval Required DME Full Clinical Examination DEPTH 22-25 IN E2351 PWR WC ACSS ELEC OP SPCH GEN DEVC PW R WC ACSS ELEC INTERFCE OPERATING DME CELL Clinical Examination SPCH GEN DEVC E2358 PWR4 NWRC WC ACCERE GRP 34 NONSEGALET NO AUTHOR - Sealed Potential Unshakable Approval Ea EA E2361 PWR WC ACSS 22NF PWR WC ACSS SEALED SEALED No Approval Required BATTERY EA E2362 PWR WC ACSS GRP 24 NON PROVISIONAL ACSSON 24 SEALED ACTSON LEAD BATTERY EA E2363 PWR WC ACSS GRP 24 SEALED BATTERY PWR WC ACSS GRP 24 SEALED LEAD No approval required EA E2364 PWR WC ACSS U- NEED 1 NON PROVISIONAL BATTERY PWR WC ACSS U-1 NEAR AUT- AUT. BATTERY EA E2365 PWR WC ACSS U-1 SEALED BATTERY PWR CART ACSS U-1 SEALED ELEAD No approval required ACID BATTERY EA E2366 PWR WC ACSS BATTERY CHARGER 1 WAY PWR WHL ACSS BATTERY CHGRGR 1 WAY/ Auth required. PWR26/Auth. WC ACSS BATTERY CHARGER DUL PWR WC ACSS BATT CHRGR DUL MODE No Approval Required MODE W/ANY BATT EA E2368 PWR WC CMPNT DR WHEEL MTR REPL POWER CHAIR CMPNT MOTOR No Approval Required REPLACE ONLY PWR GRNCHL WPL9CM WPL9CM WPL WRCHL ON CMPNNT DRIVE WHEN EL None approvals required GEAR HOUSING ONLY REPL ONLY E2370 P WC CMP INT DR WHL MTR&GB CMB RPL PWR WC COMP INT DR WHL MTR&GR No approval required BOX CAM ONLY REPL E2371 PWR WC LED ACLED SRP 27 WCSS GRP 27 S BLY No approval required ACID BATTERY EA E2372 PWR WC GRP 27 NOT -SEAL LED ACID BATT PWR WC ACSS GRP 27 NOT SEALED No Approval Required LEAD ACID BATTERY EA E2373 PWR WC MINI COMPACT REMOTE CONTROL PWR WC MINI-PROPORT J No Auth 74 PWR WC STANDARD REMOTE JOYSTICK PWR WC STANDARD REMOTE JOYSTICK No. approval required REPLACEMENT ONLY REPLACEMENT E2375 PWR WC NO -EXPANDABLE CONTROLLER PWR WC NON-EXPANDABLE CONTROLLER No approval required REPLACEMENT REPLACE ONLY E2376 PWR WC CONTROLLER PWR WC CONTROLLER No approval required REPLACE ONLY E2377 PWR WC EXPANDBL CONTROLLER PWR WC EXPANDABLE CONTROLLER No approval required UPGRADE UPGRADE INITIAL RELEASE E2378 POWER WC CMPNT ACTUATOR REPL DRIVE WHEEL COMPONENT ONLY No Authorization Required ACTUATOR REPLACEMENT ONLY E2381 PWR WC PNEUMATIC WHEEL APPLICATION WHJUL Auth. TIRE REPLACEMENT FOR EACH E2382 PWR WC TUBE WHEEL REPLACEMENT EA PWR WC TUBE PNEUMATIC DRIVE No authorization required WHEEL TIRE REPLACEMENT E2383 PWR WC INSERT WHEEL TIRE REPLACEMENT EA PWR WC INSERT PNEUMATIC WHEEL No authorization required AUTHORIZED TIRE REPLACEMENT ZATION EA 8EUMAT REPLASTI W3C W3C REPLACEMENT PNEUMATIC HOLLOW TIRES Approval not required ONLY EACH E2385 PWR WC TUBE HOLLOW TIRE REPL EA PWR WC TUBE PNEUMATIC HOLLOW TIRE No approval required REPLACE EACH E2386 PWR WC TIRE FOAM FILLED FOR WHEELS REPL EA PWR WC TUBE PNEUMATIC HOLLOW TIRE REPL EA PWR WC TUBE PNEUMATIC HOLLOW TIRE REPLACEMENT EA PWR CASTR FOAM FILLED TIRES PWR No approval required REPLACE EACH E2388 PWR WC FOAM TIRE REPLACEMENT ONLY EA PWR WC FOAM DRIVE WHEEL TIRE REPLACEMENT No approval required ONLY E23 REPL 8 EACH 9 WC 9 HOLLOW FOAM TIRE No approval required RE SET EACH E2390 PWR WC SOLID REPLACEMENT TIRE ONLY FOR EACH PWR WC DRIVE WHEEL REPLACEMENT TIRE No Approval Required EACH E2391 ONLY PWR WC SOLID WHEEL REPLACEMENT TIRE EJ WHEEL E 3 REV. 92 PWR WC S CASTR TIRE INTEGRATED REPL EA PWR WC SOLID CSTER TIRE INTEGRATED No approval required WHEELS REPL EA E2394 PWR WC DRIVE WHEEL EXCL TIRES REPL PWR WC DRIVE WHEEL EXCLUDES TIRES No approval required REPL CA 3STER ONLY WREPL W REPL WREPL ONLY C WHEELS EXCL. TIRES No Approval Required REPLACE EACH E2396 ONLY PWR TOILET FORKS REPLACE EACH ONLY PWR TOILET TOILET REPLACEMENT FORKS No Approval Required EACH E2397 POWER TOILET LITHIUM BATTERY POWER WHEELCHAIR L3uth REQUIRED NO. HEEL CHAIR AC DYN POS HARDWARE WHEELCHAIR ACCESSORIES DYNAMIC No Approval Required BAG POS HARDWARE BAG E2402 NEG PRSS WND TX PUMP STATN/PRTBL NEG PRESS TREATMENT RAN ELEC Authorization Required DME Full Clinical Exam PUMPESTATION/PRTBLE E2500 TALEDIGTIZDV

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E2502 SPCH GEN DEVC DGTZD>88 MIN 2020 MINS40 MIN REC TALE GEN DEVICE DIGITIZED >40 Approval Required General Medicine - Other Complete Clinical Examination MINS REC TIME Services and Procedures E2508 SPCH GEN DEVC SYNTHSIZD DEVICE REQ REQ. - Other Full Clinical Review SPELL & CNTCT Services & Procedures E2510 SPCH GEN DVC SYNTHSIZD MX METH SPCH GEN DEVC SYNTHESIZD MX METH Authorization Required General Medicine - Other Full Clinical Review MESS MESS&DEVC ACCSS Services & Procedures E2511 SPEECH STWARE GENERAL PC PRODUCTS Authorization Required General medicine - other Complete clinical examination DIGITAL ASSIST PROGRAM services and procedures E2512 ACSS SPCH GEN DEVICE ASSEMBLY SYSTEM ACCESS SPEECH GENERATION DEVICE Authorization required General medicine - other Full clinical examination ASSEMBLY SYSTEM services and procedures E2599 GENERATE ACCESS DEACCEESCHOR Authorization required General medicine - other Full clinical overview DEVICE NOC services and procedures E2601 GEN TOILET SEAT WIDTH < 22 DEPTH GENERAL WHEELCHAIR SEAT No approval required WIDTH < 22 DEPTH E2602 GEN TOILET SEAT CSHN SEATHL WDP2 GENERAL ENTRANCE/ENTRY No approval required WIDTH 22 IN/GT DEPTH E2603 SKN TOILET PROTECTION SEAT WDTH ANY HT E2617 CSTM FAB TOILET BACK CUSHION ALL SIZES CSTM FAB TOILET BACK CUSHION ANY SZ ALL No authorization required. EL.BACK SEAT No approval required CUSHION/BACK CUSHION EA E2620 PSTN TOILET BACK CUSHION PLANAR WD E2622 SKIN PROTECTION TOILET CUSHION WIDTH ANY DEPTH E2624 SKIN PROTECTION AND POSITION TOILET CUSHION WD SKIN CONTROL AND EXIT UD2C 6/6 REQUIRED ON 2C . C SHLDR ELB MOBL ARM SUPP ADJUSTBL WC ACCESS SHLDR ELB MOBIL ARM Authorization required DME full clinical examination SUPP WC ADJUSTBLE E2627 WC SHLDR ELB M SUPP ADJUSTBL RANCHO WC ACCESS SHLDR ELB M ARM SUPP Authorization required DME Full CDRBLINCEL MDR 2627 WC ADJUST S2627 IL SERVICING WC ACCESS SHLDR ELB MOBILE ARM Authorization required DME Full clinical examination SUPP TOILET RECLINE E2629 WC SHLDR ELB M SUPP FRICTN ARM SUPP WC ACCESS SHLDR ELB M ARM SUPP Authorization required DME Full clinical examination FRICTION ARM SUPP SHLNO ACCESS SHL ELB MOBILE Authorization required DME Full clinical examination HND MONOSUSP ARM HAND SUPP E2631 WC ADD MOBIL ARM SUPP ELEV PROX WC ACCESS ADD MOBIL ARM SUPPOR No approval required ARM ELEV PROX ARM E2632 WC ADD MOBL SUP OFFSET OFFSET/LAT ACCESS OFFSET/LAT ACCESS ROUGH ARM OFFSET/LAT RCKR ARM E2633 WC ACCS ADD MOBILE ARM SUPP SUPINATR WC ACCESS ADD MOBILE ARM SUPPOL No approval required SUPINATOR G0008 APPLICATION OF FLU VIRUS VACC APPLICATION OF INFLUENUENZA APPLICATION 09 VACC APPLICATION OF PNEUMOCOCCUS VACCINE G0010 APPLICATION OF HEPATITIS B No approval required APPLICATION OF HEPATITIS B VACCINE No approval required VACCINE G0068 PS ADM ANTI -INF PM ADM CD H E 15M PROF SRVC ADM ANTI-INFEC PM ADM No authorization required CD IND HM E 15 M G006 ADMQ IFMT ADM9 PRO SF SRVC ADM SUBQ IMT ADM CAL No authorization required DA IND HM EA 15 M G0070 PROF SRVC ADM CHEMO ADM CD H E 15 PROF SRVC ADM CHEMO ADM CAL YES No approval required M IND HOME EA 15 M G0071 PMT-BSRVC; FQHC PMT CMNCT TECHNICAL SERVICES; No Approval Required RHC OR FQHC ONLY G0076 SHORT CARE MGMT HOME VISIT NEW PT SHORT CARE MANAGEMENT HOME VISIT No Approval Required NEW PATIENT

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G0077 LIMITED CARE MGM HOME VISIT NEW PT LIMITED CARE MANAGEMENT HOME No authorization required VISIT NEW PATIENT G0078 MODERATE CARE MGMT HOME VST NEW MODERATE CARE MANAGEMENT HOME No authorization required PT VISIT NEW PTARE COMPARE G0078 MODERATE CARE MGMT HOME MGMT HOME No authorization required VISIT NEW PATIENT G0080 EXTENSIVE CARE MGMT HOME VST NEW EXTENSIVE CARE MANAGEMENT HOME No PT approval required VISIT FOR NEW PT G0081 SHORT CARE MGM HOME VISIT EXISTING PT SHORT CARE MANAGEMENT HOME required 2 MGMT HOME VST EXISTING PT LIMITED CARE HOME No approval required VISIT FOR EXISTING PT G0083 MODERATE CARE MGMT HOME VST EXST MODERATE CARE MANAGEMENT HOME No authorization required PT VISIT FOR EXISTING PT G0084 COMP CARE MGMT HOME VISIT EXISTS Required. PT G0085 EXTENSIVE CARE MGM HOME VST EXST PT EXTENSIVE CARE MANAGEMENT HOME No Authorization Required VISIT FOR EXST PT G0086 LMTD CARE MGMT HOME CARE PLAN LIMITED CARE MANAGEMENT HOME No Authorization Required OVER CARE PLAN OVERVIEW CARE P07 COMPARE CARE CARE HOME No Au th Required PLAN OVERVIEW OVERCARE G0101 CERV/VAG CANCR SCR; PELV&CLN BRST EX CERV/VAGINAL CANCER SCR; No approval required PELV&CLIN BREAST EXAMINATION G0102 PROS CANCER SCR; DIGTL RECTAL EXAMINATION PROFESSIONAL CANCER SCREENING; DIGTL No approval required ECTAL EXAMINATION G0103 PROSTATE CANCER SCREENING; PSA TEST PROSTATE CANCER SCREENING; PSA No approval required TEST G0104 COLOREC CANCER CHECK; FLEXIBLE COLORECTAL CANCER SCREENING; No approval required FLEXSIG G0105 COLOREC CANCR SCR; COLNSCPY HIGH RISK COLOREC CANCR SCR; KOLONSCPY No approval required[email protected]RISK G0106 COLOREC CANCR SCR; SIGMOIDSCOPY COLOREC CANCR SCR;ALT G0104 No approval required SIGMOIDSCPY BA ENEMA G0108 DM OP SLF-MGMT TRN SRVC IND-30 MIN DIAB OP SELF-MGMT TRN SRVC No approval required INDIVIDUAL PO 30 MT DM TSR G0MG-30 MIN DIAB SELF-MGMT TRN SRVC MT TRN SRVC GROUP No approval required SESSION PER 30 MIN G0117 GLAUC SCR HI RISK AT OPT/OFHTHLGIST GLAUC SCR HI RISIC BY No approval required OPTOMETRST/EYENLÄG G0118 GLAUC DR SCR DLAIRHI SCRUND SCRUND SCR UP No approval required OPTMTRST/OFHTHLGIST G0120 COLOREC CANCR SCR ; COLNSCPY BA COLOREC CANCR SCR; ALL G0105 No approval required ENEMA COLNSCPY BA ENEMA G0121 COLOREC CNCR SCR;COLNSCPY NO HI RSK COLOREC CANCR SCR; COLNSCPY NO Auth Required MEET HI RISK G0123 SCR CERV/VAG THIN LAY W/PHYS SUP SCR CYTOPATH CERV/VAG SCR Auth Required CYTOTECH UND PHYS SUPV G0124 SCR CERV/VAG THIN LAY SCR PHYSVATH Auth Required PREP INTEPR PHYS G0 127 TRIM DYSTROPHY NELE ANY NUMBER OF DYSTROPHY NAIL CUTTINGS ANYTIME No Approval Required NUMBER G0128 DIR SLIDE SERV RN OP REHAB EA 10MIN DIR SLIDE SERV RN OP REHAButh 10 REQ 10 ATX 5 REQ 10 ATX 10 REF QUAL TRPST PR SESSION OCCUP TX REQ SKILLS QUAL OCCUP No App roval Required TRPST PR. SESSION G0130 SEXA BN DNSITY STDY 1/>; APPNDICULR SEXA BN DNSITY STDY 1/> SITE; No authorization required APPNDICULR SKEL G0141 SCR CERV/VAG MNL RSCR PHYS INTERP SCR CYTOPATH SMER CERV/VAG MNL No authorization required RSCR INTEPR PHYS G0143 SCR CERV/VAG MNL SCR/RSCR UND PHYS PHYS SCR SCER required Auth PHYS G0144 SCR CERV /VAG SCR AUTO UND PHYS SCR CYTOPATH CERV/VAG THIN LAY SCR No approval required AUTO UND PHYS G0145 SCR CERV/VAG AUTO&MNL RSCR PHYS SCR CYTOPATH CERV/VAG SCR & VAG SCR AUTO CR&PHYSCR1 REQUIRED G0145 SCR CERV/VAG VAG AUTO UND PHYS SCR CY TOPATH SMERS CERV /VAG AUTO No Authorization Required UND PHYS SUPV G0148 SCR SMEARS CERV/VAG MNL RESCR SCR SCR CYTOPATH SMERS CERV/VAG AUTO No Authorization Required SYS W/MNL RESCREATH/VAG SRPH 5 HSP 5 YS THERAP HOME Authorization Required Home Health Services Full Clinical review HLTH /HOSPIC EA 15 MIN Valid Jan. 2021 Temporary Change: Network Validation Review G0152 SRVC OT HOM HLTH/HOSPICE EA 15 MIN. HOSPIC EA 15 MIN Effective Jan Temporary Change 2021: Network Validation Review G0153 SRVC SPCH&LANG PATH HH/HOSPIC EA 15 SRVC SPCH&LANG PATH HOME Approval Required Home Health Services Full Clinical Review HLTH/HOSPICE EA Jan 15 MIN2021. Review G0155 SRVC CLINICAL SW HH/HOSPICE EA 15 SRVC CLINICAL SOCIAL WORKER Approval Required Home Health Services Complete Clinical Review HH/HOSPICE EA 15 MIN Applicable Jan. 2021 Temporary Change: Network Validation Review G0156 SPVC AHSR/HO SRVC HSRIDE HOSPICE-AIDE AND HH/HOSPICE Authorization Required Home Health Services Complete Clinical Review SET EA 15 MIN Effective Jan. 2021 Temporary Change: Network Validation Review G0157 SRVC PT ASSIST HH/HOSPIC EA 15 MIN SERVICES PT ASSIST HOME Health Services Full Review of Required Home Health Services HEALTH/HOSPICE EA 15 MIN. Effective January 2021 Temporary Change: Network Validation Review G0158 SRVC OT ASSIST HH/HOSPICE EA 15 MIN. SERVICE OT ASSIST HOME Approval Required Home Health Services Full Clinical Review HEALTH/HOSPICE EA Jan 11 : Network Validation Review G0159 SRVC PT HH EST/DEL PT MP EA 15 MIN SERVICES PT HOME HEALTH EST/DEL PT Approval Required Home Health Services Complete clinical examination of MP EA 15 MIN. Effective January 2021 Temporary change: network validity review

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G0160 SRVC OT HH EST/DEL OT MP EA 15 MIN SERVICES OT HOME HEALTH EST/DEL OT Approval required Home Health Services Complete clinical examination MP EA 15 MIN. Effective January 2021 Temporary Change: Network Validation Review G0161 SRESTVC SLP HLPH TX MP 15 MN SERVICE SLP HH EST/DEL SPCH-LANG Authorization Required Home Health Services Full Clinical Review PATH MP EA 15 M Effective From January. Interim Change 2021: Network Validation Review G0162 SKILLED SRVC RN M&E POC; EA 15 MIN. qualified SERVICE RN M&E PLAN FOR requires authorization Home Health Services Complete clinical examination NURSING; EA 15 MIN. Effective January 2021 Temporary Change: Network Validation Review G0166 EXTERNAL COUNTERPULSION-TX SESSION EXTERNAL COUNTERPULSION PO No Auth Required TREATMENT SESSION G0168 WOUND CLOSURE TO TISSUE ADHESION ADH ACCESSORY ONLY. G0175 OVERVIEW OF THE INTERDISCIPLINARY TEAM CONFERENCE PT PRS OVERVIEW OF THE INTERDISCIPLINARY TEAM CONFERENCE. No Clearance Required W/PT PRESENT G0176 ACTV TX PTS DISABLED MENTL HLTH-SESS ACTV TX REL CARE&TX PTS DISABLED No Clearance Required MENTL HLTH-SESS G0177 TRN&ED PTS DISABLED DEVELOPED AUT. requested MENTL HLTH-SESS G0179 PHYS RE-CERT MCR-COVR HOM HLTH PHYS RE-CERT MCR-COVR HOM HLTH No authorization required SRVC SRVC RE-CERT PRD G0180 PHYS CERT MCR-COVR HOM HLTH SRVC PHYS CERT Auth MCRTHSR HVC Required PO CERT -in PRD G0181 PHYS SUPV PT RECV MCR-COVR HOM PHYS SUPV PT RECV MCR-COVR SRVC No Authorization Required HLTH HOM HLTH AGCY G0182 PHYS SUPV PT UND MCR-APPRVD HOSPICAREPT PHYS UNDERSIGNED Full Aide CPVICAREPT PHYS AIDE Review APPROV ED HOSPICE In effect from January 2021 Temporary change: G0186 DESTRUC LES CHOROID grid validation overview; PHOTOCOAG DESTRUC LOC LES CHOROID; Approval not required FEDR PHOTOCOAG FDER VES TECH G0237 FACIAL MUSCLES FACE 1 TO 1 EA 15 MIN. FACE TO FACE MUSCLE ONE ON ONE No approval required EVERY 15 MINUTES G0238 TX PROC IMPRV TX RESP NOT REQUIRED 1 OF 1 IN 15 MIN. G0237 FCE-FCE 15MIN G0239 TX PROC IMPRV RESP FUNCT 2/> IND TX PROC IMPRV RESP FUNCT/INCR RESP No approval required MUSC 2/> IND G0245 INIT PHYS E&M DIABETIC PT W/LOPS W/LOPS W/INITIAL DIABYS G0246 Required. /U EVAL DIABETIC PT W/LOPS MONITORING EVAL DIABETIC PT No Authorization Required NEUROPATHY W/LOPS G0247 ROUTINE FT CARE PHYS DIAB PT M/LOPS ROUTINE FOOTBED BY PHYS OF No Authorization W8 DIABETIC WLOPS INR. TOR DEMO HOME INR MON PT M/MECH HT No Approval Required VALVE CAF/VTE G0249 PRVS TST MATL&EQUIP HM INR MON;Q PRVS TEST MATL & EQUIP HOME INR No Approval Required WK MON; ONCE A WEEK G0250 PHYS REV INTEPR HOME INR MAN; Q WK PHYS REV INTEPR & PT MGMT HOME No approval required INR MON; 1 ONE WEEK G0257 UNSCHD/EMRG DIALYSIS AT OP NOT CERT UNSCHD/EMERG DIALYSIS TX ESRD PT No approval required AT OP NOT CERT G0259 INJECTION PROC SI JNT; INJECTION ARTHROGRAPHY PROCEDURE FOR SI JNT; Approval not required ARTHROGRAPHY G0260 INJ SI JNT; ANES &/TX AGT &ARTRHOG INJ PROC SI JNT;ANES STEROID&/TX No Approval Required AGT&ARTHROGRPH G0268 REMV IMP CERUMN SAME DATE FUNCT REMV IMP CERUMEN PHYS SAME DATE No Approval Required TSTMT AUDIO FUNKTION6CL PLCTROC9 TST G02 OCCL DEVC VENUS/ART POST No Approval Required SURG/INTRVNL PROC G0270 WITH MATE TX; ASSESSMENT W/PT EA 15 MIN WITH NUT TX; REASSESSMENT FLW 2 REF YR No approval required W/PT EA 15 MIN G0271 S NUT TX REASSESSMENT GRP EA 30 MIN WITH NUT TX REASSESSMENT FLW 2 REF YR No approval required GRP EA 30 MIN G0276 PILD/PLACEBO CONTROL/PLACEBO CONTROL TR No Authorization Required G0277 HPO UND PRSS FULL B CHMBR PER 30 MN HPO UND PRESS FULL BODY CHMBR PER Authorization Required Hyperbaric Oxygen Full Clinical Examination 30 MIN. TIME SHORT CATH G0279 DX DIGTL BRST TOMOSYNTHESIS UNI/BIL DIAGNOSTIC DIGITAL BREAST No Authorization Required TOMOSYNTHESIS UNI/BIL G0281 E-STIM 1/> CHRN STAGE III&IV ULCRS E-STIM 1/> AREAS CHRONIC STAGE Full radiology STAGE authorization CHRONIC STAGE and ULCRS authorization radiology G0283 E-STIM 1/>NOT WND CARE DEL TX PLAN E-STIM 1/> AREAS OTHER THAN WND No approval required CARE DEL TX PLAN G0288 RECON CT ANGIO AORTA PLAN VASC SURG RECON CT ANGIO AORTA required Not SURG G0289 SCPE KNEEE REMV FB TM SURG DIFF COMP SCOPE KNEEE REMV FB/SHAV TM OTH No Authorization Required SURG DIFF CMPRTMT G0293 NONCOVR SURG SEDAT ANES-MCR QUAL NONCOVR SURG SURG SURG-CONSC SEDAT Authorization Required Complete G0289 SEDAT 0294 NONCOVR PROC NO ANES/LOC-MCR QUAL NONCOVR PROC NO ANES/LOC ANES- Authorization Required Surgery Full Clinical Review MCR QUAL EXAMINATION-DAY G0296 CNSL VST DISCUSSION LDCT LW DS CT SCAN CNSL VISIT DISCUSSION NO Authenticating LDSE USER G7 LOW DOSE CT SCAN FOR LUNG CANCER SCR LOW DOSE CT SCAN FOR LUNG CANCER R Required authorization Radiology - diagnostics Complete clinical examination Radiology SCREENING Applies January. 2021 Temporary Change: Network Validation Review G0299 DIR SNS RN HH/HOSPICE MIN DOMEIRECT15RN SET HEALTH/HOSPICE Authorization Required Home Health Services Full Clinical Review SET EA 15 MIN Effective January 2021 Temporary Change: Network Validation Review G0300 DIR SNS LPN HH/HOSPCE SET EA 15 MIN DIRECT SNS LPN HOME HLTH/HOSPICE Authorization Full authorization required for clinical home health services. Overview of SET EA 15 MIN. 2021 Temporary Change: Network Validity Review G0302 PRE-OP PULM SURG SRVC PREP LVRS CMP PRE-OP PULM SURG SRVC PREP LVRS No approval required CMPL COURSE SRVC G0303 LM-PR0EPRS-1 LM YES PRE-OP PULM SURG SRVC PREP LVRS 10- No Approval required 15 YES SRVC

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G0304 PRE-OP PULM SURG PREP LVRS 1-9 YES PRE-OP PULM SURG PREP LVRS 1-9 YES No Authorization Required SRVC G0305 POST-D/C PULM SURG SRVC AFTER LVRS POST-D/C PULM SURG AFTER Auth Required 6 DAYS SRVC G0306 CMPL CBC AUTO&AUTO WBC DIFF COUNT COMPLETE CBC No approval required AUTOMATED&AUTOMATED WBC DIFF COUNT G0307 COMPLETE CBC AUTOMATED COMPLETE CBC AUTOMATED No approval required G0328 COLOREC CA SCR; FOB TST IMMUNO 1-3 COLOR CA SCR; FOB TST IMMUNO 1-3 No approval required. G0329 EM TX WOUND NOT HEALING 30 YES ELECMAGNET TX WOUND NOT INFECTIOUS Authorization required Wound Therapy PA for code in group Complete clinical examination 30 DAY CARE Applies to all codes within specific group G0RM3PN3 INHL RX;1. 30-DAY PHARM DISPENS FEE INHAL RX; HOME No Approval Required 30-DAY SUPPLY G0337 HOSPIC EVAL&CNSL SRVC PRE-SELECT HOSPIC EVALUATION & CNSL SERVICES No Approval Required PRE-SELECTION G0339 IMAGE GUIDE ROBOT ACCL SRS TX SESS ROBOTIC ATTACK Author Full View CMPL TX 1 SESS G0340 IMAGE GUID ROB SRS FRAC TX 2 -5 SESS IMAGING GUIDE ROBOTIC ACCL SRS FRAC Authorization Required Surgery Full Clinical Exam TX LES 2-5 SESS G0341 PERQ ISLET CELL TPLNT PV CATH&INFUS PERQ ISLET CELL TPLNT INCL PORTL VEN Transplants and complete examination services related to C VENOM Transplantation (including pre and post-transplant testing) G0342 LAP ISLET CELL TPLNT PV CATH&INFUS LAP ISLET CELL TPLNT INCL PORTAL VEN Authorization required Transplants and full clinical review CATH&INFUS transplant-related services (including pre- and post-transplant testing) G0343 CELLLA TPLOTIN transplant ISLET CELL TPLNT W/ PORTL authorization required Transplants & Full Clinical Review Transplant Related Services CATH&INFUS VENA (Inc Pre & Post Transplant Testing) G0372 PHYS EST & DOC NEEDED PWR MOBILE DEVC PHYS SRVC RQR FOR EST & DOC NEEDED PWR MOBILE G37 Needed PWR MOBILE HOSPITAL OBSERVATION SERVICE PR. HOURS OF OBSERVATION SERVICES IN THE HOSPITAL BY No. Authorization required TIME G0379 DIRECT ADMISSION PT HOSP NURSING NOTE DIRECT ADMISSION PATIENT HOSPITAL No authorization required. LEVEL 1 HOSPITAL EMERGENCY DEPARTMENT No authorization required VISIT TYPE B ED; G0381 LEVEL 2 HOSP ED VISIT TYPE B ED; LEVEL 2 HOSPITAL EMERGENCY DEPARTMENT No authorization required VISIT TYPE B ED; G0382 LEVEL 3 HOSP ED VISIT TYPE B ED; LEVEL 3 HOSPITAL EMERGENCY DEPARTMENT No authorization required VISIT TYPE B ED; G0383 LEVEL 4 HOSP ED VISIT TYPE B ED; LEVEL 4 HOSPITAL EMERGENCY DEPARTMENT No authorization required VISIT TYPE B ED; G0384 LEVEL 5 HOSP ED VISIT TYPE B ED; LEVEL 5 HOSPITAL EMERGENCY DEPARTMENT No authorization required VISIT TYPE B ED; G0390 TRAUMA RESPONSE TEAM W/HOSP CC TRAUMA RESPONSE TEAM ASSOC No clearance required SERV W/HOSP CC SERVICE G0396 ALC &/ SUBSTNC ABUSE ASSESSMENT 15-30 M ALCOHOL &/ABUSE ABUSE &/SYSTEMS ABUSE &/SUPPLY ABUSE &/ /STOCK ABUSE & /STOCK ABUSE &/STNC /SUBSTANCE ABUSE &/SUBSTANCE ABUSE &/SUBSTANCE ABUSE &/SUBSTANCE ABUSE &/SUBSTANCE ABUSE &/SUBSTANCE ABUSE/SUBSTANCE ABUSE 30 30 REQUIRED G0396 ALC &/ SUBSTNC ABUSE ASSESSMENT SUBSTANCE NC SUBSTANCE ABUSE ASSESSMENT > 30 MIN ALCOHOL ABUSE AND/ SUBSTANCE TYPE Approval not required ASSESSMENT >30 MIN G0398 HST W/TYPE II PRTBLE MAN MIN 7 CH HST W/TYPE II PRTBLE MON Authorization Required Sleep Studies Full Clinical Exam UNSUPERVISED MIN 7 January CH221. Temporary Change: Network Validity Review G0399 HST TYPE III PRTBLE MON MIN 4 CH HST W/TYPE III PRTBLE MON Authorization Required Sleep Studies Full Clinical Review UNSUSPECTED MIN 4 CH Effective January 2021 Temporary Change: Network Validity Review G0400 PRTBLE MON TYPE 3 CH HST M /TYPE IV PRTBLE MON Approval Required Sleep Studies Full Clinical Exam UNSUPERVISED MIN 3 CH Valid Jan. 2021 Temporary Change: Network Validation Review G0402 INIT PREV PE LTD LID 1. 12. M. MCR INIT PREV PE LTD NEW BENEF Auth. 12 MOS MCR Required G0403 ECG RTN ECG 12 LEAD 1. PREV PE ECG RTN ECG W/12 LEAD SCR INIT No Authorization Required PREVNTV PE W/I&R G0404 ECG RTN ECG W/12 LEAD ONLY MONITORING ECG1 RTN L ECG W Required U/I&R ONLY IN I&R G0405 EKG RTN EKG W/12 LEAD ONLY I&R EKG RTN EKG W/12 LEAD INTERPR & no authorization required FOR REPORTING ONLY G0406 FU IP CNSLT LTD 15 MIN VIA TELEHLTH F/UYS IP CNSLT PHMIN PT No authorization required VIA TELEHEALTH G0407 FU IP CNSLT INTRMD 25 MIN TELEHLTH F/U IP CNSLT INTRMED PHYS 25 MIN PT No approval required VIA TELEHLTH G0408 FU IP CNSLT CMPLX 35 MIN MIN/>UTELEHLNSTH 5 MIN 35 MIN/>PLXCM 5 PT No approval required VIA TELEHLTH G0409 SW & PSYCH S RVC EA 15 MIN F/F IND SOCL WRK & PSYCH SRVC EA 15 MIN No Approval Required FACE TO FACE IN G0410 GRP PSYCH NON FAM PAR AT GRPMX 50 GRPMX 50 FAM GRP PART No Approval Required AT 45-50 MIN G0411 INTRACTV GRP PSYCH PAR AT 45-50 MN INTERACTV GRP PSYCHOTX DEL HOS No authorization required 45 TO 50 MIN G0412 OPN TX ILIAC PLUS SPINE/OPIAC FX authentication SPINE/OPIAC WIRED AVUL/ILIAC WING FX G0413 PERQ SKEL FIX POST PELV BONE FX PERQ SKEL FIX POST PELV BONE None Approval Required FX&/DISLOC UNI/BIL G0414 OPN TX ANT PELV BONE FX &/ DISLOC OPN TX ANT PELV BONE FX &/ UNI/BIL G0415 OPN TX POST PELV BONE FX &/ DISLOC OPN TX POST PELV BONE FX &/ DISLOC No approval required UNI/BIL G0416 SURG PATH PROS NEEDLE BX ANY SURGICAL WAY PROSTATE NEEDLE No approval required G0416 SURG PATH PROS NEEDLE BX ANY SURGICAL WAY PROSTATE NEEDLE No approval required G4F0 EDU SRVC CKD; PER SESSION 1 HOUR EDU FACE TO FACE SRVC CKD; IN No PR approval required. SESS 1 HR G0421 F/F EDU SRVC CKD; GRP PR. SESSION 1 HOUR FACE TO FACE EDU SRVC CKD; GRP No PR approval required. SESSION 1 HOUR

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G0422 INTENSIVE SHORT REHABILITATION; W/WO EKG W/EXER INTENSIVE CARD REHAB; W/WO CONT No Approval Required ECG MON M/EXER G0423 INTENS CARD REHAB; W/WO EKG W/O EX INTENSIVE CARD REHAB; W/WO CONT No Approval Required EKG MAN U/O EXER G0424 PULM REHAB EXER 1 SAT SESS 2 PR. /IP 30 MIN No approval required W/PT TELEHLTH G0426 TELEHEALTH CONSULT ED/IP 50 MIN PT TELEHEALTH CONSULT ED/IP 50 MIN No approval required W/PT TELEHLTH G0427 TELEHEALTH CONSULT ED/IP CONPT TELEHEALTH/> 70 MIN/> No approval required PT TELEHELTH G0428 COLL MENISCUS IMPL FIL MENISCAL DEFEC COLL MENISCUS IMPL PROC FULFILLMENT Authorization required Complete clinical examination MENISCAL DEFECTS G0429 DERMAL FILLERS INJ TREATMENT INJ DERM FILERS LDS DERM FILERS Required G0432 INF AB EIA TECH HIV -1 &/OR HIV-2 INF AGT AB DETECT EIA TECH HIV- No approval required 1&/HIV-2 SCR G0433 INF AB ELISA TECH HIV-1 &/OR HIV-2 INF ANTISTOF ELISA TECH HIV-1 &/OR No approval required HIV-2 SCREEN G0435 INF AGT ANTIC DETECT RPD AB TST OMT INF AGT ANTIG DETECT RPD AB TST No approval required OMT HIV-1/-2 SCR G0438 ANNUAL WELLNESS VST; PERSNL PPS INIT ANNUAL WELLNESS VISIT; PERSONALIZATION No approval required PPS FIRST VISIT G0439 ANNUAL WELLNESS VST; PPS SUBSQT VST ANNUAL WELLNESS VST; PERSON No approval required PPS SUBSQT VST G0442 ANNUAL ALCOHOL ABUSE SCREENING 15 ANNUAL ALCOHOL ABUSE SCREENING No approval required MIN 15 MINUTES G0443 BRF F/F BHVR CNSL ALCMIN MISURE BEQ 15 ABUSE 15 MIN G0444 ANNUAL DEPRESSION SCREENING ING 15 MIN ANNUAL DEPRESSION SCREENING IJE 15 No approval required MINUTES G0445 HI INTNS BHV CNSL PREV STI; In the ED; HIGH INTENS BHV CNSL PREV STI; IN No ED SEX BHV approval required; G0446 ANN F2F INT BEHV TX CV DZ In 15 Mn Annual FCE-FCE INFECT VEST TX CV NO AUTHIVE Urgent DZ IN 15 MIN G0447 FCE-FCE BEARRL CNSL OBESITY 15 min Face-Face Behavioral Counseling No Authorization Obesity 15 min G0448 INS / RPL PRM CV-DFIB TV Lead Temp E INS/RPL PRM CV-DFIB TV Lead InSrt No Author Required Temp Elctrode G0451 DVLPMNT Test I&R Standard Instr Form Develpmnt Testing I&R No Authorization Required Standardizd Instrument Form G0452 MOLECULAR PAT STYLE PROCEDURE; DOCTOR No Authorization Required INTEPR REPORT G0453 C IO NEUROPHYS MON OUTSD OR EA 15 M CONT IO NEUROPHYSIOL MON OUTSD Authorization Required Surgery Full Clinical Review OR-PT EA 15 MIN G0454 PHYS DOC F2F DOCET F2F DOC F PHNPME VST DME DETRM No Appr oval Required PERF NP PA/CNS G0455 PREP IT FEC MICROBIOTA ASMT D SPEC PREP IT FEC MICROBIOTA ANY METH No approval required ASMT DONOR SPEC G0458 LDR PROSTATE BT SERVICE COMPOS RATETX LOW DOSAGE PROVC4 AUT. INPATIENT TELEHEALTH PHARMACOL INPATIENT TELEHEALTH No approval required MGMT PHARMACOLOGY MANAGEMENT G0460 AUTOLOGOUS THROMBOLIC PLASMA AUTOLOGOUS THROMBOLIC PLASMA No approval required G0463 IN OP ASSPTOS CLIN & VISIT CLIN VISIT CLIN No approval required EVALUATION & MGMT PT G04 66 FQHC NEW PATIENT VISIT ; FEDERALLY QUALIFIED HEALTH CENTER No approval required VISIT NEW PT; G0467 FQHC VISIT SPECIFIC PATIENT FEDERALLY QUALIFIED HEALTH CENTER No approval required ESTAB PT VISIT G0468 FQHC VISIT IPPE OR AWV; FEDERALLY QUALIFIED HEALTHCARE CENTER No VST IPPE/AWV approval required; G0469 FQHC VISIT MENTAL HEALTH NEW PT; FEDERALLY QUALIFIED HEALTH CENTER No approval required VST MH NY PT; G0470 FQHC VISIT MENTAL HEAT ESTAB PT; FEDERALLY QUALIFIED HEALTH CNTR No approval required VST MH ESTAB PT; G0471 COLL V BLD VP/URN SMP CATH IND SNF COLL V BLD VP/URN SMP CATH IND No approval required SNF/LAB BHALF HHA G0472 HEP C ABO SC IND HI RSK&OTH COV IND HEPATITIS C ABO SCUT REQUIRED HIGH RISK & G0473 FTF CNSL BEHAVIOR OBESITY GRP 30 MIN FACE TO FACE COUNSELING REQUIRED No approval required OBESITY GRP 30 MIN G0475 HIV ANTIGEN/ANTISTUB KAMM ANALYSIS SCR HIV ANTIGEN/ANTISTUB COMBINATION IN GASSAY SCREENDNA 0 GRANA CHECK REQUIRED IN GGT4 DNA; HPV ADD PAP T INF AGT DETECT DNA/RNA; HPV PERF No approval required ADD TO PAP TEST G0480 DR TST DEFIN DR ID M P D 1-7 DR CL DRUG TEST DEFINITV DR ID METH P DAG No approval required 1-7 DRUG CL G0481 DR TST DEFIN DR ID M P D DR 8-14 TEST DEFINITV DR ID METH P DAY No Approval Required 8-14 DRUG CL G0482 DR TST DEFN DR ID M P D 15-21 DR CL DRUG TEST DEFINITV DR ID METH P DAY No Approval Required 15-21 DR CL ID T0483 DR 22/M DR CL DRUG TST DEFINITV DR ID METH P DAG No Approval Required 22/MORE DR CL G0490 FTF HHN VST RHC/FQHC AREA SHTG HHA FACE TO FACE HH NSG VST RHC/FQHC No Approval Required HHAISTH1 DHAYSH AREA MC ESRD AC KID INJ NO ESRD DIALYSIS MCARE CERT ESRD FAC AC KID No Approval Required INJ U/O ESRD G0492 DIALY 1 EVL PHYS AC KID INJ NO ESRD DIALYSIS 1 EVAL PHYSICIAN AC KID INJ No Approval Required G0VCO9 3 SKD OBV&ASMT PT C EA 15 MIN EXPERIENCED SERVICES RN OBV & ASMT PT No Approval required COND EA 15 MIN G0494 SKD SRVC LPN OBS&ASMT PT C E 15 MIN. PT/F HH/HSPC E 15M SKD SRVC RN TRAIN&/EDU PT/FAM No Approval Required HH/HOSPC EA 15 MIN G0496 SKD SVC LPN T&/E PT/F HH/HSPC E 15M SKD SRVC LPN TRAIN&/EDU PT/FAM Approval not required HH/HOSPC E 15 MIN G0498 CTX IV INF T; INI INF OFC/CLIN SET CHEMOTX ADM IV INF TECH; INI INF No approval required OFFICE/CLIN SET G0499 HEP B SCR I NERID PREG HIGH RISK IN HEPATITIS B SCREENING AND NON-PREG No approval required HIGH RISK IN

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G0500 MOD SED SVC PRV SM PHYS PRV SM PHYS PER GI ENDO MODERATE SEDAT SRVC PROV SAME No approval required PHYS PERF GI ENDO G0501 RES-INT SVC PT SPZ M-ASST TECH MN RESOURCE-INT SRVC PT SPZ M-ASST No A06 CMP ASMT & C PLN PT RQR CC MGMT SVC COMP ASMT OF & CARE PLNG PT RQR No approval required CC MGMT SRVC G0508 TH C CC INT PHYS 60 M CMNCT PT&PROV TH CONSULT CC INIT PHYS C CC SB PHYS 50 M CMNCT PT&PROV TH CNSLT CC SUBS QT PHYS 50 MIN No approval required CMNCT PT & PROV G0511 RHC/FQHC G C MGMT 20 M/>C T-CAL MO RHC/FQHC ONLY GEN 20 M AMG CARE required >CLIN TM-CAL MO G0512 RHC/FQHC PS COCM 60 M/ > C TM-CAL MO RHC/FQHC PSYCHIATRIC COCM ONLY 60 No Approval Required M/>C TM-CAL MO G0513 PRLNG PREV SVC OFC/OTH O/P; 1ST 30 M PRLNG PREV SRVC OFC/OTH O/P RQR No DIR CTC Approval Required;1ST 30 M G0514 PRLNG PRV SVC OFC/O O/P;EA ADD 30 M PRLNG PREV SRVC OFC/OTH O/P DIR No CTC Approval Required ;EA ADD 30 M G0516 INSRT NONBIODEGRADABLE RX PART IMPL 4/> INSERT NONBIODEGRADABLE RX No approval required DELIVERY IMPL 4/> G0517 REMV NONBIODEGRADABLE RX PART IMPL 4/> REMOVE NONBIODEGRADABLE NØV-IMPLE 4/> G0518 REMV CONTROLS NON-BIODEG RX D IMPL 4/> REMV CONTROLS NON-BIODEGGRADABLE No approval required DRUG PART IMPL 4/> G0659 DRUG TST DEFIN DR ID M ANY # DR CLS DRUG TEST DEFINIT DRUG ID required. Lab Full Clinical Exam ALL # DR CLASS G0913 IMPRV VF ACHV IN 90 DA FLW CAT SURG IMPROVE VISUAL FUNCTION ACHV W/I 90 No approval required. FROM PATIENT G0915 IMPRV VF NOT AND 90 YES FLW CAT SURG IMPROVEMENT OF VISUAL FUNCTION NOT ACHV 90 No Approval Required DAN FLW CAT SURG G0916 CAREGIVER SATISFACTION AND 90 D FLW KAT SRG SATISFACTION M/CARE AUT REQUIRED 90 D FLW CAT SRG G0917 PT SATISFACTION SURVEY NO CMPL PT SURVEY PATIENT SATISFACTION NO No Approval Required PUN PATIENT G0918 CAREGIVER SATISFACTION NO 90 D FLW CAT SRG M/CARE SATISFACTION NO ACHV 90 No Approval Required PRG G0 0 0 0 0 0 0 0 1 CR AUC CDS MECH APPL P/W DFND MCR No approval required APPROP APPLICATION CRITERIA G1001 CDS MECH EVICORE DFIND MCR AUC CLIN DEC SUPP MECH EVICORE DEFIND No approval required PROG MCR AUC PROG G1002 CDSM MEDCURRUC PPCL WITH DFIND MCR Obtained No IND MCR AUC PROG G1003 CDSM MEDICALIS DEFINED MCR A UC CLIN DEC SUPP MECH MEDICALIS No approval required PROG DEFIND MCR AUC PROG G1004 CDSM NDSC DEFINED MEDICARE AUC CLINICAL DEC SUPP MECH NDSC No approval required MCR A PROG DEFINED G A10 DEFINED MEDICINE. CLINICAL DEC. SUPP MECH NIA DEFINED No approval required MCR AUC PROG G1006 CDSM TEST APPROP DEFINED MCR AUC CLINICAL DEC SUPP MECH TEST APPROP No approval required DFIND MCR AUC G1007 CDSM AIM DEFINED MEDICARE AUC PROG CLINICAL MECH Auth Auth 8 CDSM CRANBERRY PEAK DEFINED MCR CLIN DEC SU PP MEH CRANBERRY PEAK No approval required AUC DEFIND MCR AUC G1009 CDSM SAGE HMS DEFINED MCR AUC PROG CLIN DEC SUPP MECH SAGE HMS No approval required DEFINED MCR AUC PROG G1010 PROFINEDSM MCRAN G1010 PROFINEDSM MCR CHIN A DEC. Approval required DEFINED MCR AUC PROG G1011 CDSM QUALITY TOOL NO. DEFINED MCR AUC CLIN DEC SUPP MECH QUAL TOOL NOS No approval required DFIND MCR AUC G2000 BLINDED ADMN BY CONVULSIVE TX PROC BLINDED BY ADMIN NO. 20 MIN IH VST NEW PT PST-D/C. SHORT 20 MINUTES HOME VISIT NEW No PT POST-D/C approval required. G2002 LTD 30 MIN IH VISIT NEW PT PST-D/C LIMITED 30 MIN HOME VISIT No approval required NEW PT POST-D/C G2003 MOD 45 MIN IH VISIT NEW PT PST-D/C MODERATE 45 MIN. No approval required NEW PT POST-D/C G2004 COMP 60 MIN IH VST NEW PT POST-D/C COMP 60 MINUTES HOME VISIT NEW No approval required PT POST-D/C G2005 EXTSV 75 MIN IH VST NEW PT PST- D/ C APPROXIMATELY 75 MIN HOME VISIT No approval required NEW PT POST-D/C G2006 CARD 20 MIN IH VST XST PT PST-D/C CARD 20 MIN HOME VISIT FINDER No approval required PT POST-D/C G2007 LTD 30 MIN IH VISIT XST PT PST -D/C LIMITED 30 MIN HOME VISIT EXISTS No approval required PT POST-D/C G2008 MOD 45 MIN IH VISIT XST PT PST-D/C MODERATE 45 MIN HOME VISIT No approval required EXISTS PT POST-D/C G2009 COMP 60 MIN IH VST XST PT POST-D/C COMP 60 MIN HOME VISIT EXISTS PT No approval required POST-D/C G2010 RMT EVAL REC VIDEO &/ IMG SB EST PT REMOTE EVAL RECORDED VIDEO &/ No approval required PHOTOS SB ESTAB PT G2011 ALC& /SA STRCT ASMT & BRF INT 5-14 M ALC&/SA STRCT ASSESS & BRIEF No approval required INTERVENT 5-14 MIN G2012 TBS BRIEF; 5-10 MIN WITH DISCUSSION SHORT COMMUNICATION TBS; 5-10 MINUTES Approval not required WITH DISCUSSION G2013 EXTSV 75 MIN IH VST XST PT PST-D/C EXTSV 75 MIN. HOME VISIT AVAILABLE PT No approval required POST-D/C G2014 LIMITED 30 MIN. CARE PLAN 30 MIN. PLAN No Approval Required SUPERVISION G2015 COMP 60 MIN HOME CARE COVERED BY PLAN 60 MIN HOME CARE No Approval Required SUPERVISION PLAN SUPERVISION G2021 HEALTH PRACTICE RENDING ADVICE HEALTHCARE PHYSICIANS No Approval REND2SR2 CFL DL MDL PRTCP RECEIVER REFUSES SRVC No Approval Required CO VR UNDMDL G2058 CCM SRVC EA A 2 0 m CS TM DIR CA MO CCM SRVC EA ADD 20 MIN CLIN STF TM No approval required DIR HCP CA MO G2061 Q NP HCP ONLY E PT 7D CT 17M Q NP HCP ONLY ASNT EST PT 7D CUM TM No approval required DUR 7D;5-10 M G2062 Q NP HCP OL E PT 7D CT DR 7D;11-20M Q NP HCP ONLY ASMT EST PT 7D CUM T No approval required DUR 7D 11-20 M

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G2063 Q NP HCP ONLY E PT 7D CT DR 7D;21/>M Q NOMD HCP ONLY AST EST PT 7D CUM No approval required TM DUR 7D;21/>M G2064 CCM 1 HR DZ AL 30 M PHYS T CA 1 CCM SRVC HR DZ AL 30 M PHYS/HCP No Approval Required TIME CA MO G2065 CCM 1 HOUR DZ SRVC PCM AL 30 MIN CM CCM 1 HOUR DZ SRVC PCM MIN 30 No Approval Required MIN CAL MONTH G2066 INTG & DVC E TRANS; TR INTG DVC EVAL RMT TO 30 D;RCPT No Clearance Required TRANS & TECH RVW G2067 WITH ASST TX METHADONE; WEEKLY MEDICATION ASSISTANCE TX LOCATION No approval required BUNDLE METHADONE; WEEKLY G2068 MAT BUPRENORPHINE ORAL; WKLY S ASST TX BUPRENORPHINE ORAL; No Approval Required BUNDLE WEEKLY BUNDLE G2069 MAT BUPRENORPHINE INJ; WEEK WITH ASST TX BUPRENORPHINE INJ; No approval required BUNDLE WEEKLY BUNDLE G2070 MAT BUPRENORPHINE IMPL INSRT;WKLY MAT BUPRENORPHINE IMPLANT INSRT; No approval required BD WEEKLY BUNDLE G2071 MAT BUPRENORPHINE IMPL REMV;WKLY MAT BUPRENORPHINE IMPL REMOVAL; No Approval Required BD WEEKLY BUNDLE G2072 MAT BUPRENORPHINE IMPL I&RWKLY BD MAT BUPRENORPHINE IMPLANT I & R; No Approval Required WEEKLY MEETING G2073 WITH ASST TX NALTREXONE; WKLY DRUG SET ASSIST TX NALTREXONE; No Approval Required WEEKLY KIT G2074 WITH ASSIST WEEKLY KIT DOES NOT INCLUDE MEDICATION ASSIST WEEKLY KIT No Approval Required DOES NOT INCLUDE MEDICATION G2075 MAT MEDICATION NO.; WEEKLY DRUG SET ASST TX DRUG No NOS approval required; WEEKLY KIT G2076 INTK ACT WITH EX CMPL DOC P EVL&ASMT INTK ACT INCL INT WITH EX CMPL DOC P No approval required EVL&INT ASMT G2077 PA;PRD Q PERS DET APPR KAMM SRVC&TX PA;TXASSESS PRD Q PERS REQUEST G7 AUT. TH SUP METHADONE; TO 7 ADD D SUP; TAKE HOME SUP METHADONE; TO 7 No approval required ADD DAY SUP; G2079 TH SUP BPN ORAL; TO 7 ADD D SUP; TAKE HOME SUP BUPRENORPHINE No approval required ORAL; TO 7 ADD D SUP; G2080 EA ADD 30 MIN CNSL WK WITH ASST TX; EA ADD 30 MIN CNSL WK WITH ASSISTANCE No approval required TREATMENT; G2082 OFF/OT OP E&M E PT 56MG ESKTMN N SA OFF/OTH OP E&M EST PT PROV 56 MG No approval required ESKETAMINE N SA G2083 OFF/OT OP E&M E PT>56MG ESKTMN N SA OFF/OTHER OP E&M EST> 56 MG No Approval Required ESKETAMINE N SA G2086 TX ODU;AL 70 M 1ST CA MO TX OPIOID USE NON-BASED D/O; AL 70 No confirmation required MIN 1. CA MO G2087 OFF-BSD TX OUD;AL 60 M SUBSEQ CA MO OFF-BASED TX OUD; AL 60 MIN SUBSEQ None Author does not require calendar MO G2088 OFF-B TX OUD; EA Add 30m BYD 1ST120M TX OUD based OFF; Ea add 30 min offer no ER 1. 120 min g2089 latest HbA1c lvl 7.0% to 9.0% latest hemoglobin a1c level No approval required 7.0% to 9.0% G2090 pt 66 y &> 1 clm frlty & d s dmnt mp pt pt pt Pt Pt &> 1 Clm & DIS WITH No approval required DMNT MP/YR PRIMP F66TY&> ACCV ADV. ILL MP PT 66&>CLM FRLTY & 1 AC IP ADV ILL No approval required MP/YR PR MP G2092 ACE I/ARB/ARNI TH PRSC/CUR BNG TKN ACE INHIB/ARB/ARNI TH No approval required PRSC/TAKET CURRENT G2093 DC MD RSN N PRSC ACE INHB/ARB/ARNIX DOC MED REASN NONE PRSC ACE No approval required INHIB/ARB/ARNI TH G2094 DOC PT RSN N PRSC ACE INHB/ARB/ARNI DOC PT REASON NONE PRSC ACE No approval required INHIB/ARB / ARNI THERAPY G2095 DC SYS RSN N PRSC ACE INHB/ARB/ARNI DOC SYS RSN NOT PRSC ACE No approval required INHIB/ARB/ARNI THERAPY G2096 ACE INHB/ARB/ARNI TH NO PRSC NO RSN ACE INHIB/ARB/ARNI TO NOT PRSC No approval required RSN NOT GIVEN G2097 CHILD COMP UR INF W/I 3 DX DX PHY CHILD COMP DX UR INF W/I 3 DAYS DX No approval required FARINGITIS G2098 PT 66 Y&>1 CLM FRLTY&D WITH DMNT 1 CLM FRLTY & DIS WITH None approval required DMNT MP/YR PRI MP G2099 PT 66&>1 CLM FRLTY & DUR/YR PRI MSR PT 66&>1 CLM FRLTY DUR MSR & No approval required DUR/YR PRI MSR PRD G2100 & PT >1 CLM FRLTY&D S DMNT MP PT 66 Y&>1 CLM FRLTY & DIS MED No approval required DMNT MP/YR PRI MP G2101 PT 66&>1 CLM FRLTY&1 AC IP ADV ILL PT 66&>1 CLM FRLTY&1 ACuth IP ADV ILL No A DR/YR PRI MSR G2102 DIL RET EYE EX OPH/OPTOM DOC & REV DILAT RET EYE EXAM INTERPR No Authorization Required OPH/OPTOM DOC & REV G2103 7 STD FLD STREO PH OPH/OPTM DOC&REV 7 STD FI INTERPR. /OPTM DOC & REV G2104 EYE IMG V 7SD FLD STEREO P RSL D&R EYE IMG VAL DX 7 SD FLD STEREO No approval required IMAGE RSLT DOC&R G2105 PT 66/>INST SNP/RSD LTC>90 D INST DR MSR 6/> SNP/ RESID LTC >90 D No approval required DUR MSR PRD G2106 PT 66 Y&>1 CLM FRLTY&D MED DMNT MP PT 66 Y&>1 CLM FRAILTY & D MED No approval required DMNT MP/YR PRI MP G2107 PT FRLTY 66 &> AC IP ADV IL MP PT 66 &>CLM FRLTY & 1 AC IP ADV ILL No Approval Required MP/YR PRI MP G2108 PT 66/> INST SNP/RES LTC >90 D MSR PT 66/OLDER INST SNP/RES LTC >90 D No Approval required DUR MSR PRD G2109 PT 66 &>CLM FRLTY&1 AC IP ADV IL MP PT 66 &>CLM FRLTY &1 AC IP ADV ILL No approval required MP/YR PRI MP G2110 PT 66 &>CLM FRLTY&1 AC IP ADVIL PT 66 &>1 CLM FRLTY&1 AC IP ADV ILL No approval required MP/YR PRI MP G2112 PT RCV6 MO & No approval required AC IMP/NO CHNGE DZ ACT G2114 PT 66-80 1 CL FRLTY&DIS MED DMNT MP PT 166 KRAV FRAILTY & DIS MED No approval required DEMENTIA DUR G2115 PT 66 &>1 CLM FRLTY&D MED DMNT MP PT 66 &>1 CLM FRLTY & DISP MED No approval required DEMENT MP/YR MP G2116 PT 66&> CLM AD FRLTY&1 PT 66&>1 CLM FRLTY & 1 IP ADV ILL None approval required DUR/YR PRI MP G2117 PT 66-80 CLM FRLTY&1 AC IP AD IL MP PT 66-80 1 KRAV FRLTY & 1 AC IP ENC No approval required ADV ILL MP G2118 ILL PT 81 YR & > EVID FRAILTY DUR MSR PT 81 YEAR & > EVID FRAILTY DUR No approval required MSR PERIOD

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G2119 W/ PST 2 Y CA &/ VITD OPT ORD/PERF W/I PAST 2 YR CALCIUM &/ VITD OPT No Approval Required ORDERED/PERF G2120 W/I PST 2 Y CA&/VITD OPT NO ORD/PR W/I PAST 2 YR CALCIUM &/ VIT D OPT No approval required NON WORD/PERF G2121 PSY DEPR ANXIETY APTHY & ICD ASSESSMENT PSYCHOSIS DEPRESSION ANXIETY No approval required APATHY & ICD ASSESSMENT G2122 PSY DEPR ANXIETY ANXIETY AKSTY & NR No approval required ICD NOT EVALUATED G2 123 PT 66 -80 YR/&AL 1 CLM FRLTY DUR MSR PT 66-80 YR /& AL 1 CLAIM FRAILTY DUR No approval required MSR PERIOD G2124 PT 66-80 & 1 CL FRLTY MP&D 60PT DMNT-1 CLM FRAILTY MP & DIS No approval required DEMENT S G2125 PT 81 YR&STAR EVID FRAILTY MSR PRD PT 81 YRS AGE & OLDER EVIDENCE No approval required Frailty ACCORDING TO MSR PRD G2126 PT 66 YR/STAR&ALTY MSR 66 YRS/STARI&AL 1 CLR FRAILPT/6 CLM FRAILTY No approval required DUR MSR PRD G2127 PT 66 />&CLM FRLTY DUR MP&D DMNT PT 66/> & 1 CLAIM FRAILTY DUR MP & No approval required WITH DIS DMNT WITH G2128 DOC WITH RSN NOT ON DAILY SNAP ASP/ NOT ON DAILY ASP/OTH No approval required ANTIPROMCAT G2129 PROC REL BP'S NOT TAKEN DURING OPER VST PROCESS RELATED BP'S NOT TAKEN Consent not required DURING OPER VISIT G2130 PT 66/> INST SNP/RES LTC INST66/RES LTC INST6 SNP/RESID LT NURSING Consent not required >90 DAYS MSR G2131 PATIENTS 81 YR. AND OLD DX DENIED PATIENTS 81 YEARS AND OLDER S A No approval required DX DENIAL G2132 PT 66-80 MP 66-80 CLM DMNTTY&CRAIL DIS MED No approval required DEMENTIA DUR MP G2133 PT 66-80 CLM FRLTY&1 AC IP ADV I MP PT 66-80 80 1 CLAIM FRLTY & 1 AC IP ENC No approval required ADV ILL MP G2134 PT 66< W/1+ FRAILY WITH DEMENT PT 66< W/1+ FRAILTY DISP MED No approval required DEMENTIA DUR/YR PRI G2135 PT 66< W/ 1 + ENC FRAILTY ADV ILNS YR PT 66< W/1+ FRAILTY 1+ ENCNT ADV. PR G2136 BCK BOL VAS 3 MON PO3.0 CHG 5/> MEASUREMENT OF BACK PAIN VAS 1 YEAR PO>3.0 No approval required DEMS CHNG 5 PNT/> G2139 BACK PN MEASURING YOU 1 YEAR PO>3.0 CHG 3.0 No approval required 3.0 DEMS CHNG CHG 3.0 No approval required DEMS CHNG 22 ODI 3 MN PREO PO 30> FUNC ST ODI 1YR PO >=22 ODI 3 MN No approval required PREO 1YR PO 30> G2144 ODI 3MO PO FUNC ST ODI 3MO PO G2145 ODI ODI 3 MN PREO PO 30> FUNC ST ODI 3MO PO >=22 ODI 3 MN No approval required PREO 1YR PO 30> G2146 PN MEASUREMENT OF LEG OF YOU 1 YEAR PO>=3.0 CHG 5> MEASUREMENT OF PAIN IN LEG OF YOU 1 YEAR PO>=3.0 DEM Not required approval CHANG 5 PNT/> G2147 LEG PN GOAL VAS 1 YEAR PO >3.0 CHG 3.0 DEMS No approval required CHNG 0 EFFECT SATISFACTORY RESIDUAL CHNG No approval required SCORE = INCLUDED OR > 0 G2153 IN HOSPICE/US HOSPICE HOSPICE / UTILIZATION HOSPIA DURING No approval required MEASUREMENT BY. G2154 PT REC 1TD VAC OR/1TDAP BTW 9YR MEA PT REC1 TD VAC OR/1 TDAP BTW 9YR No approval required PRI START MEASR G2155 TD PT HX ANAPH CN 1+ DN + KONTR ANAPH TDAP VAC No approval required ANAP TD ENCPH TDAP G2156 PT NOT REC 1TD VAC OR/1TDAP BTW 9YR PT NOT RECD 1 TD VAC OR/1 TDAP BTW No approval required 9YR PRI START G2157 CONJVAL 2NE VAL>60 PT REC 13-VALENT PNEUM CONJ& 23- No approval required VAL POLYS12 M>60 G2158 PT PRIOR PNEUM VAC ADV REAC B4 MEASUREMENT PT PRIOR PNEUM VAC ADV REAC ANY No approval required TIME IN NOT/B4 13 G2 VAL CONJ & 23-VAL >60 PT NOT REC 13-VALENT PNEUM CONJ& No approval required 23-VAL12 MNT>60 G2160 PT LST 1DS HRP ZOST LIV OR 2DS =>50 PT REC AT LEAST 1DS HERP ZOST LIV REQUIRED OR NO ADS RCM=>50 G2161 PT ASSUMED ADVS REAC ZOSTER WHEN TIME PT PRE ADV REAC ZOSTER VA ALL No approval required TIME DURATION/B4 MEASUREMENT G2162 PT NOT RECORDED 1DS HRP ZOST OR 2DS =>50 PT NOT REC Auth Required BAR 1ST OR 2DS RCM=>50 G2163 PT RC INFLUENZA ON/BTW JUL1 YR JN30 PT REC INFLUENZA VAC ON/BTW JULY1 YR PRI &JUN30 G2164 PT NOT RECORDED PT ASSUME INFLU ADVS I REACT EVERY ASSUME AUT. TIME G2165 PT NOT RECV IV 7/1 YEAR PRI&6/30 MSR; PT NOT RECV FLU VAC 7/1 YR PRI No approval required MSR&6/30 MSR; G2166 PT REFUSES PARTICIPATION ADM &/ D/C; PATIENT REFUSED TO PARTICIPATE No authorization required ACCESS &/ D/C; G2167 Performance was not delivered: residual CHG grade <0 Performance was not exhibited: residual does not need to approval change the grade <0 G6001 U/S GUID PLCMT RADIATION TX FIELD Ultrasound GUID location no rejoice radiation 600 Field Stereo 6001 GUID RIPOCS approval required TRG VOL PART RT G6003 RT D 2 TX AR PT/PL OPP PT:TO 5 MEV RAD TX PART 2 TX AREA PORT/PL OPP No approval required PORTE:TO 5 MEV

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G6004 RT D 1 TX AR PT/PL OPP PT: 6-10 MEV RAD TX DIO 1 TX USE PRINCIPLE/PL OPP No Potential Oil Breaker PRINCIPLE: 6-10 MEV G6005 RT D 1 TX AR PT/PL OPP PT:11-19 MEV ROW TX PART 1 TX AREA PORT/PL OPP Not required authorization PRICE: 11-19 ME G6006 RT D 1 TX AR PT/PL OPP PT:20 MEV/> RAD TX DIO 1 TX AREA PORT/PL OPP Not required PORTS authorization : 20 ME/> G6007 RT PART 2 SEP 3/>PT 1 TX AR:TO 5 MEV RT PART 2 SEP 3/> PT 1 TX AR MX Nije potrebno airbrake BLKS:TO 5 MEV G6008 RT PART 2 SEP 3/ >PT 1 YEAR:6-10 MEV RT PART 2 SEP YEAR 3/> PT 1 TX AR MX Nije potrebno odobrange BLKS:6-10 MEV G6009 RT PART 2 S YEAR 3/>PT 1 YEAR:11-19 MEV RT PART 2 SEP AR 3/>PT 1 TX AR MX Niche Porebno Dust Brake BLKS:11-19 MEV G6010 RT PART 2 SEP AR 3/>PT 1 AR:20 MEV/>RT PART 2 SEP AR 3/>PT 1 TX AR MX No Potential Outerbreak BLKS:20 MEV/> G6011 RT D 3/> S TX AR CSTM BLK;TO 5 MEV RAD TX DEL 3/> SEP TX AR CSTM No Potential Outerbreak BLOCKING; DO 5 MEV G6012 RT D 3/> S TX AR CSTM BLK;6-10 MEV RAD TX DEL 3/> SEP TX AR CSTM Niche Porebno Odobridge BLOCKING; 6-10 MEV G6013 RT D 3/> S TX AR CSTM BLK;11-19 MEV RAD TX DEL 3/> SEP TX AR CSTM Nije Porebno Odobrake BLOCK;11-19 MEV G6014 RT D 3/> S TX AR CSTM BLK ;20 MEV/> RAD TX PART 3/> SEP TX AR CSTM No Potential Power BLOCK; 20 MEV/> G6015 INTENZIVNI MOD TX DIO 1/MX FLDS TX SESS INTENSITY MODULIRANT TX DIO 1/MX Nije Potential Odor Brake FLDS PER 16ESS CMP-B BM MD TX DIO I PLND TX P TX S COMP-BAZIRANI ZRAK MOD TX DIO I PLND No Rear Rain Break TX 3 > HR SESS G6017 INTRA-F LOC&TRCK TRGT/PT M EA F TX INTRA-FRAC LOC & PRAINJE No Rear Rain Break TARGET/PT M EA FRAC TX G8395 LVEF >=40% ILI NORMAL/BLAG DEPR LVS LVEF > =40% ILI DOC NORMAL/BLAGO NOT POTREBNO Odobrenje PRITISNUTA LV FUNKCIJA G8396 LVEF NO ENGINE ILI DOCUMENTARY NOT DOCUMENTARY POTREBNO INJINE/DOC G8397 PREGLED PROŠIRENE MAKULE/FUNDUSA PREGLED PRO PREGLED MACULAR DIL ATED G8398 MACULAR DILAT / PREGLED FUNDUSA NO PROXYRENA MAKULA ILI PREGLED FUNDUSA Esophagus no foal G8398 PREGLED FUNDS/FUNDUSA PERF PATIENT W/DOC RESULTS CENTRL DXA No foal esophagus EVER BEING PERF G8400 PT W/CNTRL DXA RSLTS I HAVE A PATIENT W/CENTRAL DXA RESULTS I HAVE Odobrenje I could DOCUMENTARY DOCUMENT G8404 LOWER EXTERM NEURO EXAM LOVER EXTREMITY NORTH EXTERM. &DOC G8405 LOWER EXTREME NEURO PREGLED NOT DONJI EXTREME NEUROLOGICAL PREGLED NOT PRFRM NOT PREGLED G8410 LOWER EXTREME NEURO PREGLED I DOCUMENTARY G8415 EVALUATION OF THE PROCJENA OF THE PROCESS 8 Br. ODEĆA EVAL CLIN DOC PT NO ELIG OBUĆA No Potential Water Break MJERENJE PROCJENE G8417 BMI DOC ABV NML PARAM & F/U PLN DOC BMI DOC IZNAD NORMALNOG PARAMA & No Potential Water Break F/U PLAN DOCUMENT G8418 BMI DOC BLW NML PARAM & F/U PLN BMI PARAM & A N/N U No Possible Outer Breaker DOC PLAN I DOCUMENTED G8419 BMI DOC OUT NL PARM NO F/U DOC NO R BMI DOC OUT NML NO F/U PLN No Possible Other Breaker DOC NO RSN GVN G8420 BMI DOC NML PARAM & NO F/U PLAN BMI DOC W/I NORMALNI PARAM & WITH NO POTREBAN PLAN RQR F/U PLAN POTREBAN G8421 BMI WITH DOCUMENTATION & BY REPORT BMI DOCUMENTATION I NE No Potential Oil GVN DAT REPORT G8422 BMI WITH DOC DOC PT NI I ELG BMI IZRAČUN DOC PT NO QUALIFICATION No eligible authorization BMI IZRAČUN G8427 ELIG CLIN DOC M UPDTD REC PT MEDS ELIG CLIN ATTSTS DOC M REC OBTD No eligible authorization UPD/REV PT MEDS G8428 CUR MEDS NO DOC ELG CLN CLN RSN NOT UPD NO/ . CVRE ELIG No Auth Potreban CLIN RSN N GVN G8430 ELIGIBILITY CLIN DOC PT NOT ELIGIBILITY MEDS REV ELIGIBILITY CLIN DOC MR PT NOT ELIGIBILITY CUR No Auth Required MEDS UPDATE/REV G8431 SCR CLIN DEPR DOC POS & F/U PLN DOC DOC SCR CLIN F/U-PLAN ER Niche potrebno odobrenje DOCUMENTARY G8432 DEPRESSION SCR NO DOCUMENTARY RSN NO GVN DEPRESSION SCR NO DOCUMENTARY No potrebno odobrenje NO NAVEDEN RAZLOG G8433 SCR DEPR NO DOVRŠEN DOCUMENT RSN PROVJERA NA DEPR NOT COMPLICATIONS NOT POTREBNA4 DOC. PT NO ELG PA ENC PA NO DOC PERF DOC PT NO KVALITETNO PA No foot odorbreak VRIJEME ZA ENC G8450 PROPISANA THERAPY BETA BLOKATOM PROPISANA THERAPY BETA BLOKATOM No foot odobrenje G8451 BB TX LVEF

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G8509 PN ASMT DOC POS F/U PLN NO DOC NO R PN ASMT DOC STD TOOL POS F/U PLN No Approval Required NOT DOC NR RSN G8510 SCR DEPR DOC NEG A F/U PLAN NOT RQR DEPRESSION SCREENING DOC NEG A No Approval Required F /U PLAN NOT RQR G8511 SCR DEP DOC POS F/U PLN NO DOC NO R SCREEN DEPR DOC POS F/U PLN NOT No approval required DOC RSN NOT GVN G8535 EM SCR NR D;D PT NOT ELG EM SCR ENC EM SCR NOT doc - other Complete clinical examination DOC CARE PLAN DOC services and procedures G8540 FNC OC ASMT NO D P D PT NOT ELG ENC FUNC O/C ASMT NOT DOC PRF DOC PT No approval required NOT ELIG TM ENC G8541 FUNC OUTCOME ASSESSMENT NOT DOC NO RSN FCN ASMT STD TOOL NONE No approval required DOC RSN NOT GIVEN G8542 FCN OC ASMT; NO FAULTS PLN NOT RQR FCN OUTPUT ASMT DOC; NO DEFECT No approval required ID PLAN NOT RQR G8543 DOC P FCN ASMT STD;PLN NOT DOC NO R DOC POS FCN ASMT STD T;PLN NOT No approval required DOC RSN NOT GVN G8559 PT REF TO Phys. Otology evaluation no authorization required g8560 pt hx active draining ear in previous 90 days pt history active ear drainage no authorization required in previous 90 days g8561 pt ineligible NO HX DRAINAGE EAR IN PREVIOUS 90 DAYS PT NO HISTORY OF ACTIVE EAR DRAINAGE No authorization required in PREVIOUS 90 DAYS G8563 PT NOT REF PHYS OTO EVAL RSN NOT GV PATIENT NOT REF PHYS OTOLOGIC EVAL No approval required RSNEF OTO GIFT NOT REA5 REFERRED PHYS OTOLOGIC EVAL No approval required CAUSE NOT SPEC G8565 VEIFICATION & DOC SUDDEN HEARING LOSS VERIFICATION & DOC SUDDEN/RAPID No approval oval required PROG HEARING LOSS G8566 PT NOT ACCEPTABLE REF OTO DEVELOPMENT OF HEARING LOSS REV. MSR G8567 PT NO CHECK SUDDEN HEARING LOSS PT NO CHECK AND DOCUMENTATION SUDDEN Approval not required HEARING LOSS G8568 PT NO REF PHYSICAL OTO EVALUATION NO RSN PATIENT NO REF PHYSICAL OTOLOGY EVALUATION No approval required RSN NOT GIVEN 8568 PT. PERATIVE No Authentication Required INTUBATION REQUIRED G8570 EXTENDED PROCEDURE INTUBATION NOT EXTENDED POSTOPERATIVE No Authentication Required RQR INTUBATION NOT REQUIRED G8571 DVLP DP STRNL WND I/MDSTNT 30 D PO DVLP DP STRNL WND INF/NO DE 2 BR. EP STRNL WND INF/MEDIASTINITIS NO DEEP STERNAL WOUND No Approval Required INFECTION/MEDIASTINITIS G8573 CEREAL STORK FLW ISOLATED CABG SURGERY STRIKE FEE ISOLATED CABG No Approval Required SURGERY G8574 NO STROKE FLW NO STROOK FLW NO BRAIN STORK FLOW ISO LATE CABG FLOW CABG SURGERY Approval Required G8575 DEV POST UP RENAL FAIL/ REQ DIALYSIS DEVELOPED POSTOP RENAL No Authorization Required FAIL/Q DIALYSIS G8576 NO PO RENAL FAIL/DIALYSIS NO REQ NO POSTUP RENAL FAIL/DIALYSIS No Authorization Required NOT REQUIRED G8577 REOP G8577 REOP MDOCCT/DIALYSIS WITH V Not Required authorization DYSFUNC/ OTH RSN G8578 REOP NOT REQUIRED WITH BLD GFT OCCL/OTH REOP NOT REQUIRED MEDIAST BLEED GFT No authorization required OCCL/OTH REASN G8598 ASPIRIN/OTHER ANTI-PLATELET TX USED ASPIRIN OR OTHER ANTI-PLACELET TX USED ITHROMB NOT USED US9 RSN ASPIRIN /OTHER ANTITHROMBOTICS NOT Required No Approval Required USED RSN NO GVN G8600 IV T-PA INITIAL W/IN 3 HOURS LAST WELL IV T-PA INITIATED W/IN 3 HOURS TIME No Approval Required LAST KNOWN WELL G8601 IV T-PA NO INITIAL 3 HOURS OK RSN DOC IV T-PA NOT INIT IN 3 HOURS LAST OK No Clearance Required RSN DOC CLIN G8602 IV TPA NOT IN 3 HOURS TME KNWN NO RSN IV TPA NOT STARTED W/IN 3 HOURS TIME No Clearance Required KNOWN RSN NOT GVN G8627 SURG PROC 30 DAY FLW CAT SURG COMP SURG PROC W/IN 30 YES FLW CATARACT No Approval Required SURG MAJ COMP G8628 SURG PROC NOT FOR 30 YES FLW KAT SURG SURG PROC NOT W/IN 30 DAY. MAJ COMP G8633 PHARM TX FOR OSTEOPOROSIS PRESCRIBING PHARMACOLOGY TREATMENT FOR No approval required Osteoporosis PRESCRIBED G8635 PHARM TX OP NOT PRSC REASON NOT PHARM TX Osteoporosis NOT PRSC No approval required GVN GRISK REASON K8JCNE IMP />0 RISK ADJ FUNC NATIONAL STATUS KNEE No approval required SCORE DAMAGE =/>0 G8648 RISK-ADJ FUNC STATUS KNEE IMPAIR 0 G8652 RISK-ADJ FUNCT STS HIP IMPAIR SC 0 RISK-ADJ FUNCT STAT LOW LEG = ANK Required 0 Auth G8656 RISK-ADJ F STS CH SC FT/ANK IMPR 0 G8660 RSK -AD F ST CH RSD SC LB IMPR SC

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G8662 RSK-AD ST CH R SC LB IMPR RSN N GVN RISK-ADJ FCN STS CH RSD SC LB IMPAIR No approval required RSN NOT GVN G8663 RISK-ADJ FCN STS SHOULDER IMPR =/>0 RISK-ADJ FUNCT STS No approval required SHOULDER IMPR SCORE =0/ >0 G8664 RISK-ADJ FUNC ST SHOULDER IMPAIR 0 RISK-ADJ FUNC STS ELB WRST HND No clearance required IMPAIR SC =0 / >0 G8668 RISK-AD FCN ST ELB WR H IMPR SCADJ < 0 RISK-ADJ FUNC ST ELBOW No approval required IMPAIR SC < 0 G8670 RSK-A F ST E W H IMPR NO MSR NO RSN RISK-ADJ FCN ST E WR HND IMPR NO No approval required MSR RSN NOT GV G8671 RSK-A ST CH R SC N CR M TS RBS=0/>0 RISK-ADJ F STS CHG RSD SC N CR M TS No Approval Required RIBS SC=0/>0 G8672 RSK-A ST CH R SC N CR M TS RIB SC= 140MM HG G8754 LATEST DIASTOLE BP < 90MM HG RECENT DIASTOLIC BLOOD No clearance required PRESSURE < 90MM HG G8755 RECENT DIASTOLIC KT >= 90MM HG RECENT DIASTOLIC BLOOD No clearance required PRESSURE 90MM HG NO 70MM NO G80MMSR > NO DOC BLOOD PRESSURE MSR CAUSE No clearance required NOT GIVEN G8783 NORMAL BP - READING DOC F/U NOT RQR NORMAL BLOOD PRESSURE READING DOC No authorization required F/U NOT REQUIRED G8785 BP READING NOT DOC REASON NOT SPECIFIED BLOOD PRESSURE Authentication not required G7 SPEC.SITE EXCEPT ANAT LOC ESOPH SITE EXCEPT ANATOM No authorization required ESOPHAGUS LOCATION G8798 SITE OTHER THN ANAT LOC PROS SITE EXCEPT ANATOMC No approval required LOCATION PROSTAPER/TRFNSVAD TRANSVAD/TRANSVAD TRANSVAD/TRSPG -ABD/TRANS -VAG U/S No approval required DOC & PREG LOC DOC G8807 TRANSABD/VAG U/S NOT PRF DOC CLIN TRANSABD/TRANSVAG U/S NOT PERF No Approval Required RSN DOC CLINICIAN G8808 TRANS-ABD/VAG U/S NOT P RSN NOT GVN TRANS-ABD/TRANS-VAG U/S NO No Approval Required PRFRM RSN NOT GIVEN G8809 RH IMMUNOGLOBULIN RHOGAM RH IMMUNOGLOBULIN RHOGAM No approval required ORDERED ORDERED G8810 RHOGEAM NOT ORDERED NO ORDER NO. requested CLIN REASONS DOC CLIN G8811 DOCUMENT RHOGRAM NOT ORDERED DOCUMENT RH IMMUNOGLOBULIN No approval required RSN NS NOT ORDERED RSN NS G8815 DOC RSN S REC STATIN TX NOT PRSC DOCUMENTED REASON S REC TX WHY NO APPROVAL REQUIRED G8816 PR STATIN S 8 PR STATIN CODE D / C STATIN DRUG PRESCRIBED No authorization required PRINT G8817 STATIN TX NOT PRSC D/C RSN NOT GVN STATIN TREATMENT NOT PRESCRIBED D/C No authorization required RSN NOT GIVEN G8818 PT D/C HOME NO LATER THN PROCEDURE YES 7 PATIENT LATER THAN No authorization required PROCEDURE DAY #7 G8825 PT NOT D/C TO HOME UNTIL PROCEDURE DAY #7 PATIENT NOT DISCHARGE HOME NO APPROVAL REQUIRED UNTIL PROCEDURE DAY #7 G8826 PT D/C HOM NO LATR PO YES 2 FLW EVAR PT D /C HOME LATER END PROCEDURE No Approval Required DAY #2 FLW EVAR G8833 PT NOT D/C HOM PROCEDURE D #2 FLW EVAR PATIENT NOT D/C HOME PROCEDURE DAY No Approval Required #2 FOLLOW EVAR G8834 PT D/C HOM NR LATR PO DA #2 FLW CEA PT D/C HOME NO LATER PROCEDURE DAY No Approval Required #2 FOLLOW CEA G8838 PT NOT D/C HOME ON PO DAY 2 FLW CEA PATIENT NOT D/C HOME WITH PROCEDURE No Approval Required DAY # 2 FLW CEA

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G8839 SLEEP APNEA SX ASSESSMENT CORD DAY SSS SLEEP APNEA SYMP ASSESSMENT PRES/ABS No approval required CORD DAY SSS G8840 DOC RSN NOT DOCUMENT ASMT SLEEP DOC GROUND DO NOT DOCUMENT No approval required CORD DAY SSS G8840 DOC RSN NOT DOCUMENT ASMT SLEEP DOC GROUND DO NOT DOCUMENT No Authorization Required SNORING DAY SSS VN SLEEP APNEA SX NOT ASSESSED CAUSE No Authorization Required NOT Given G8842 AHI/RDI MEASURED AT INITIAL DX AHI/RDI MEASURED AT INITIAL No Authorization Required DIAGNOSIS G8843 DOC RSN NOT MSR AHI/RDI TM INIT AHI/ RDI ATH INIT DX DOCRAuth No. TIME REQUIRED INIT DX G8844 AHI/RDI NOT MSR TIME DX RSN NOT GVN APNEA HYPOPNIC IND/RDI NOT MSR TM No Authorization Required DX RSN NOT GVN G8845 PAPA THERAPY PRESCRIBED POSITIVE AIRWAY PRESSURE TREATMENT NO. EP APNEA MODERATE OR SEVERE OBSTRUCTIVE No approval required SLEEP APNEA G8849 DOCUMENT CAUSE NOT PRESCRIBED PAP TX DOCUMENT RSN NOT PRSC POS No approval required AIRWALL PRESS TX G8850 PAP TX NOT PRSC CAUSE NOT GIVEN POSITIVE NOT AIR WEIGHT 1 JECTIVE TARGET HAND PAP TX DOC TARGET MEASURE PAP ADHERENCE No authorization required TX DOCUMENTED G8852 PAP THERAPY PRESCRIBED POSITIVE AIRWAY PRESSURE THERAPY No authorization required PRESCRIBED G8854 DOC RSN NOT OBJ MSREATHERATION ADHERENCE OBJ. CPAP G8855 OBJ MSR ADH PAP TX NOT PERF NOT GVN OBJ MSR COMPLIANCE WITH PAP TX NO No Approval Required PRF RSN NOT GVN G8856 REFER PHYS OTOLOGIC EVAL DONE REFER PHYS OTOLOGIC EVAL DONE REFER PHYSICIAN OTOLOGIC No Approval Required EVAL DONE G8857 PT NOT ACCEPTABLE REFLIG OTOLOGIC Furnished NO ACCEPTABLE REFLIG OTOLOGIC Equired VAL MSR G8858 REF PHYS OTOLOG EVAL NOT PRF N GVN REF TO PHYS OTOLOGIC EVAL NOT No approval required PRFRM RSN NOT GVN G8863 PTS NOT ASSESSED RSK BL RSN NOT GVN PATIENTS NOT ASSESSED KNOLE RISK No approval required PRFRM RSN NOT G VN G8863 PTS NOT ASSESSED RSK BL RSN NOT GVN PATIENTS NOT ASSESSED KNOLE RISK No authorization required PRFRM RSN NOT GVN G8863 PTS NOT ASSESSED RSK BL RSN NOT GVN PATIENTS NOT ASSESSED RISK BÖNLE No authorization required PRFRM RSN NOT GVN CCAL VACCINE ADMINISTRATOR OR not required authorization RECEIVE PREVIOUS USER G8865 DOC WITH RSN NOT ADM/PREV REC PN DOC WITH RSN NOT ADM/PREV RECV No approval required VAC PNEUMOCOCCAL VAC G8866 DOC PT RSN NOT ADM/PREV NOT RECV PREV RECV No approval required PNEUMOCOCCAL VAC G8867 PCV NOT ADM/ PREV RECV RSN NOT GIVEN PNEUMOCOCCAL VAC NOT ADM/PREV No Approval Required RECV RSN NOT GVN G8869 PT IMA DOC IMM HB&INIT DOC ANTI-MMUNT HUT Required ANTI-TNF TX G8872 EXCSD TISS EVAL IMAG IO CNF TGT LES EXCISED TISS EVAL IMAG INTRAOP CNF None approvals required INCL TGT LES G8873 PT NDLE LOC SPEC VERFD IO INSP/PATH PT W/NEEDLE LOC I SPuth G8874 EXC TISS NOT EVAL IMAG IO TARG LES EXCIS TISS NOT EVAL IMAG IO CONFRM No approval required INCL TARG LES G8875 CLIN DX BR CA PREOP MIN INV BX METH CLINIC DX BREAST CA PREOP MIN INV DX NO Auth B8 NO Auth Rquired DIAG BRST CA PREOP DOC RSN NO MIN INVASIVE BX No Authorization Required DIAGNOSIS BR CA PREOP G8877 CLN NOT DX BR CA PRE BX RSN NOT GVN CLIN NOT DX BR CA PREOP MIN INVAS No approval required BX RSN NOT GVN GINEL BX PROMPHENT NODE LYMPH NODE BIOPSY No approval required PERFORM PROCEDURE DONE G8880 DOC REASON SLN BIOPSY NOT DOCUMENT RSN SENTINEL LYMPH No approval required NODE DONE BX NOT PRFRM G8881 BREAST STAGE CA > T1N0M0 BREAST STAGE CA > T1N0M0 BREAST 0 /T2N0M0 STAGE STAGE/STAND0. 1N0M0/T2N0M0 G8882 SENTINEL LN BX NOT PERF RSN NOT GVN SENTINEL LYMPH NODE BX NOT PERF No approval required REASON NOT PROVIDED G8883 BX RSLT REV COMMUNICATED BIOPSY RESULTS REPORT No approval required TRACKD&DOC COMMUNICATION TRACK & DOC NOT PROVIDED G8884 RSN. PT BIOPSY RESULTS None Auth Required NOT REVIEWED G8885 BX RESULTS NOT REVIEWED SPORTS/DOC BIOPSY RESULTS NOT REVIEWED No Auth Required COMMUNICATE TRACK/DOC G8907 PT DOC NO:BRN;WRG EVNT;/TRF/ADM PT DOC NO:BURN;FALL A FACWRequired ; /C EVENT;/IN TRANSMISSION G8908 PT DOC RECEIVED BRN PRIOR TO D/C PATIENT DOC RECEIVED BURN No authorization required PREREQUISITE G8909 PT DOC DID NOT RECORD BURN PRIOR TO D/C PT DOC NO APRICEOR REQUIRED G0 PT DOC EXPERIENCED A FALL IN ASC PATIENT DOC EXPERIENCED FALLS Authorization not required INSIDE ASC G8911 PT DOC NOT EXPERIENCED FALLS IN ASC PT DOC NOT EXPERIENCING FALLS IN AMB No authorization required SURGERY CENTER G89EXPT SURGERY CENTER G89EXPT PL. DOC HAS EXP WRG SITE PAGE PT No Approval Required PRO/IMPL EVENT G8913 PT DOC NO EXP WRG SITE S PT P/IMPL PT DOC NO DEFAULT SITE PAGE PT No Approval Required PROC/IMPLANT EVENT G8914 PT DOC EXP/ADM TRNS C ASC PT DOC HAS EXPERNCD HOSP No Authorization Required TRNSF/ADM UPON D/C ASC G8915 PT DOC NOT EXP HOSP TRF/ADM D/C ASC PT DOC NOT EXPERNCD HOSP No Authorization Required TNSF/ADM UPON D/C ASC P8OP1 ASC ORD IV ABP SSI ABX INIT TM PT PREOP WORD IV ABX PROPH ABX No confirmation required INITIATED TIME G8917 PT PREOP WORD IV ABP SSI NOT INIT TM PT PREOP WORD IV ABX SSI PROPH NOT No confirmation required INITIATED TIME G8918 NO. PROPH PT NO ORDER PREOP. IV ABX SSI No approval required PROFILAX G8923 LVEF

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G8934 LVEF = 10 g/dl Recent Hemoglobin HGB no approval required Level> = 10 g/dl G9001 Coordinated Care Fee Initial Key Coordinated Care Fee Initial Key No Coordinated Care Approval Required Cee R. Ate G9003 Coordinative Fee Adjusted hi init COORDINATED CARE FEE RISK No approval required ADJUSTED HIGH INITIAL G9004 COORDINATED CARE FEE RISK ADJUSTED LW COORDINATED CARE FEE RISK INITIAL FEE No approval required ADJUSTED LOW INITIAL G9005 MA COORDINATED CJUSTARE FEE RISK. uth CUSTOM MAINTENANCE required G9006 FEE FOR COORDINATED CARE HOME MONITORING FEE FOR COORDINATED CARE HOME Approval not required MONITORING G9007 FEE FOR COORDINATED CARE TEAM CONF. COORDINATED CARE FEE SCHEDULE No approval required TEAM CONFERENCE G9008 COORD CARE PHARE CORD. No approval required SUPERVISION SRVC G9009 Coord Care Fee Risk Adj Main Lvl 3 Coordinated Care Fee Risk Adjno Author RISK ADJ No approval required MAINTENANCE LEVEL 5 G9063 ONC; STATUS; NSCLC; ST AND NO PROGRSN ONC; STATUS; NSCLC; STAGE I NO DZ No approval required PROGRESSION G9064 ONC; STATUS; NSCLC; ST II NO PROGRESS ONC; STATUS; NSCLC; STAGE II NO DZ No approval required PROGRESSION G9065 ONC; NSCLC; ST III A NO PROGRESS; STATUS; NSCLC; PHASE III A NONE DZ No approval required PROGRESSN G9066 ONC; STATUS; NSCLC; ST III B-4 MET ONC; STATUS; NSCLC; STAGE III B-4 MET No approval required LOC RECUR G9067 ONC; STATUS; NSCLC; SCOPE DZ UNKN ONC; STATUS; NSCLC; SCOPE DZ UNKN No approval required ACCORDING TO EVAL G9068 ONC; STATUS; SC&COMBLTD NO ONC; STATUS; SC& COMB SM/NONSM; No Approval Required PROGRSN LTD NO PROGRESSN G9069 ONC; STATUS; SCLC SC&COMB EXT MET ONC; STATUS; SCLC SM CELL&COMB No SM/NONSM approval required; EXT MET G9070 ONC;STATUS;SCLC SC&COMBEXTENT ONC; STATUS; SCLC SC&COMB No approval required UNKN SM/NONSM; SCOPE UNKN G9071 ONC; BRST; ACA;ST I/II;POS; NO PROG ONC; F BRST;ACA; ST I/II;ER&/PR No Approval Required POS;NO PROGRESSN G9072 ONC; BRST; ACA; ST I/II; NEG; NO PROG.ONC; F BRST;ACA; ST I/II; ER&PR No NEG approval required; NO PROGRESS

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G9073 ONC; BRUSH; ACA; ST III; POS;NO PROG ONC; F BRST;ACA; ST III; ER&/PR Approval not required POS;NO PROGRESSN G9074 ONC; BRUSH; ACA; ST III; NEG;NO PROG ONC; F BRST;ACA; ST III; ER&PR NEG; NO No approval required PROGRESSN G9075 ONC; STATUS; F BRST CA; ACA; M1 MET ONC; STATUS; FE BRST CA; ACA; M1 No approval required MET LOC RECUR G9077 ONC;PROS CA;T1-T2C& PSA20 NO METS G9079 ONC;PROS CA; T3B-T4N; T N1 NO PROG.; STATUS; PROS CA; T3B-T4N; T N1 Approval not required NO PROGRSSN G9080 ONC; PROS CA; TX INCREASE PSA ONC; STATUS; PROS CA; TX INCREASING No confirmation required PSA/FAIL REJECT G9083 ONC; PROS CA ACA; SCOPE UNKN ONC; STATUS; PROS CA ACA; SCOPE No approval required UNKN POD EVAL G9084 ONC; COLON CA; T1-3 N0 M0 NO PROG. ONC; STATUS; COLON CA; T1-3 N0 M0 No approval required NO PROGRESSION G9085 ONC; COLON CA; T4 N0 M0 NO PROG. STATUS; COLON CA; T4 N0 M0 NO No approval required PROGRESSION G9086 ONC; COLON CA; T1-4 N1-2 M0 NO PROG. ONC; STATUS; COLON CA; T-14 N-12 M0 No Approval Required NO PROGRESSN G9087 ONC; COLON CA; M1 MET W/CURR DZ ONC; STATUS; COLON CA; M1 MET Approval not required W/CURR EVIDENCE DZ G9088 ONC; COLON CA; M1 MET NO CURR DZ ONC; STATUS; COLON CA;M1 MET NO Approval not required CURR EVIDENCE DZ G9089 ONC; STATUS; COLON CA; SCOPE OF UNK ONC; STATUS; COLON CA; SCOPE DZ No approval required UNKN POD EVAL G9090 ONC; RECTAL CA; T1-2 N0 M0 NO PROG. ONC; STATUS; RECTAL CA; T1-2 N0 M0 No approval required NO PROGRESSN G9091 ONC; RECTAL CA; T3 N0 M0 NO PROG. STATUS; RECTAL CA; T3 N0 M0 NO No approval required PROGRESSION G9092 ONC; RECTAL CA;T1-3 N1-2 M0 NO PROG ONC; STATUS; RECTAL CA;T1-3 N1-2 M0 No approval required NO PROGRESSN G9093 ONC; RECTAL CA; T4 ANY N M0 NO PROG. STATUS; RECTAL CA; T4 ANY N M0 No confirmation required NO OUTPUT G9094 ONC; STATUS; RECTAL CA; M1 MET ONC; STATUS; RECTAL CA; M1 No approval required METASTATIC LOC RECUR G9095 ONC; STATUS; RECTAL CA; SCOPE OF UNK ONC; STATUS; RECTAL CA; SCOPE DZ No approval required UNK POD EVAL G9096 ONC;ESOPH CA;T1-T3 N0-N1/NX NO PROG ONC; STATUS; ESOPH CA;T1-T3 N0- No Approval Required N1/NX NO PROGRSSN G9097 ONC; ESOP CA; T4 ANY N M0 NO PROG. STATUS; ESOP CA; T4 ANY N M0 No confirmation required NO OUTPUT G9098 ONC; STATUS; ESOPH CA; M1 METASTATIC ONC; STATUS; ESOPH CA; M1 No approval required METASTATIC LOC RECUR G9099 ONC; STATUS; ESOP CA; SCOPE OF UNK ONC; STATUS; ESOP CA; SCOPE DZ No approval required UNKN POD EVAL G9100 ONC; GASTR CA; R0 RESECT NO PROG.; STATUS; GASTRIC CA; R0 RESECT No approval required NO PROGRESSN G9101 ONC; GASTR CA; R1/R2 RESECT NO PROG.; STATUS; GASTRC CA; R1/R2 Approval not required RESECT NO PRGRESSN G9102 ONC; GASTR CA; M0 URESEKT NO PROG.; STATUS; GASTRIC CA; M0 No authorization required UNRESECT NO PROGRSSN G9103 ONC; STATUS; GASTR CA; CLIN M1 MET ONC; STATUS; GASTRIC CA; CLIN M1 No approval required MET LOC RECUR G9104 ONC; STATUS; GASTR CA ; SCOPE OF UNK ONC; STATUS; GASTR CA ; SCOPE DZ No approval required UNK POD EVAL G9105 ONC; PAN CA; R0 RESECT NO PROG.; STATUS; PAN CA; R0 RESECT NO No approval required DZ PROGRESSION G9106 ONC; PAN CA; R1/R2 RESECT NO PROG.; STATUS; PAN CA; R1/R2 RESECT No approval required NO PROGRESSION G9107 ONC; PAN CA; UNRESECTBL M1 MET ONC; STATUS; PAN CA; UNRESECTBL M1 No clearance required MET LOC RECUR G9108 ONC; STATUS; PAN CA; SCOPE DZ UNK ONC; STATUS; PAN CA; SCOPE DZ No approval required UNKN POD EVAL G9109 ONC; H&N CA; T1-T2&N0 M0 NO PROG. ONC; STATUS; MAIN&NCK CA; T1- No Approval Required T2&N0 M0 NO PROGRSS G9110 ONC;H&N CA; T3-4&/N1-3 M0 NO PROG. ONC; STATUS; HEAD&NCK CA;T3-4&/N1- No confirmation required 3 M0 NO PROGRS G9111 ONC; STATUS; H&N CA; M1 MET LOC ONC; STATUS; MAIN&NCK CA; M1 No authorization required METASTATC LOC RECUR G9112 ONC; STATUS; H&N CA; SCOPE UNKN ONC; STATUS; HEAD&NECK CA; SCOPE No approval required BY DZ UNKNOWN G9113 ONC DS STATUS OV CA ST IA-B NO PROG ONC DS STATUS OVARIANA CA ST IA-B NO No approval required PROGRESSN G9114 ONC; OV CA; ST IA-B; IR; II;NO PROG ONC;OV CA; ST IA-B GR 2-3; ST IC; ST II; Approval not required NO PROGRS G9115 ONC; OV CA; ST III-IV; NO PROG ONC; STATUS; OVARY CA; ST III-IV; NO No approval required PROGRESSN G9116 ONC; OV CA; PROGRSSN&/PLATINM RSIST ONC; STATUS; OVARY CA; Approval not required PROGRSSN&/PLATINM RSIST G9117 ONC; STATUS; OV CA; SCOPE UNKN ONC; STATUS; OVARY CA; SCOPE No approval required UNKN POD EVAL G9123 ONC; CML; CP NO HEM CYT/MOL REMISS ONC; CML; CHRON PHASE NOT No approval required HEMATOL CYT/MOL REMISS G9124 ONC;CML; AP NO HEMA CYT/MOL REMISS ONC; CML; ACCEL PHASE NOT HEMA No approval required CYT/MOL REMISS G9125 ONC; CML BP NOT HEM CYT/MOL REMISS ONC; CML BP NOT HEMAT No authorization required CYTOGENIC/MOLECULAR REFERRALS G9126 ONC; CML HEM CYTOGN/MOLECULR ONC; CML HEMATOLOGIC No approval required REMISS CYTOGEN/MOLECULAR REMISS G9128 ONC; MX MYELOMA SYS DZ; SMOLDR ST IN ONC; LTD TO MX MYELOMA SYS DZ; Approval not required THINNER ST I G9129 ONC; MX MYELOMA SYS DZ ST II/HIGH ONC; LTD TO MX MYELOMA SYS DZ ST No approval required II/HIGHER G9130 ONC; MX MYELOMA SYS DZ SCOPE UNKN ONC; LTD MX MYELOMA SYS DZ No approval required SCOPE UNKN UND EVAL G9131 ONC;DZ STS;F BRST CA;STG NOT LISTED ONC;DZ STS;F BRST CA;ADENOCA;DZ No approval required STAG NOT LISTED G9132 ONC;DZ STS ; CA;CLIN METS ONC;DZ STS;PROS CA No Approval Required ADENOCARCINOMA;CLIN METS G9133 ONC;DZ STS;PROS CA;CLIN METS/M1 ONC;DZ STS;PROS CA No Approval Required ADENOCARCINOMA;CLIN METS/M1

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G9134 ONC;DZ STS;NHL;STAGE 1 2 NOT RELPSD ONC;DZ STS;NHL;STAGE I II NOT RELPSD No approval required NOT RFRCTRY G9135 ONC;DIZ STS;NHL;STG 3 4 NOT RELAPS ONC;DIZ STS;NHL; STG III IV NOT RLPSD No approval required NOT RFRCTRY G9136 ONC;DZ STS;NHL TRNS 2ND CELLR CLSS ONC;DZ STS;NHL TRNSFRM ORIG CELLR No approval required 2ND CELLR CLSS G9137 ONC;DZ STS;NHLRE; DZ STS; NHL; No Clearance Required RECURRENT/REFRACTORY G9138 ONC;DZ STS;NHL;STAGE NOT DETERMINED ONC;DZ STS;NHL;DIAG EVAL STAGE NOT Clearance Required DETERMINED G9139 ONC;DZ STS;CML;STAGE NOT SMALL ONC;DZ STS; SCOPE DZ UNKN No approval required STAG NOT ON LIST G9140 FRONTIER EXTENDED STAY CLIN DEMO; BORDER EXTENDED STAY CLIN DEM0; No CMS Authorization Required Demo Proj G9143 Warfarin RSPN Test Tech Use # Warfarin RSPN Test Test Tech Use Requires Authorization Pathology & Lab Complete Clinical Review meth any # Spec G9148 NAT Committee QA LIVER HOME NATION Q A LCON National No. G9149 NIGHT BOARD QA LEVEL 2 WITH HOME NATIONAL BOARD QA LEVEL 2 No Approval Required MEDICAL HOME G9150 NIGHT BOARD QA LEVEL 3 WITH HOME NATIONAL BOARD QA LEVEL 3 No Approval Required DEMOMONICAL HOME M G915CP STANDARD HOME STATUS No Approval Required DEVELOPED SERVICES G9152 MAPCP DEMO COMMUNITY Health MAPCP Community No Authorization Teams G9153 MAPCP Demonstration Doctor Doctor No Authorization Encourage Whevalys Facing No Authorization Visit Doctor G9157 TransesOfAge Doppler Heart TransesOphage Doppler for No Don Renje Mon CARDIAC MONITORING G9187 BPCI HOME VST PT ASMT QUAL HC PROF BPCI HOME VISIT PT required PLC-8 VISIT PT 8 ASSESSMENT No PROKRF1 TX NOT PRSC RSN NOT GIVEN BETA BLOCK THERAPY NOT PRSC No approval required REASON NOT GIVEN G9189 BETA-BLCKR TX PR SC/ CURR TAKEN BETA-BLOCKER THERAPY No authorization required PRSC/PO CURRENT G9190 DOC SA RSN NOT PRSC BETA-BLOCKR TX DOCUMENTATION BETA-BLOCKR TX DOCUMENTATION BE- Auth NOT Required BLOCKER TX G9191 DOC PT RSN NOT PRSC BETA-BLOCKER TX DOCUMENTATION PT CAUSE NOT REQUIRED No approval required PRSC BETA-BLOCKER TX G9192 DOC SYS RSN NOT PRSC BETA-BLOCKR TX DOCUMENTATION SYSTEM RSN NOT No approval required DTX G9BLOCKRSC9 NO WORD 1/2 GEN CPH DOC Approval not required AMP GEN CPH AMP G9197 DOC WORD FOR 1./2. GEN CEPH AMP DOC WORD 1./2. CEPHALOSPORIN No approval required ANTIMICROBL AMP G9197 DOC R NOT GVN ORDER 1/2. GEN CEPH AMP NO No approval required DOC RSN NOT GIVEN G9212 DSM-IVTM CRITERIA MDD DOC INIT EVAL DSM-IVTM CRITERIA MDD DOC INITIAL No approval required EVALUATION G9213 DSM-IVTM DCR -IV-TR CRITERIA MDD NOT DOC INIT No approval required EVAL RSN NOS G9223 PCP PRSC 3 MO CD4+ 200 COPIES/ML/VL No Approval Required NOT PRFRM G9243 DOC VIRAL LOAD < 200 COPIES/ML DOCUMENTATION VIRUS REQUEST TO00 REQUIRED. COPY/ML G9246 PT NOT 1 VST IN 24 MONTH MSR PERIOD PT NOT 1 VST IN 24 MONTH MSR PERIOD No Approval Required MIN 60 YES BTWN G9247 PT HAD 1 VST IN 24 MONTH MSR PERIOD PT HAD 1 VST IN 24 MONTH Not Required ASR MIN 60 YES BTWN G9250 DOC BETTER UNTIL CMFRT 48 hours init ASMT DOC PT Pain Used comfort no approval Need 48 hours init asmt g9251 Doc pain no CMFRT 48 hours init asmt docut Pain claim not used 4 anr 5 g9 doc d/c later PST- OP DAY 2 FLW CAS DOC PT D/C HOME LATER FROM POST - Approval not required OP YES 2 FLW CAS G9255 DOC D/C NO LTR PST OP DAY 2 FLW CAS DOC PT D/C HOME NO LTR FROM PST No authorization required OP DAY 2 FLW CAS G9256 DOC PATIENT DEATH AFTER CAS DOCUMENTATION OF PATIENT DEATH No authorization required AFTER CAS G9257 DOC PATIENT STROKE AFTER CAS DOCUMENTATION PATIENT CAS DOCUMENTATION NO. OF STROKE PATIENTS AFTER CEA DOCUMENTATION OF PATIENT STROKE No approval required AFTER CEA G9259 DOC PT STROKE SURVIVAL & ABSENCE FLW CAS DOC PT SURVIVAL & ABSENCE No approval required AFTER STROKE AFTER CAS G9260 DOC PATIENT DEATH AFTER CEA DOCUMENT REQUEST UIREMENT

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G9261 DOC PT SURVEILLANCE & ABSENCE TERMS FLW CEA DOC PT SURVEILLANCE & ABSENCE TERMS No approval required FOLLOWING CEA G9262 DOC PT DEATH HOSPITAL FLOW EVAR DOC PT DEATH HOSPITAL FLW No approval required 2 ALAAAAPROC G 6 EFL 9 DEATH HOSPITAL VAR AAA REPR DOC PT D/ C CALIVE FLW ENDOVASCULAR No approval required AAA REPAIR G9264 DOC PT RCV MNT HD>/=90 D CTH DC RSN DOC PT RECV MNT HD >/= TO 90 D No approval required CATHETER DOC RSN G9265=PT MAINT HD >/ 90 DAYS KAT AS VA PT RECV MAINT HD >/= 90 DAY CATH AS No authorization required VASC ACCESS G9266 PT MAINT HD >/=90 DAY NO CATH AS VA PT RECV MNT HD >/= 90 DA NO CATH No authorization required AS VASC ACCESS G9267 DOC PT 1/ > COMPLICATION/MORTALITY IN 30 DAYS DOC PT 1/MORE No approval required COMPLICATION/MORTALITY W/I 30 DAYS G9268 DOC PT 1/> COMPLICATION W/I 90 DAYS DOC PT 1/MORE A COMPLICATION required WITHIN 90 DAYS G9269 DOC PT U/O 1/> COMP NO M W/O 30 DAY DOC PT U/O 1/MORE COMP NO No approval required MORTALITY W/I 30 DAYS G9270 DOC PT U/O 1/MORE COMP W/ AND 90 DAYS DOC PT WITHOUT ONE OR MORE No approval required COMPLICATIONS W/U 90 DAYS G9273 KT SYSTOLIC < 140 DIASTOLIC < 90 KT HAS SYSTOLIC VALUE < 140 No approval required DIASTOLIC VALUE= < 400 D G900/21400 D S

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G9315 DOC AMOX PRESC 1ST LINE ABX TIME DX DOC AMOXICILLIN PRESCRIBED 1ST LINE No approval required ABX TIME DX G9316 DOC PT RSK ASSESSMENT RSK CALCULATION W/PT/FAM DOC PT RISK ASSESSMENT RISK No approval required WPT37FOC 937FOC/937/9 ASMT CA LC PT / FM NOT CMPL DOC PT RISK ASSESSMENT RISK CALC Approval not required W/PT/FAM NOT COMPL. No Authorization Required 12-MO PRIOR CURR G9322 CNT CT CRD NM NOT DOC 12-MO PREV NO RSN C NM NOT DOC 12- No Authorization Required MO RSN NOT GVN G9326 CT NOT RPT RD INDX REG RSN NOT GVN CT PERF NOT RPT RAD DOSE INDX REG No approval required RSN NOT GVN G9327 CT RPT RD INDX REG ALL DATA PERFSE RCT ELEMENT INDX REG ALL No approval required DATA ELEMENTS G9329 DICOM AVAIL 12-MO NOT DOC NO RSN DICOM DATA AVAIL PT AU 12-MO NOT No approval required DOC RSN NOT GVN G9340 FINAL RPT DOC DICOM DATA 12TH AFTR. PT No Approval Required AU 12-MO AFTR G9341 SEARCH PREVIOUS CT EXT ENTITIES 12-MO SEARCH PREVIOUS. CT EXT HC FAC/ENT 12- No approval required MO PRI FOR IMAG G9342 SRC NOT CD PRI I S PT CT S CPL NO R SR PRI IMAG S PEF PT CT S No approval required CMPL NO RSN G9344 SRCH PRIOR DICOM NOT CMPL SYS RSN SEARCH PREVIOUS CMPL DICOM IMAGES No approval required NOT CMPL SYS RSN G9345 F/U REC DOC DOC-DOCET DETECTED Approval required PULM NODULER G9347 F/U REC NOT DOC GLS PNS RSN NOT GVN F/U REC NOT DOC ACC REC GLS PNS RSN No approval not required GVN G9348 CT SCAN PNS RESERVED TIME DX DOC RSN CT SCAN ET PARANASAL SINUS DX DOC RSN G9349 CT SCAN PARANASAL SINUS ORD DX/RCV 28 D CT SCAN PARANASAL SINUS ORD TM No approval required DX/RECV 28 YES DX G9350 CT PARANASAL SINUS NON WORD DX/IN 28 D CT AUT PARANASAL TMX Auth PARANASAL TMX No /IN 28 YES AFTR G9351 MULTIPLE 1 CT PARNSL SINUS 90 D AFTR DX MULTIPLE 1 CT PARANSL SINUS ORD/REC No Authorization Required 90 DAYS AFTR DX G9352 MULTIPLE 1 CT PARNSL SS 90 DX NO RSN 90Nasal sinus more 1 CT required aftr DX No RSN G9353 More 1 CT PARNSL SS 90 D DX DOC RSN More 1 CT paranasal sinus 90 days no clearance required AFTR DX RSN G9354 1/No CT SSL DSCX/NOCT SS ORD No Approval Required 90 D AFTR DOD G9355 EARLY SELECT PART/EARLY IN NON PERF EARLY ELECTIVE DELIVERY/EARLY No Approval Required INDUCTION NON PERF G9356 EARLY ELECTION PART/EARLY IN PERF. EARLY ELECTIVE/5 EARLY IN PERF. EARLY LIFE. 7 POST-PARTUM SCREEN EVAL EDU POST-PARTUM PROJECTS EVAL Approval not required PERFORM TRAINING G9358 POST-DEL SCREEN EVAL EDU NOT PERF POST-PARTUM SCREEN EVAL Approval not required TRAINING NOT DONE G9359 DOC NOT ACCRNG/MN EVAL DOC NOT PERF. NEG/MAN P TB SCR E TB NOT AC No approval required W/I 1 Y PT VST G9360 NO DOC NEG/MANAGED POS TB SCREEN NO DOC NEGATIVE/MANAGED POSITIVE No approval required TB CHECK G9361 MEDICAL INDICATION FOR INDUCTION MEDICAL INDICATION Approval required G9364 SINUSITIS CAUSE/PRESSURE CAUSE BACT INF SINUSITIS CAUSED BY/PRESS CAUSE No Approval Required BACTERIAL INF G9365 ONE HIGH RISK DRUG ORDERED ONE HIGH RISK DRUG ORDERED G9 ONE DRUG NOT REQUIRED - 6 REQUIRED GH RISK DRUG NOT REQUIRED RED No Approval Required MINIMUM G9367 2 WORDS ORDERED SAME HIGH RISK WITH. MINIMUM 2 ORDERS FOR SAME HIGH RISK No approval required S G9368 MINIMUM 2 WORDS SAME HR DRUGS NO ORDERING MINIMUM 2 ORDERS REQUIRED. NO WORDS G9380 PT OFFRD ASST ROF PROBLEM ACCORDING TO MSR PRD PATIENT OFFERED ASST ROF PROBLEM No Approval Required DUR MSR PRD G9382 PT NO OFFER ASST EOL PROBLEM MSR PRD PT NO OFFER ASST PROBLEM END OF LIFE G9382 PT NO OFFER ASST EOL AND SSUE MSR PRD PT NOT OFFRD ASST END OF LIFE ISSUES D3 HCV INF W/I 12 MONTHS PRD PATIENT RECV SCREENING HCV INF W/I No approval required 12 MONTHS PERIOD G9384 DOC S RSN NOT RECV AN SCR HCV INF DOC S RSN NOT RECV ANNUAL SCREENING No approval required HCV HCV INF GOC93PTV INF AN SCR HCV INF DOC PT REASON NOT RECEIVED No approval required ANNUAL SCR HCV INF G9386 SCR HCV NOT REC 12 M P RSN NOT GVN SCR HCV INF NOT RECV W/I 12 MO PR No approval required RSN NOT GIVEN RPLQR8 D CC SUR UNPLANNED RUPT POST CAP RQR No approval required VITRECT DUR CAT SURG G9390 NO UNPLN RUP PC RQR VITRECT CC SURG NO UNPLAN RUP POST CAP RQR No approval required VITRECT DUR CC SURG G9393 PH PT I 2> PH 9 SC9 RM 12 MO D 12 MO No approval required PHQ-9 SC 9 NO RM NA 12 MO PT INIT PHQ-9 SC >9 NOT WELL ACHV No approval required REMISSION 12 MO G9396 PT I PHQ-9 SC >9 NO ASSESSMENT RM 12 MO PT INIT PHQ-9 SC >9 NOT ASSESSED RM No KL approval required. 12 MO G9399 DOC PT RCRD DISC BTW PHYS/CLIN & PT DOC PT RECORD DISCUSSION BETWEEN No approval required PHYS/CLIN I NOT PT G9400 R DOC PT G9400 R DOC DISC TX OPTIONS; DOC MED/PT RSN FOR NON DISC No TREATMENT OPTION approval required; G9401 NO DOC PT RCRD DISC BTW PHYS & PT NO DOC DISC PT RCRD DISC BTW No approval required PHYS/Q HC PROF & PT G9402 PT RCV F/U D D/C/WI/30 YES AFTR D/C PATIENT RECV F/U ON DATE D/C/WI 30 No Approval Required DAYS AFTER D/C G9403 CLN DOC RSN PT BR 30 D F/U INPT D/C CLIN DOC RSN PT NOT CMPL 30 DA F/U No Approval Required AC INPT D/C

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G9404 PT FAILED RCV F/U DT D/C/WI 30 YES D/C PT FAILED RCV F/U DATE D/C/WI 30 No approval required DAYS AFTER D/C G9405 PT RECV F/U WITHIN 7 DAYS AFTER D /C PATIENT RECEIVED F/U WITHIN 7 DAYS No Authorization Required AFTER D/C G9406 CLN DOC RSN PT NO 7 YES F/U INPT D/C CLIN DOC RSN PT NOT CMPL 7 DAYS F/U No Authorization Required AC INPT D /C G9407 PT NOT RECV F/U ON/WI 7 YES AFTER D/C PATIENT DID NOT PROVIDE RECV F/U ON/WI 7 No Authorization Required DAYS AFTER D/C G9408 PT CT &/PERICARDIOCENTEZY WI 30 YES PATIENTS W / CT No Clearance Required &/PERICARDIOCENTEZ OCR WI 30 YES G9409 PT WO CT &/PERICARDIOCENT WI 30 YES PATIENTS WO CT No Clearance Required &/PERICARDIOCENTEZ OCR WI 30 YES G9410 PT ADM WI 180 DAYS WILD 180 DAYS ON 8 CI ED W/INF No Approval Required RQR DEVC REMV G9411 PT NOT ADM WI 180 D PST CIED W/INF PT NOT ADM WI 180 D PST CIED W/INF No Approval Required RQR DVC RMV G9412 PT ADM WI 180 DPVC ADM WI 180 D PST CIED M/INF DVC No approval required RMV/SURG REV G9413 PT NOT ADM WI 180 D POST CIED W/INF PT NOT ADM WI 180 DAY POST CIED No approval required W/INF DEVC REMV G9414 DMC VAC ON/BETWN PT 11&13 BD PT HAD 1 DOSE MC VAC ON/BETWN PT No approval required 11TH & 13TH BD G9415 PT NO 1 DOS MC V ON/BTW PT 11&13 BD PT NO 1 PT DOSE/BETWN required V 11TH & 13TH BDAG G9416 PT 1 TET DT TDAP ON/BTW 10 & 13 BD PATIENT HAD 1 TET DT & TDAP ON/BTW No PT Clearance Required 10 & 13 BD G9417 PT NO 1 TET & DTBTW TDAP 1 PATIENT & DT 3BD 1 TDAP TET DT & TDAP ON/BTW No PT 10 Clearance Required & 13 BD G9418 P NSCLC BX&CY SPEC DOC CL NSCLC-NOS PRIM NSCLC BX&CY SPEC DOC CLASS No approval required NSCLC-NOS EXPLAN G9419 DOC M RSNC PLN DOC S RSN NOT INCLUDING ITS T/NSCLC- No approval required NOS CLASS EXPLAN G9420 SPEC S NOT LOK LUNG/NON PRIM NSCLC SPEC SITE EXCEPT LOK LUNG/NOT No approval required CLASS PRIM NSCLC G9421 NSCLC DOC CL SSC NOS PRIM NSCLC BX&CY S NO DOC CLASS No approval required NSCLC-NOS EXPLAN G9422 NSCLC BX & CYTOLOGY SPEC RPRT NON-SMALL CELL LUNG CANCER BX & No approval required CYT SPEC RPRT G9423 DOCLC S RSN NO. RSN NOT RPRT H TYP/NSCLC- No approval required NOS CLASS EXPLN G9424 SPEC SITE EXCEPT LOC L NOT NSCLC SPEC SITE EXCEPT ANAT LOC LUNG No approval required NOT NSCLC/NOS G9425 NSCLC BX & NSC CY SPC-NOSOC NOT & CY SPC NON DOC CLASS No approval required NSCLC-NOS EXPLAN G9426 IMP MED TM ED AR-INIT P MED PRF ADM IMP MED TM ED AR-INIT ED PN MED No approval required ADMIN PRF ADM PT G9427 IMP MN TM ED AR-I P MED NOT PRF ADM IMP WITH TM ED AR-INIT PAIN WITH No approval required ADMIN NOT PRF ADM G9428 PA RPRT PT CAT & STM THK WOUND & MR-STI RPRT PT CAT & STM THK WOUND & No approval required MITOTIC RATE G9429 DOC MED RATE NO PT CAT&STM THK DOC WITH RSN NOT INCL PT CAT & STM No approval required U&MR THK MARSÅR & MR G9430 SITE EXCEPT ANAT SKIPT LOC SITE EXCEPT ANATOMY No approval required SKIN LOCTH & G9431 THK TM G9431 PATH RPRT NO PT CAT & STM THK No App roval Required MARSAR & MITOTIC RA G9432 ASA WC ACT C-ACT ACQ/ATAQ RSLT DOC ASTHMA WELL-CNTRL ACT C-ACT No Approval Required ACQ/ATAQ SC RSLT DOC G9434 CTRA ASA NOT WC NOT U RSN NOT GVN ASTHMA NOT WC SPEC CTR ALT NO Not Required approval IS USED RSN NOT GVN G9448 PT BORN YEARS 1945-1965 PATIENTS BORN YEARS No approval required YEAR 1945-14965 HPRIS 9 BLOOD TRANSFUS 9 BLOOD HISTORY No approval required TRANSFUSION PRI 1992 G9450 HISTORY HISTORY OF INJECTION USE USE FOR INJECTIONS No approval required G9451 PATIENTS NT RECV ONE SCR HCV INF REQUIRED PATIENT REQUIRED 9 REQUEST. 2 DOC WITH RSN NOT RECV 1-TIME SCR HCV DOC WITH RSN NOT RECV 1-TIME SCR No approval required HCV INFECTION G9453 DOC PT RSN NOT RECV 1-T SCR HCV INF DOC PT RSN ZA NOT RECV 1-TIME SCR No approval required FOR HCV INF 1 G9454 T SCR HCV NOT RECV 12 MO NO RSN 1-TIME SCR HCV INF NOT RECV WI 12 No approval required MO RSN NOT GVN G9455 PT ABD IMAG U/S CE CT/C MRI HCC PT UNDRWNT ABD IMAG U/ S CE No approval required CT/CONT MRI FOR HCC G9456 DOC MED/PT RSN NO ORDR/PERF SCR HCC DOC MED/PT RSN FOR NO No approval required ORDER/PRFRM SCR HCC G9457 PT NO A I&NO DOC RSN NO A I SBMS P PT NO ABD IMAG & NOT DOC RSN NR No approval required ABD IMAG SBMS P G9458 PT DOC TOB USER & RECV TOB CESS INT PT DOC TOBACCO USER & RECV No approval required. ASMT/CESS INT NOT PRFR NO RSN TOBACCO ASMT/CESS DO NOT INTERVENTE No approval required PRFR RSN NOT GVN G9468 PT NOT REC CS>/=10 MG/D PRD EQ 60 D PT NOT REC CS >/= TO 10 MG/D PRD EQ No Authorization Required 60/GT CONS D G9469 PT RECV CS>/=10 MG/D PDN EQ 90/> D PT RECV/RCVNG CS >/= 10 MG/D PDN No Authentication Required EQ 90/GT CONS D G9470 PT NO CS >/= 10 MG/D PDN EQ 60/> D PT NOT RECV CS >/= 10 MG/D PDN EQ No Approval Required 60/GT CONS D G9471 WI PAST 2 YEARS CTR DXA NO ORDER/DOC WITHIN PREVIOUS 2 YEAR CENTRAL DXA No Approval Required NOT ORDERED/DOC G9473 SRVC PERF CHAPLN HOSPIC EA 15 MIN SERVICES PERF CHAPLAIN HOSPIC No Approval Required Hospice SET EA 15 MIN G9474 CSRVC PRFHOUN DIEFRY SELOR No Approval Required Hospice HOSPIC EA 15 MIN G9475 SRVC PERF OTHER COUNSELORS HSPCE EA 15 MIN SERVICES PERF OTHER COUNSELORS No approval required Hospice HOSPIC SET EA15 MIN G9476 SRVC PRF VOLUNTEER HOSPIC EA15 MIN SERVICES SERVICES Hospice MIN SERVICES 15 MIN G9477 SRVC PRF CARE COORD HOSPIC EA 15 M SRVC PERF CA RE COORDINATOR No approval required Hospice HOSPIC SET EA 15 A MINUTE

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G9478 SRVC PRF OTHER QUAL TH HOSPICE EA 15 M SRVC PERF AND QUAL THERAPIST No authorization required Hospice HOSPIC EA 15 MIN G9479 SRVC PRF QUAL PHARM HOSPIC EA 15 M SRVC PERF HOSPIC QUAL. PERF HOSPIC 15 M SRVC PHARMACEUTICAL QUAL. SET ON WHICH 5 MIN G9480 ACCESS MCCM PROGRAM ACCESS MEDICARE CARE CHOICE No Authentication Required MODEL PROGRAM G9481 RMT IH VST FOR E/M NEW PT;TYP 10 MN HOME REMOTE CONTROL VST FOR E/M OF No Authentication Required NEW PT;TYP 10 MIN G9482 RMT IH VST FOR E M NEW PT:TYP 20 MN REMOTE HOME VISIT FOR E/M OF No approval required NEW PT;TYP 20 MN G9483 RMT IH VST FOR E/M NEW PT;TYP 30 MN REMOTE HOME VISIT FOR E/M M OF No approval required NEW PT ;TYP 30 MN G9484 RMT IH VST FOR E/M NEW PT;TYP 45 MN REMOTE HOME VISITATION FOR E/M OF No approval required NEW PT;TYP 45 MN G9485 RMT IH VST FOR E/M NEW PT;TYP 60 MN REMOTE HOME VISIT FOR E/M OF No Approval Required NEW PT;TYP 60 MN G9486 RMT IH VST FOR E/M EST PT;TYP 10 MN REMOVED HOME VST FOR E/M OF No Approval Required ESTAB PT;TYP 10 MN G9487 RMT IH VST FOR E/M EST PT;TYP 15 MN REMOTE IN-HOME VST FOR E/M OF No authorization required ESTAB PT;TYP 15 MN G9488 RMT IH VST FOR E/M EST PT; TYP 25 MN REMOTE IN-HOME VST FOR E/M OF No Authorization Required ESTAB PT;TYP 25 MN G9489 RMT IH VST FOR E/M EST PT;TYP 40 MN REMOTE IN-HOME VST FOR E/M OF No Authorization Required ESTAB PT;TYP 40 MN G9490 CMS IC MDL HV PA CLN;NOT BLL 30-D P CMS IC MDL HV PT ASMT CLIN;NOT BILL No approval required 30-DAY PO. /PROXY HOLDS Approval not required SMOKING DAY SX G9498 ANTIBIOTIC REGIMEN PRESCRIBED ANTIBIOTIC REGIMEN PRESCRIBED No approval required G9500 RADIATION EXPOSURE INDICES DOC RAD EXP INDICES/EXP INDICES/EXP EXP TM & EXP GOD5 CS/EXP TM&NO FL I N DOC N RSN RAD EXP INDICES/ EXP TM & NO FLUORO Approval not required IMG N DOC N RSN G9502 DOC S RSN FOR DOCUMENTATION FOR NEPERF FOD EXAMINATION MEDICAL RSN FOR No approval required NON PERF FOD EXAMINATION G9503 PT TAMSULOSIN TAMSULOSIN HYDRESSULOSIN DYCHLORIDE G95 04 DOC DO NOT ASSESS HBV PRI ANTI- TNF TX DOC RSN DO NOT ASSESS HBV STS PRI INIT No approval required ANTI-TNF TX G9505 ABX PRSC 10 D AFT ON SX DOC S RSN ABX REG PRSC W/I 10 YES AFTR ONSET No DOC required SA SX RSN G9506 BIOLOGICAL IMMUNSPONS AG PRSC BIOLOGICAL IMMUNSPONS No approval required PRESCRIBED CHANGE G9507 DOC PT TO STATIN MED/DOC VALID CNTRA DOC PT TO STATIN MED/DOC VALID No approval required G9508 CONTRAINDICATION NOT G9508 DOC. ATION PT NOT FOR No approval required STATIN MEDICINE G9509 ADULT 18Y/O MD/DYSTHYMIA R 12MO ADULT 18Y/OLD MD/DYSTHYMIA No approval required REMISS AT 12MO G9510 ADLT 18/>MD NO REM-12M NO. DEM No Authorization Required 12 MO PHQ-9 9 DOC DUR 12 M DNM ID P IDX PHQ-9/PHQ-9M SC>9 DOC DUR 12 No Authorization Required MO DNOMN ID PRD G9512 INDIVIDUAL HAD A PDC OF 0.8/MORE INDIVIDUAL PDC OF 0.8 OR GREATER No Approval Required G9513 INDIVIDUAL HAD NO PDC OF 0.8/> PERSON HAD NO PDC ON No Approval Required 0.8 OR GREATER G9514 PT RQRT RTN TO OR W/I 90 D OFFER FOR REV. OR W/I 90 No Approval Required DANA SURG G9515 PT NOT RQR RTN OR W/I 90 D SURG PT NOT RQR RTN OR W/I 90 No Approval Required. DANA SURG G9516 PT ACHVD PREOPPRV IM 90 D SX PT RECEIVED IMPRV I VA FROM PREOP No approval required LVL 90 D SURG G9517 PT NO IMPRV VA PREOP LVL 90D S NO R PT NOT ACHV IMPRV VA PRE LVL 90 D No approval required SUR NR . ACTIVE DOCUMENTATION No approval required INJECTABLE USE G9519 PT FINL RFR +/- 1.0 D RFR 90 D SURG PT FINAL REFR +/- 1.0 D REFR W/I 90 No approval required DANA SURG G9520 REFRIO NO. D SRG PT NO F REFR +/- 1.0 DIO REFR W/I 90 D No Approval Required SURG G9521 TOT # ED VSTS & IP HOSP>2 LAST 12M TOTAL VISITS ED & IP HOSP < 2 No Approval Required PAST 12M G9522 TOT #ED VST&IP=/>2 12 M/NO SCR NO R TOT #ED VISIT & IP=/>2 PAST 12 No Authorization Required MO/NO SCR NO R G9523 PT DXD HEMODIAL/PERITONEAL DIALYSIS PT COMPLETED No Authorization Required HEMODIALYSIS / PERITONEAL DIALYSIS G9524 PATIENT WAS REFERRED TO HOSPIC HIS PATIENT WAS REFERRED TO HOSPIC HIS Approval not required CARE G9525 DOC PT RSN FOR NOT REF HOSPIC HIS REFERRED TO HOSPICE No approval required RSN NOT GIVEN G9529 PT MIN BLNT HD TRMA APPROP IND CT CT PT MIN TUP HEAD TRAUMA APPROP No approval required INDICAT HEAD CT G9530 PT W/MIN BLUNT HD WCPMIN PLUNT AUT. Required TRAUMA CT ORD BY ECP G9531 PT DOC VENT SHNT MXSYS TR TAK AP RX PT DOC VENT SHUNT MXSYS TR/CURR No approval required. HEAD G9533 PT MIN BLNT HD TRMA NO INDCAT HD CT PT MIN BLUNT HEAD TRMA NO APPROP No authorization required INDICAT HEAD CT G9537 DOC SYS RSN OBT HEAD CT MRI STUDY DOC SYS RSN ORD ADVANCE HEAD9 Auth REQUIRED HEAD5 MTL CT NO. BY PLCMT REGARDING POTENTIAL REMOVAL TIME Approval not required BY LOCATION G9540 PATIENT ALIVE 3 WAYS. AFTER PROCEDURE PATIENT ALIVE 3 MONTHS AFTER PROCEDURE No approval required. PROCEDURE G9541 FILTER REMOVED W/I 3 M. 3 WAY LOCATION. ACEMENT G9542 DOC FILTER APPROVAL RE-ASSESSMENT RMVL 3 M DOC FILTER APPROVAL RE-ASSESSMENT No approval required REMOVAL W/I 3 M

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G9543 DOC AT LEAST TWO ACCESS ATTEMPTS TO PT DOCUMENTATION AT LEAST TWO Approval not required ATTEMPTS TO ACCESS PT G9544 PT NOT FILTERED RMVD PATIENTS NOT Required Approval not required G9544 PT RUT. VN DOES POINT TIME OF >2 HOURS Approval not required NO REASON GIVEN G9583 PT PRSC OPIOIDS FOR 6 WEEK LNGR PATIENTS PRESCRIBED OPIOIDS FOR 6 WEEK LNGR Approval not required G9584 PT ASSESSMENT CONDITION RISK APPLY ANY USED STATE OPI BRF VAL INSTRUM G9585 PT Not EVL RSK MSUSE OPI VAL INSTRM PT Not Eval Risk of Abuse Intoxicate BRF NO AUTH Author Required VAL INSTRUM G9593 PED PT M BLNT HD TRMA LW RSK PECARN PED PT MIN BLUPT HEAD TRMA LW RISK BLUNT HT & HEAD CT TR ECP PT PRES MIN BLUNT Head Tr & Head No clearance required CT order Tr ECP G9595 PT has Doc Vt Shunt PT has Doc ventricular Shunt No clearance required Bt/coagulopathy bt/coagulord o shn ped pt head CT trauma ord ecp no clearance required or remor TR G9597 PED PT MI HD TRMA NOT LW RSK PECARN PEDIATRIC PT MI BLNT HEAD TRMA NOT No approval required LW RSK PECARN G9598 D5CL 5.MX 9CM-5. /MI D AX CT AA 5.5 - 5.9 CM MAX DIA CL FRMT No approval required CT/MIN DIA AX CT G9599 AA 6.0 CM/>MX DIA CL CT/M DIA AX CT AA 6.0 CM/ >MAX DIA CL FRMT CTMIN No approval required DIA AX FRMT CT G9600 SYM AAAS AT RQR URGENT/URGENT SYMPTOMATIC AAAS AT RQR No approval required REPR URGENT/URGENT REPAIR G9601 PT D/C HOME NO LTR THN POST-NE DLA THANTER HOME POST- OP DLA #7 No Approval Required POST -OP DAY #7 G9602 PT NOT D/C HOME FOR PROCEDURE. DAY #7 PATIENT NOT D/C HOME ON POST- No approval required SURVEY DAY #7 G9603 PT SURV SCR IMPRV FROM BASE FLW TX Patient Survey Result IMPR from No Approval Required Baseline Flw TX G9604 Patient Survey RSLT Not Available Patient Survey Results Not No Approval Required Available G9605 PT Surv Scre No IMPRV BASE FLW NOT TX REQUIRED Patient Survid Aut BFL TX G9606 iort Cystscpy PERF EVAL LW TRCT INJ Iort Cystoskopi PERF EVALUATE FOR no Approval required LWR TRACT INJ G9607 D M RSN NOT PRF IO CYSTO/CASE PT D DOC WITH RSN NOT PERF IO CYSTO/IN No approval required CASE PT DEATH G9608 I TRORT CYSTPY LW NOT TRCT INJLSC IORT CYSTOSCOPY NOT PERF EVAL LWR No approval required TRACT DAMAGE G9609 DOC ORDER FOR ANTI-THROMBOTIC AGENTS ORDER DOCUMENTATION FOR ANTI-THROMBOTIC AGENTS No approval required G9610 DOC S RSNPT REC NOT ORD MEDICAL AP AGT Auth GT G9611 ORD AP AG NOT DOC PT R RSN NOT GVN ANTI-PLATELETECITE ORDER AGT NOT DOC PT No approval required REC RSN NOT GVN G9612 PHDOC 2/MORE CECAL LDMK EST CMPL EX PHOTODOCUM 2/ MORE CECAL No approval required LANDMARK EXAMINATION CURGMENT LANDMARK EXAMINATION CURGMENT 3 POST-OPERATIVE DOCUMENTATION No approval required ANATOMY ANATOMY G9614 PHOTODOC

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G9616 DOC RSN Not DOC A Preoperative assessment documentation RSN no. Author requires preop evaluation documentation G9617 Preop evaluation no Doc rsn no GVN Preop evaluation no Doc No Author required RSN No GVN G9618 DOC SCR NO MALIG/US &/ENDOMET DOCUMENTATION SCR NO NO approval required SAMP MALIG/US&/ENDOMET SAMP G9620 PT NOT SCR UTERINE MALG/NO U/S NO RSN PATIENT NOT SCR UTERINE MALIG/NO No approval required U/S RSN NOT GVN G9621 PT ID UNHLTHY ALC USR SCR&BRF ADVICE PATIENT USER no. SCR & BRF COUNS Approval Required G9622 PT NOT ID UNHLTHY ALC USR SCR ALC U PT NOT ID UNHLTHY ALC USER SCR No Approval Required UNHLTHY ALC USER G9623 DOC WITH RSN NO SCR UNHLTHY AL USER ALC REQUEST NO MEDICAL AHL DOCUMENTATION USER G9624 PT NOT SCR UHLTY AU USE SYS SCR M PT NOT SCR UHLTY ALCOHOL USE USE No authorization required SYS SCR METH G9625 PT SUST BLAD INJ SRG/DSCV SUBSQ >30 PT SUSTAIN BLAD INJ SRG/DSCV No Auth PSU SURED G9626 DOC WITH RSN NOT REPORTING BLADDER INJ THE DOCUMENT WITH RSN NOT No Approval Required REPORTING BLADDER INJURY G9627 NOT SUST LIST INJ SRG/NOR 30D P S NOT LIST INJ SRG/NOR DSCV No Approval Required 6JSUBSQ INJ 280BSQ 6J20BSQ. C Sub 30d PST Pt Sustn Intestinal Inj Surg/Disc No Authorization Required Subseq 30D PST SRG G9629 DOC WITH RSN No Report Intestinal Inj With RSN No Author /DISC TO No Authorization Required 30 D POST SURG G9631 PT URETR INJ SRG/DISC 30 D POSTSURG PT SUSTAIN URETER INJ SURG/DISC 30 No authorization required DAY POST SURG G9632 PT NOT ELG E.g. GIN/OTHER PLV MAL DOC PATIENT NOT ELIGIBLE NPR. Gyn/OTH No approval required for PELV Malig Doc G9633 PT not maintained Ureter Inje 30d Ps Pt NO MAINTENANCE INS SX/DISC 30D No approval Required after SRG G9634 H-REL QOL ACSENCENCENE 2 VST & QOL SME/QOL Impressel 2 No OPPOSITION INTERB / IMPR G9635 HLTH-REL QOL NOT ASSESSED TL DOC RSN HEALTH-REL QUALITY OF LIFE NOT ASSESSED No approval required ALT DOC RSN G9636 H-REL QOL NOT ASSESSED 2 VST/QOL NOT DCLREL HEALTH-Q2 No approval required VST/QOL REJECTED G9637 FINAL RPT DOC 1/MORE DOSE RED TECHNICAL FINAL REPORT W/DOC 1/MORE DOSE No approval required REDUCTION TECHNICAL G9638 FINAL RPT U/O DOC 1/> DOS RDUCPORT TECHNICAL/FINAL 1/MORE No approval required DOSE REDUCTION TECHNICAL G9639 MAJOR AMP /OPEN SURGICAL BYPS NOT RQR MAJOR AMPUTATION/OPEN SURGICAL No authorization required BYPASS NOT RQR G9640 DOCUMENT SCHEDULED HYBRID/STAGED HYBRID/STAGED NO PROC. DURE G9641 MAJOR AMPUTATION /OPEN SURGICAL BYPS MAJOR AMPUTATION/OPEN SURGICAL No approval required RQR BYPASS REQUIRED G9642 CURRENT SMOKER CURRENT CIGARETTE SMOKER No approval required G9643 ELECTIVE SURGICAL ELECTIVE No. A4 AUT SURGEON. NES D SX/PCR PT NO SMOKING AT TO ANES DAY No Approval Required SURG/PROC G9645 PT NOT F ABST SMK PRI ANES D SX/PCR PT NO SMOKING AT TO ANES DAY No Approval Required ANES DAY SX/PCR G9646 PATIENTS W/ 90 YES MRS SCORE 0 TO 2 DAYS MRS SCORE FROM No approval required 0 TO 2 G9647 PT MRS SCORE NOT OBTAINED 90 YES F/U PATIENTS MRS SCORE NOT OBTAINED No approval required 90 DAY FOLLOW-UP G9648 PATIENTS WITH 90 DAY MRS SCORE NO MRS 90 Approval required MORE THAN 2 G9649 PSORIASIS DOC ANY 1 BNCHMK BSA SEV PSORIASIS ASSESSMENT TOOL DOC ANY 1 No approval required BNCHMK BSA SEV G9651 PSO TL DOC NONE 1 SPEC BENCHMK PSO NOT ASSESSMENT TOOL MONC1 DOC1 None MTG AUT DOC1 SPEC. SUPERVISED AESTHESIA CARE SUPERVISED ANESTHESIA CARE No approval required G9655 A TRAN OF CARE PROT/H/O TL/CHCKLISTE A TRANSFER OF CARE PROTOCOL/H/O No approval required TOOLS/CHECKLIST G9656 PT TR D F AA LOC TO PACE/OTHER TRANSICU DIRECT F ANES LOC TO Approval not required PACE/OTHER N-ICU LOC G9658 A TRAN CARE PROT/HO TOOL/CHECKLIST A TRANSFER OF CARE PROT/HANDOFF Approval not required TOOL/CHECKLIST G9659 PT>85 YRS NO HX CC/MED RSN CO. PT>85 YRS NO HX COLORECTAL CA/MED No authorization required RSN COLONOSCOPY G9660 DOC S RSN COLONOSCOPY PT>85 YRS DOCUMENTATION WITH RSN No authorization required COLONOSCOPY PERF. WHO RECV Approval not required ROUTINE COLONOSCOPY G9662 PREVIOUS DX/ACTIVE DX CLIN ASCVD PREVIOUSLY DIAGNOSED/HAVE ACTIVE No approval required DX CLIN ASCVD G9663 ANY F/DIR LDL-C LT RSLT

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G9682 ONSITE AC T NF RES SKN INF BILL SID ONSITE AC TX NSG FAC RES W/SKN INF No Auth Required BILL SID-BNEF G9683 FAC AC TX NSG FL/ELCT TO BILL SID FAC ONSITE AC TX NSG FAC RES Auth/ELCT No Auth Required DO BILL SID G9684 ONSITE AC TX NF RES UTI BILL SID ONSITE AC C TX NSG FAC RES UTI BILL No approval required SID-BENEF G9685 PHYS OTHER PROF E&M BENEF CHG COND PHYS OTHER PROF E&M BENEFIC CHG required G7 HOSPC SVC PROV PT ANY TM DUR MSR PR HOSPIC SRVC EVIDENCE FOR PT ALL TIME No Approval Required DUR MSR PR G9688 PT HOSPIC SRVC WHEN UNDER MSR PR PATIENTS USE HOSPIC SRVC EVERY No Approval Required TIME A968 MSRPT AUTO. PATIENT ADM DONE ELECTIVE Authorization not required CAROTID INTERVENTION G9690 PT RECV HSPC SRVC ANY TM DUR MSR PR PATIENT RECV HOSPIC SRVC ANY Authorization not required DUR MSR PR G9691 PT HAD HOSPC TM SRAD SRV SERVC ANY Authorization required DUR MSR PERIOD G9692 HSPC SRVC REC V PT ANY TM DUR MSR PR HOSPICE SERVICES RECEIVED PT ANY Approval not required TIME VI MSR PR G9693 PT HOSPICE SRVC ALL TIME UNDER MSR PR PATIENT USAGE OF HOSPICE NO. SRVC IN PT FULL TIME UNDER MSR PR HOSPICE SRVC USES PT ALWAYS No approval required DUR MSR PR G9695 LONG TERM INHALATION BD PRESCRIBED LONG TERM INHALATION No approval required BRONCHODILATOR PRESCRIBED G9696 PR DOCLA S DOCLA DOCLA NE G9696 LA IN HALATED No approval required BRONCHODILATOR G9697 DOC PT RSN NOT PRSC LA INHALED BD DOC OF PT RSN NOT PRSC LA INHALED No Authorization Required BRONCHODILATOR G9698 DOC SYS RSN NOT PRSC LA INHALED BD DOC SYS RSN NOT REQUIRED G9C AUT. LANG- ACT INHAL BD NOT PRSC RSN NOS LONG ACT INHAL BRONCHODILATR No approval required NOT PRSC RSN NOS G9700 PT USE HOSPC SRVC ANY TM DUR MSR PR PATIENTS USING HOSPIC SRVC ANY No approval required TIME LID 970AK1 CH PRLD 3DATE. ENC CHILDREN TAKING ABX 30 DAYS AT TO No approval required DATE ENCNTR G9702 PT USE HOSPC SRVC ANY TM DUR MSR PR PATIENTS USING HOSPIC SRVC ANY No approval required TIME DURING MSR PR G9703 CLDN 30DAKY ABX 30 30 YES PRI TO DX No approval required FARING ITIS G9704 AJCC BRST CA STAGE I T1 MIC/T1A DOC AJCC BREAST CANCER STAGE I T1 MIC No approval required OR T1A DOC G9705 AJCC BREAST CANCER STAGE I T1B BREAST CANCER STAGE I T1B BREAST CANCER Acquired No DOCUMENT G9706 LOW RISK OF PROSTATE RECURRENCE LOW RISK FOR PROSTATE RECURRENCE No approval required CANCER CANCER G9707 PT RCV HOSPC SRVC ANY TM BELOW MSR PR PATIENT RCV HOSPIC SRVC WHEN TIME No approval required W H7 MH0D REQUIRED BH0X CAR WOMEN WHO HAVE HAD CA No approval required MAST MASTECTOMY/HX CAR MASTECTOMY G9709 HOSPIC SRV C PT ALWAYS CONSIDERED MSR PR HOSPIC SRVC PATIENT WHEN TIME NUR No Approval Required MEASUREMENT PR G9710 PT PROV HSPC SRVC ANY PRIVICE SRVC ANY PRTI DSRNY TM DUR MSR PR G9711 PT M/DX PASSED HX TOTAL COLECTOMY/CRC PATIENTS WITH DX PASSED HX TOTAL No authorization required COLECTOMY/ CRC G9712 DOC WITH RSN FOR PRESCRIB/DISP ABX DOCUMENTATION WITH RSN FOR No authorization required G9DISPENS PRES3X US SRVC ANY TM DUR MSR PR PATIENT USING HOSPIC SRVC ANY No authorization required TM DUR MSR PR G9714 PT USING HOSPC ANY TM DUR MSR PR PATIENT USING HOSPIC SRVC EVERY No approval required TIME DUR MSRPT USURE HVC SRPC TM G9715 PR PATIENT USING HOSPIC SRVC EVERY No approval required TM DUR MSR PR G9716 BMI DOC ONLY FU PLN NO CMPL DOC RSN BMI DOC OUTSD NORMAL LMT F/ U PLAN No approval required NOT CMPL DOC RSN G9717 DOC PT DPRX DPR. /O DOCUMENTATION PT HAS ACTIVE DX Approval not required DEPRESSION/BD G9718 HSPC SRVC PT PROV ANY TM DUR MSR PR HOSPIC SERVICES PATIENT PROVES POSSIBLE No approval required TM DUR MSR PR G9719 PATIENT NOT OUTPATIENT B R ALLOWED No approval required FOR CHR WC BND G9720 HSPC SRVC PT OCRD ANY TM DUR MSR PR HOSPICE SRVC PATIENT APPEARANCE ANY No approval required TM DUR MSR PR G9721 PATIENT NON-MOVING PATIENT NOT REQUIRED BID BED BED Ruth D2 HX RNA FAIL/BSE S-CR=4.0 MG/DL; DOC HX RENAL FAILURE/BASELINE S- No approval required CR=4.0 MG/DL; G9723 HSPC SRVC PT RECV ANY TM DUR MSR PR HOSPICE SRVC PATIENT RECEIVING ANY No approval required TIME DURING MSR PR G9724 PATIENTS DOC AC WITH OVERLAP MSR YEAR PATIENTS DOC ANTICOAGULANT MEDICAL No approval required G9P MSR 5SR NEW AUT. DUR MSR PR PATIENTS USING HOSPCE SRVC ANY No authorization required TIME UNDER MSR PR G9726 PATIENT REFUSED TO PARTICIPATE PATIENT REFUSED TO PARTICIPATE No authorization required G9727 PT UN CMPL KN FS PROM INIT EVL&/D/C DEVELOPED POSSIBLE COMPLETELY SEPARATED PATIENTS. / D/C G9728 PATIENT REFUSED TO PARTICIPATE PATIENT REFUSED TO PARTICIPATE No approval required G9729 PT UN CMPL HIP FS PROM INT EVAL&D/C PATIENT UN TO COMPLETE HIP FS PROM No approval required INIT EVALEF30 PATIENT GENTPUSENT FOR R7 PARTICIPATION No approval required G9731 PT UN CMPL ANK/FT FS PROM AND EV&/D/C PT UNABLE COMPL ANK/FT FS PROM No Approval Required INIT EVAL &/ D/C G9732 PATIENT REFUSED TO PARTICIPATE PATIENT REQUIRED FOR A93. PT UN CMPL LB FS PROM INT EVL&/D/C PT UNABLE COMPL LW BACK FS PROM No authorization required INIT EVAL &/ D/C G9734 PATIENT REFUSED TO PARTICIPATE PATIENT REFUSED TO PARTICIPATE No authorization required G9735 SHINT /D/C PT UNABL COMPL SHOULDER FS PROM No approval required INIT EVAL &/ D/C G9736 PATIENT REFUSED TO PARTICIPATE PATIENT REFUSED TO PARTICIPATE No approval required G9737 PT UN CMPL E/W/H FS PROM/ C EVL& UN COMPL ELBO/WRST/H FS PROM No approval required INIT EVAL &/ D/C

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G9738 PATIENT REFUSED TO PARTICIPATE PATIENT REFUSED TO PARTICIPATE No authorization required G9739 PT UN CMPL G ORTH FS PROM I EVL&/DC PT UNABL CMPL GEN ORTHO FS PROM No authorization required INIT EVAL &/ D/CSR G PR HOSPIC SRVC DAN PT WHEN ANY None approval required DUR MSR PR G9741 PT USE HOSPC SRVC ALL TM DUR MSR PR PATIENTS USING HOSPIC SRVC EVERY No approval required TM DUR MSR PR G9744 PATIENT NOT EXPOSED D/TTN D/T ACTIVE DX No approval required HYPERTENSION G9745 DOC RSN FOR NON SCREE /REC F/U HBP DOCUMENTED REASON FOR NO No approval required SCREENING/REC F/U HBP G9746 PT HAS MS/PROS HV/PT TSNT/R CAUSE PT HAS MS/PROS HEART VLV/PT TSNT/R No approval required REASON AF G9747 PT IS UNDRGO PALLIAT DIALYSES CATH PATIENT UNDER PALLIATIVE No authorization required DIALYSIS W/CATH G9748 PT APV QUAL PT TP TP PROGID & Prog & plan no authorization required ld kid tplnt g9749 pt not drgo palliat dialysis cath patient under palliative none author TPLNT G9751 PT ALWAYS DIED UNDER 24-MO MSR PRD PATIENT ALWAYS DIED WITHIN 24- No authorization required MONTH MSR PERIOD G9752 EMERGENCY SURGICAL EMERGENCY SURGICAL No authorization required G9753 DC MED RSN W/ NOT S DI MEDCOM R2 W/ NOT S DI SRCH DI COM F Not required authorization IMAG W/I P 12 MO G9754 INCIDENTAL LUNG NODLE FINDING CASE FINDING No authorization required LUNG NODULUM G9755 DOC RES NOT INTVL MOD FU OR NO DOC Auth MOD Required NOT OR NO FU RECOM G9756 SURGICAL PROC INCL. SURGICAL USE OF SILICONE OIL INCLUDING USE No approval required SILICONE OIL G9757 SURGICAL PROCEDURE. INCLUDING THE USE OF SILICONE OIL SURGICAL PROCEDURES THAT REQUIRE THE USE OF Auth 98 OIL. DUR MSR PER PT TO HOSPICE FULL TIME DURING Approval not required MEASUREMENT PERIOD G9759 HISTORY PREOP POS CAPSULE RUPTURE HISTORY PREOPERATIVE POSTERIOR No approval required CAPSULE RUPTURE G9760 PT USE HSPC SVC ALL TIME DURING MSR REQUIRED PER. 9761 PT USES HOSPC SRVC ALL TM DUR MSR PR PATIENTS USING HOSPC SRVC EVERY No approval required TIME WHEN YOU MSR PR G9762 PT HAD 2/3 HPV VACC ON/BTWN 9&13 BD PT HAD 2 HPV/3 HPV VACC ON/BTWN Not required approval 9BDTH & 973TH 9 PT HAD NO 2/3 HPV VACC ON/BTW PT HAD NO 2/3 HPV VACC No approval required ON/BTW 9 & 13 BD G9764 PT TREATED W SYSTEMIC FOR PSORIASIS PT TREATED W SYSTEMIC DRUGS No approval required DSOGRIAS G9764 PT DECLIN CHG MED/ALT TX UNAVBL DOC PT REJECTED CHG MED/ALT No approval required TREATMENTS UNAVBL G9766 PT TRNS FRM 1 INST TO ANR DX CVA PT TRNS FRM 1 INST TO ANR KN DX CVA No approval required G9PT767 HTX DX CVA EVAR STRK TX HOSPITALIZED PT NEW DX CVA CNSDR No approval required EVAR STRK TX G9768 PT UTILZ HSPC SVC ANY TM DUR MSR PR PATIENTS AS UTILZ HOSPIC SVC ANY No approval required TM BM DUR 9 PR GVRC /T P 12 MO PATIENT HAD BMDT P 2 YR /RECV OPO No Authorization Required MED/TX P 12 MO G9770 PERIPHERAL NERVE BLOCK PERIPHERAL NERVE BLOCK No Authorization Required G9771 AT LEAST 1 BDY TMP MSR5 DEG C35 B. MSR No Authorization Required =/>35.5 DEG CELS G9772 DC MD RSN NO ACHV 1 BT MSR =TO/>35.5 DOC S RSN NOT ACHV AL 1 BT MSR No authorization required =TO/> 35.5 DEG G9773 AL 1 BT MSR =/> 35.5 C NO ACHV AA AT LEAST 1 BT MSR =/ >35.5 DEGC NOT Not approval required ACHV ANES ET G9774 PATIENTS WHO HAD PATIENTS WHO HAD No approval required HYSTERECTOMY HYSTERECTOMY 5 PRODUCT G97V 5 RECVAL 2 PRO PHARMACOL ANTI- No approval required EMTC AGT DIF CLS G9776 DOC M R NO 2 PRO P ANTI-EMTC DF CL DOC M RS N NO RECVAL 2 PRO PHRM No approval required ANTI-EMTC DIF CLS G9777 PHRM NO 2 -EMTC AG DF CL PT NOT RCVAL 2 PRO PHARM ANTI- No approval required EMETIC AGT DF CLS G9778 PATIENTS, HAVE DX PATIENTS WHO HAVE DIAGNOSIS NOT REQUIRED AUTHORIZATION PREGNANCY DEAF PREGNANCY G9779 PATIENTS EDING No Auth Required G9780 PT HAVING DX RHABDOMYOLYSIS PATIENTS DIAGNOSED OF RHABDOMYOLYSIS No Authorization Required G9781 DOC S RSN NO CUR USER/RCV STATIN DOC S RSN NO CURRENT USER/RCV AN DTXX NO. IAL /PURE HCL HISTORY/ACTV DX FAM/PURE No Clearance Required HYPERCOLESTEROLEMIA G9783 DOC P DIA LDL-C R140/90 MM HG/BR No Clearance Required NOT DOCUMENTED G9791 RECENT TOBACCO STS NO TOBACCO TOBACCO TOKAT TOBACCO FREE G97 92 MOST RCNT TOBACCO STS NO TOBACCO FREE RECENT SMOKING STATUS NO No Approval Required NO TOBACCO G9793 PT CUR ON DAILY ASP/OTHER PATIENT ON DAILY ASPIRIN/OTHER No Approval Required

150

G9794 DOC WITH RSN NOT ON DAILY ASP/OTHER AP DOC WITH RSN FOR NOT ON DAILY No authorization required ASPIRIN/OTH AP G9795 PATIENT NOT ON DAILY ASP/OTHER AP PATIENT NOT ON DAILY No authorization required ASPIRIN/ G9796 PATIENT ON STATIN TX PATIENT CURRENTLY ON STATIN No approval required TREATMENT G9797 PATIENT NOT ON STATIN TREATMENT PATIENT NOT ON STATIN TREATMENT No approval required G9798 D/C AMI Y6TW /30 MSR D/C AMI BTW JULY 1 YEAR ON MSR TO No approval required JUNE 30 MSR G9799 PT ISSUING EVNT INDIC HX ASTHMA PATIENTS ISSUING EVENT No Approval Required INDICATR HX ASTHMA G9800 PTSHO ARE IN PTSHOBBIENG ID HAV No Approval Required INTOLERANCE/ALLERGY BB TX G9801 AT PT TRANS DIR NA NON-ACF ANY DX NA PT TRANS DIR TO NON-AC CARE No FAC approval required FOR ANY DX G9802 PT USE HOSPC SVC ANY PR TM DUR MSR HOSPIC SRVC ALWAYS No approval required DUR MSR PR G9803 PT PRSC 180-D MSR BB PST D/C AMI PT PRES 135 DA TX180 -YES MSRMT BB Approval not required PST D/C AMI G9804 NO PRS LST 135 BB DC AMI PT NOT PRSC LST 135DA 180-YES MSR Approval not required BB POST DX AMI G9805 PT USE HSPC SVC ANY DURING MSR PR PATIENTS USING HOSPIC SRVC ANY No approval required TIME DUR MSR PR G9806 RECLOGER TPVH RECVEST PATIENTS RECEIVED CERVICAL No approval required CYTOLOGY/HPV TEST G9807 PT NOT RECEIVED CERV CYTOL/HPV TEST PATIENTS NOT RECV CERV No approval required CYTOLOGY/HPV TEST G9808 CERV TEST NOT HPV TEST NO HPV CONTR MED No approval required DISP DUR MSR YR G9809 PT USE HOSPC SRVC ANY TM DUR MSR PR PATIENTS USE HOSPIC SRVC WHEN TIME No approval required POD MSR PR G9810 PT ACHV PDC AL 75% ASTHMA CONTROL PATIENT required none 7. ACHIEVED 5 % ASTHMA CONTROLLED PATIENT WITH G9811 PT NONE ACHV PDC 75% ASTHMA CNTRL PATIENT NOT ACHV PDC AL 75% No Clearance Required WITH ASTHMA CONTROLLED WITH G9812 PT DIED INCLUDING G9813 PT NOT ABLE W/I 30 YES PROC/LID IN HSP PT DIED NOT W/I 30 YES AF No Authorization Required PROC/DUR INDEX HOSP G9814 DEATH SOCR DUR INDEX ACUTE CARE HOSP DEATH SOCR UNDER INDEX ACUTE CARE None Auth G9815 D DIRECT NOT OCR DUR IDX AC CARE HOSP DEATH NOT COME UNDER INDEX No Authorization Required ACUTE CARE HOSP G9816 D OCR AFT D/C HOSP W/I 30 D P PCR DIED SOCR AFTR D/C HOSP BUT Not W/I 30 Needed D POST PROC G9817 D NOT OCR AFT DC HOSP W/I 30 D P PCR DIED NOT OCR AFT D /C AT W/I 30 No Authorization Required DAYS POST PROC G9818 DOCUMENTATION OF SEXUAL ACTIVITY DOCUMENTATION OF SEXUAL ACTIVITY G9 Auth HOSPC SVC ANY TM DUR MSR PR PATIENTS USING HOSPIC SVC ANY No Authorization Required TIME DUR MSR PR G9820 DOC CHLAMYDIA SCR TEST PROPER F/ U DOCUMENTATION CHLAMYDIA No authorization required SCREINING TST PROPER F/U DOC SCRLASMY NO. NO DOCUMENT CHLAMYDIA SCR No approval required TEST PROPER F/U G9822 WOMEN HAD EA DUR YR PRI TO IDX DATE WOMEN WHO HAD EA IN YEAR PRI No approval required TO INDEX DATE G9823 ENDOMTRL SMP/HYSTROSCY NO. A FEED EXERCISE RESPONSE INIT CHEMO PATIENT TRANSFER TO PRACTICE AFTER No approval required START CHEMO G9827 HER2-TRG THER NOT ADM DUR INIT TX HER2-TARGETED THERAPIES NOT ADM No approval required DUR INIT CRS TX G9828 HER2-TRG THER-CRS TARGET HER-2 -TRG THER ADM. ADM DUR No approval required INITIAL CRS TX G9829 ADDITIONAL BREAST CHEMOTHERAPY ADM ADDITIONAL BREAST CHEMOTHERAPY No approval required APPLIED G9830 HER2/NEU POSITIVE HER2/NEU POSITIVE Approval not required G9831 STG BREAST AJ BREAST II APPLIED G9831 CANCER No approval required DIAGN. OSIS = II / III G983 2 AJCC STG BC DX=I&T-ST NO=T1 T1A T1B AJCC STG BC DX = I & T-STG NOT = No approval required T1 T1A T1B G9833 PATIENT TRANSPORT TO PRAC AFT INI TRANSFER TO CHEMO AFTER Not authorization required INI CHEMO G9834 PATIENT HAS METASTATIC DZ TO DX PATIENT HAS METASTATIC DISEASE TO No authorization required DIAGNOSIS G9835 TRASTUZUMAB ADM W/I 12 MO DX ADMINISTERED TRASTUZUMAB No Auth/9 REQ. WHY NOT ADM TRASTUZUMAB REASON NOT APPLICABLE No approval required DOC TRASTUZUMAB DOC G9837 TRASTUZUMAB NOT ADM W/I 12 MO TRASTUSUMAB NOT APPLICABLE No approval required DX W/I 12 MONTHS DX G9838 PATIENT HASTIASE METASTATCDISUT AT DISAT HASTIASE METASTATCDISU TH required DIAGNOSIS G9839 ANTI -EGFR MONOCLONAL ANTIBODY TX ANTI-EGFR MONOCLONAL ANTIBODY No approval required TREATMENT G9840 RAS G MUT T P B4 INT ANTI-EGFR MOAB RAS GEN MUT TEST PRFRM BEF INT No approval required MOABI B4 G9840 RAS G MUT T P B4 -EGFR RAS GEN MUT TST NOT PRF BEF INIT No authorization required ANTI-EGFR MOAB G9842 PATIENT HAS METASTATIC DZ AT DX PATIENT HAS METASTATIC DISEASE AT No authorization required DIAGNOSIS G9843 GENE MUTATION RAS RAS GENE MUTATION RAS Auth4 MUTATION RAS D9 Mutation required Auth4 EGFR MAB TX PATIENT HAS NOT RECEIVED ANTI-EGFR None approvals required MONOCLONAL ABO TX G9845 PATIENT RCVD ANTI-EGFR MAB TX PATIENT RECEIVING ANTI-EGFR No approval required MONOCLONAL ANTICOF TX G9846 PATIENT RCVD ANTI-EGFR MAB TX PATIENT RECEIVING ANTI-EGFR No approval required. uth necessary

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G9847 PT RECVD CHMO LAST 14 DAYS OF LIFE PATIENT RECVD CHEMOTHERAPY LAST No Clearance Required 14 DAYS OF LIFE G9848 PT NOT RECV CHMO LST 14 DAYS OF LIFE PATIENT NOT RECV CHMO LAST 14 DAYS OF 9 DEAD F9. ROME CANCER PATIENTS WHO DIED OF CANCER No Authorization Required G9850 PT HAD >1 ED VST LST 30 YES LIVING PATIENT HAD >1 ED VST AT LST 30 No Authorization Required. DAYS ALIVE G9851 PT HAD 1/< ED VST LAST 1 PATIENT LIFE /< ED VST IN LAST No authorization required 30 YES OF LIFE G9852 PATIENTS WHO DIED OF CANCER PATIENTS WHO DIED OF CANCER No authorization required G9853 PTT ADM NA ICU IN LST 30 PATIENT YES LIFE ADM NEEDED FOR AUT 30 DAYS LIFE G9854 PT NOT ADM. IN ICU IN LST 30 DAYS OF LIFE PATIENT WAS NOT REFERRED TO ICU 30 YES OF LIFE G9855 PATIENTS WHO DIED OF CANCER PATIENTS WHO DIED OF CANCER UNTIL 85 NOT REQUIRED. PATIENT NOT ADMITTED TO HOSPICE No Authorization Required G9857 PATIENT ADMITTED TO HOSPICE PATIENT ADMITTED TO HOSPICE No Authorization Required G9858 PATIENT ADMITTED TO HOSPICE PATIENT ADMITTED TO HOSPICE No Authorization Required G9859 DEAD PATIENT WHO IS A PATIENT. No authorization required G9860 PT SPENT < 3 DAYS IN HOSPICE HIS PATIENT RETURNED LESS THAN 3 DAYS IN HOSPICE CARE No authorization required G9861 PT BACK >/=3 DAYS IN HOSPICE CARE PATIENT RETURNED >/ RESPONSE WITH 3 DAYS IN HOSPICE CARE Not required approval G9862 RCM AL MED R 10 Y F/U INT DOC S RSN FOR NOT RECOMMENDED No approval required AL 10 YR F/U INTVL G9868 RCPT & ANLYS REMT ASYNC IMG MINS G9873 1ST MDPP COR SESS ATD MDPP B UND EM 1ST MDPP C SESS ATDIC R. MDPP EM G9874 4 T MDPP COR SESS ATD MDPP B UND EM 4 TOTAL MDPP CORE SES ATD MDPP No approval required BENEF UND MDPP EM G9875 9 T MDPP COR SESS ATD MDPP B UND EM 9 TOTAL REQUIRED MDPP COR SES MDPP EM G9876 2 MDPP COR MS ATD BNF MO 7-9 UND EM 2 MDPP C MS ATD MDPP BENEF IN MO No approval required 7-9 UND MDPP EM G9877 2 MDPP C MS ATD BNF MO 10-12 UND C MS 2 MDPP ATD MDPP BENEF MO 10 - None Approval required 12 UND MDPP EM G9878 2 MDPP COR MS ATD BNF MO 7-9 UND EM 2 MDPP C MS ATD MDPP BENEF IN MO No approval required 7-9 UND MDPP EMTD G9879 MS 2 MD BNF MO 10-12 UND EM 2 MDPP C MS ATD MDPP BENEF MO 10- No approval required 12 UND MDPP EM G9880 MDPP BNF ACHV AL 5% WL MO 1-12 U EM MDPP BNF ACHV AL 5% WL BW MO 1- No approval required 12 MDPP SP UND EM G9881 MDPP BNF ACHV AL 9% WL MO 1-24 IN EM MDPP BNF ACHV AL 9% WL B WT MO 1- No approval required 24 UND MDPP EM G9882 2 MDPP O MS 13- BNF 15 IN EM 2 MDPP IN PROGRESS MS ATD BNF MO 13 - No approval required 15 UND MDPP EM G9883 2 MDPP OM S ATD BNF MO 16-18 U EM 2 MDPP ONGO MS ATD MDPP BNF MOUND No approval required 16-18EM 2 MDPP OM S ATD BNF MO 19-21 U EM 2 MDPP ONGO MS ATD MDPP BNF MO No approval required 19-21 UND MDPP EM G9885 2 MDPP OM S ATD BNF MO 22-24 U EM 2 MDPP MDPP ONGO MS ATD No approval required 22-24 UND MDPP EM G9890 BRDG PMT:1ST MDPP SPL BNF M 1-24 EM BRDG PMT:1ST MDPP CS C/OM S SPL No approval required BNF MO 1-24 EM G9891 MDPP S RPT LN-I MDPP EM mdpp sess rpt as ln-i on clm w/o author NONE No Authorization Required DONE REASON NO G9894 AD TX RX/ADMN KAMM EXT BEAM RT ANDROGEN DEP TX RX/ADMN KAMM Authorization Required Radiotherapy Full Clinical Review PROS EXT BEAM RT TO PROS G9895 D M R NOT PRX/COMADM ADM M RSN NOT RX/ADM AD TX KAM Authorization Required Radiotherapy Complete Clinical Examination EXT BEAM RT PROS G9896 D PT R NO RX/ADMN AD TX COM EBRT PR DOCUMENT PT RSN NOT RX/ADMN AD Authorization Required Radiotherapy Complete Clinical Examination TXCOM EBRT PROS G9897 PT NO RX/ADM AD TX COM EBRT PR NO R PTS NOT RX/ADM AD TX COM EBRT No approval required PROS RSN NOT GVN G9898 PT 65/> INST SNP/RSD LTC >90 DA MSR PT 65/> INSTITUTION SNP/RESID LTC No approval required >90 DA MSR G9899 SCR DX F DGTL/DBT MAMMO RSLT D&REV SCR DX FILM DIGITAL/DBT MAMMO No approval required RESULTS DOC & REV G9900 SCR DX MAMMO DAMMO RESULT/DOC MAMMO RESULT/DOC FSNGD R. RSLT NO No approval required NOS DOC&REV RSN NOS G9901 PT 65/ > INST SNP/RSD LTC >90 YES MSR PT 65/> INSTITUTIONAL SNP/RESID LTC No Approval Required >90 DAYS MSR G9902 PT SCR TOB USE & ID ASTI ASTI SCR TOBACCO USER & ID SOM No Approval Required TOBACCO USER G9903 PT SCR TOB USE AND ID AS TOB NON-USER PATIENT SCR TOBACCO USE AND ID AS TOB No approval required NON-USER G9904 DOC S RSN FOR NON SCR TOBACCO WITH RSN DOCUMENTATION NO No approval required SCR TOBACCO USE G9905 PATIENT NOT SCR TOB USE RSN NOT GVN PATIENT NOT SEARCHED FOR TOBACCO No approval required USE RSN NOT GVN G9906 PT ID TOB USER RECV TOB CESS INT PT ID TOB USER RECV Required G9 S RSN NOT PROVEN TOB CESS INT DOC S RSN NOT PROV TOBACCO No approval required CESS INTERVENTION G9908 PT ID T U NOT RECV T CESS INT NO R PT ID TOB NOT USER RECV TOB CESS INT No authorization required RSN NOT GVN G9909 D M R NOT PROV INT IF ID T U DOC S RSN NOT PROV TOB CESS INT No authorization required IDENT TOB USER G9910 PTS 66/> INST SNP /RSD LTC >90 D MSR PTS 66/> INSTITUTIONAL SNP/RESID LTC No approval required >90 YES MSR G9911 NODE NEG IBC BEF/AFT ON SYS TX CLINICAL NODE NEG IBC BEF/AFT No approval required NEOADJUVANT SYS TX G9912 HBV EVALUATION INTRP PRI ANTI -TNF TX HBV STS EVALUATION & RSLT INTERP PRIORTX-TNF REQUIRED

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G9913 HBV ASSESSMENT INTRP PR ANTI-TNF NO RSN HBV STS ASSESSMENT INTRP PRI ANTI-TNF TX No authorization required RSN NOT GVN G9914 PATIENT RECEIVING ANTI-TNF AGENT PATIENT RECEIVING ANTI-TNF AGENT PATIENT RECEIVING ANTI-TNF AG ENT NO Auth REGISTRATION OF HBV RESULTS No Approval Required DOCUMENTED DOCUMENT G9916 FUNC STS PERF ONCE IN LAST 12 MONTHS FUNC STATUS DONE ONCE IN LAST 12 MONTHS No Approval Required LAST 12 MONTHS G9917 DOC ADV. SCENE DEMENT & OFFICI. KNWL RESTRICTED G9918 FUNCTIONAL STATUS NOT DONE RSN NOS FUNCTIONAL STATUS NOT DONE No approval required SUFFICIENT REASON G9919 CHECK PERF & POS & PROV REC CHECK PERF & POS & PROVISION No approval required RECOMMENDATION G9920 CHECK NCR AND EXTRACT. ATIVE No approval required G9921 NO SCR P PR SCR P/POS NO REC&RSN NO SCR PRFRM PR SCR PRFRM/POS SCR No approval required NO REC&RSN G9922 SAF CNCRNS SCR PRV&IF POS DOC MIT R SECURITY CNCRNS SCR PROV & IF POS No approval required SO DOC MIT SAFE REC G9 CONT2CTYER3 Neg Screen Security No Approval Required and Negative G9924 Doc Med No r SAF CNCRN/REC POS SCR DOC MED RSN NOV SAF NO Approval Required CNCRN/REC/REF POS SCR G9925 Security Request SECURITY Approval Required DELIVERED RSN NOS G9926 SAF CNCRN SCR POS SCR NO PROV MIT R SECURITY PROCEDURES SCR POS SCR W/O No approval required PROV MIT REC G9927 DOC SY RSN NO RX WF/ANR FDA-APV AC DOC SY RSNAN NOT RX W FDA -APV No approval required AC D/T PT IN CT G9928 WF/ANR FDA-APV AC NO PRSC R NOT GVN WARFARIN/ANR FDA-APV AC NOT PRSC No approval required CAUSE NOT GVN G9929 PT TRANSIENT/REVERSIBLE CAUSE BY PATIENT S TRANSIENT OR No approval required REVERSIBLE CAUSE AF G9930 PTS WHO ARE RECV COMFORT CARE ONLY PATIENTS RECEIVING COMFORT CARE ONLY Clearance Required SCORE 0/1 G9932 DOC PT RSN NO REC N/MNG POS TB SCR DOC PT RSN NO REC NO. approval required NEG/MANAGED POS TB SCR G9933 ADENOMA/CRC DETECTED DUR SCR COLO ADENOMA/COLORECTAL CANCER D3 CANCER D3 DOC NEO D ONLY DX TD WITH SS PLYP/SSA DO ONLY NEO D DX TRAD SERRATED AD No approval required SS POLYP/SSA G9935 ADENOMA/CRC NOT DETECTED UNDER SCR ADENOMA/CRC NOT DETECTED UNDER None G C9CCOS CO SCRV- 3 PH CLNC PLYP CC/O MN R RSJ&A SURV COLO-PH CLNC PLYPS CC/OTH No authorization required Colonoscopy PA for code in group MAL NEO R RSJ & A Applies to all codes within a given group G9937 DIAGNOSTIC COLONOSCOPY DIAGNOSTIC COLONOSCOPY DIAGNOSTIC COLONUTICS for code in a group Applies to all codes within a given group G9938 PT 66/> INST SNP/RSD LTC >90 D MSR PT 66/> INST SNP / RESID LTC >90 DAYS No approval required DUR MSR PRD G9939 STI/DERMATOPATH SAME CLIN PRFRM PATHOLOGY/DERMATOPATH SAME No approval required BX CLINIC PRFRM BX G9940 DOC MEDICAL RSN FOR NOT ON STATIN DOCUMENTATION MEDICAL REASON No approval required FOR NOT ON ST. ATIN G9942 PT ADD SP PROC SD LUMB DISC DISC SLUMB DISC DISC SLUMB DISC Spinal Care combined with full clinical examination DISCECTOMY/LAMI Neck and back conditions including: G9943 BP NOT MSR VAS WI 3 M PRIJE&AT 3 M PO BP NOT MSR BY VAS W /I 3 MOS PRE & No approval required AT 3 MOS P/O G9945 PT CA. /I 3 MOS PREOP Approval not required & AT 1 YR P/O G9948 PT ADD SP PROC SD LUMB DISCECT/LAM PT ADD SPINE PROC SAME DT LUMB Approval not required DISCECCTOMY/LAMI G9949 LEG PAIN NOT MSR PREOP AT 3 NOT MEASURED BY YOU No Authorization Required AT 3 MO PROCEDURE G9954 PT EXH 2/> RISK FAC P/O PATIENT RETURN 2/> RISK FAC POST- No Authorization Required OP RETURN G9955 CASES NOT WANT TO IND CAN INHALATOR No Authorization Required USER FOR IN ONLY G9956 PATIENT RECEIVED COMBIN TX PATIENT RECEIVED COMB No approval required TREATMENT G9957 DOC MEDICAL REASON NOT RECV COMB DOCUMENTATION MEDICAL REASON PATIENT RECEIVED COMBINATION No approval required TREATMENT G9957 DOC MEDICAL REASON NOT RECV COMB DOCUMENTATION MEDICAL REA SIN PATIENT RECEIVED COMBINATION NOT REQUIRED 9 TX PATIENT NOT RECEIVED No necessary approval COMBINATION THERAPY G9959 SYSTEMIC ANTIMICROBIAL WITHOUT PRSCR SYSTEMIC ANTIMICROBIAL NO No approval required PRESCRIBED G9960 DOC S RSN PRSCR SYS ANTIMICROBIAL DOC WITH RSN PRESCRIPTION SYSTEMIC ANTIMICROBIAL 9B1 PRESCRIPTION SYSTEMIC No approval required PRESCRIBED SYSTEMIC ANTIMICROBIAL No approval required PRESCRIBED G99 62 EMB EPT D SEP EA EMBO VES&OA EMBO EPT DOC SEP EA EMBO VESSEL & No approval required AG/EMB OA ANGIO/EMBO G9963 EMB EPT NOT DOC SEP VESS NOT PERF EMB EPT NOT DOC SEP EMB VESS/OA No approval required AG/EMB NOT PERF G9964 PT. 1 WCV PCP DUR PRF P PT RECV MIN 1 WCV W/PCP DUR Approval not required PRFRM PERIOD G9965 PT NOT RECV MIN 1 WCV DUR PER. DVLP BEHA & SOC DLA CHLDRN WHICH WAS SCR RISK DVLP No approval required BEHAV & SOC DLA G9967 CHDRN NOT SCR RSK DVLP BEHA&SOC DLA CHDRN NOT SCR FOR RISK DVLP BEHAV No approval required & SOC DLA G9968 PROVRF A REFERRED ANR PROV/SPEC D UR None Approval Required PRFRM PER G9969 PRV REF PT PROV RCV RPRT PRV PT REF PROV REF PT ANR PROV RECV REPORT No Approval Required FRM PROV PT REF

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G9970 PROV REF PT PROV NO RPRT PRV PT REF PROV REF PT ANR PROV NOT RECV RPRT No Approval Required PROV PT REF G9974 EXTENDED MACULAR EXAM DONE EXTENDED MACULAR EXAM DONE No Approval Required G9975 NO S R975 R PRFRM A No Approval Required DILATED MACULAR EXAMINATION G9976 Dilated macular exam not prfrm DIL Macular Ex Doc Pt RSN for not prrm Divani approval Macular exam required G9977 DiLated Macular Ex not perf RSN NOS Distribute Maculae R9 78 RMT IH VST E/M NP MCR BPCI ADV 10 M RMT IH VST E /M NP MCR-APVD BPCI No approval required ADV EOC TYP 10 M G9979 RMT IH VST E/M NP MCR BPCI ADV 20 M RMT IH VST E/M NP MCR-APVD BPCI No approval required ADV EOC TYP 20 M G9980 RMT IH VST E /M NP MCR BPCI ADV 30 M RMT IH VST E/M NP MCR-APVD BPCI No approval required ADV EOC TYP 30 M IH V981 E RMT /M NP MCR BPCI ADV 45 M RMT IH VST E/M NP MCR- APVD BPCI No approval required ADV EOC TYP 45 M G9982 RMT IH VST E/M NP MCR BPCI ADV 60 M RMT IH VST E/M NP MCR-APVD BPCI No approval required ADV EOC TYP 60 M G9983 R IH V E/M EP MC -APVD BPCI ADV 10 M RMT IH VST E/M EST PT MCR-APVD BPCI No approval required ADV TYP 10 M G9984 R IH V E/M EST -APVD BPCI ADV 15 M RMT IH VST E/M EST PT MCR-APVD BPCI Not required approval ADV TYP 15 M G9985 R IH V E/M EP MC-APVD BPCI ADV 25 M RMT IH VST E/M EST PT MCR-APVD BPCI No approval required ADV TYP 25 M G9986 R IH V E/M EP MC-APVD BPCI ADV 40 M RMT IH VST E/M EST PT MCR-APVD BPCI No Approval Required ADV TYP 40 M G9987 BPCI ADV H V CLPT AS BPCI ADV MOD HOME VISIT PT ASMT No Approval Required PERF CLIN STAFF H0016 ALCOHL &OR RX SRVC; MEDICAL/SOMATIC ALCOHOL AND/OR DRUG SERVICES; Approval Required General Medicine - Full Clinical Examination MEDICAL/SOMATIC Health and Behavioral Assessment/Intervention H0018 BHVAL HLTH; SHORT-TERM RES PER DIEM BHVAL ZDAVLJE; SHORT TERM RES WITHOUT AUTHORIZATION REQUIRED General Medicine - Full Clinical Screening ROOM&PANSION-DIEM Health & Behavioral Assessment/Intervention H0019 BHVAL HLTH; LNG-TERM RES PER DIEM BHVAL HEALTHCARE; LONG TERM RES WITHOUT AUTHORIZATION General Medicine Required - Full Clinical Examination ROOM&PANSION-DIEM Health & Behavioral Assessment/Intervention H0046 MENTAL HEALTH SERVICES NOS MENTAL HEALTH SERVICES NO Authorization Required Full Clinical Examination OTHER SPECIFIC H004BS OR ALCOHOL H0047 ALCOHOL / OR OTHER SUBSTANCE ABUSE Authorization Required Full Clinical review SERVICES NR Full clinical review TIME PROGRAM TIME H2036 ALCOHOL AND OR OTHER DRUGS TX PROGM- ALCOHOL AND OR OTHER DRUGS TREATMENT Approval required Full clinical review DIEM PROGRAM PER DAILY J0120 TETRACYCLINE INJECTION UP TO 250 MG TETRACYCLINE INJECTION UP TO 2C ADMINISTRATION D 1C ADMINISTRATION UD1C ADMINISTRATION U1C . DACYCLINE 1 MG INJECTION OMADACYCLINE 1 MG No Approval Required J0122 ERAVACYCLINE INJECTION 1 MG INJECTION ERAVACYCLINE 1 MG No Approval Required J0129 INJ ABATACEPT 10 MG MEDICR ADM PHYS INJ ABATACEPT 10 MG USED MEDICARE Approval Required Drug Administration J0129 INJ ABATACEPT. 10 MG INJECTION ABCIXIMAB 10 MG No Authorization Required Drug Administration J0131 INJECTION ACETAMINOPHEN 10 MG INJECTION ACETAMINOPHEN 10 MG No Authorization Required Drug Administration J0132 INJECTION ACETYLCYSTEIN 100 MG INJECTION ACETYLCYSTEIN 100 MG INJECTION 100 MG INJECTION YSTEIN 100 MG No authorization required J013 2 INJECTION TION ACICLOVIR 5 MG No authorization required Drug administration J0135 INJECTION ADALIMUMAB 20 MG INJECTION ADALIMUMAB 20 MG authorization required Drug administration Full clinical review J0153 INJECTION ADENOZINE 1 MG INJECTION ADENOZINE 1 MG No authorization required Administration of medicine J0171 INJ ADRENALINE EPINEPHRINE 0.1 MG INJECTION ADENOZINE NO. 78 INJECTION AFLIBERCEPT 1 MG INJECTION AFLIBERCEPT 1 MG Approval required for drug administration Full clinical review J0179 INJECTION BROLUCIZUMAB-DBLL 1 MG INJECTION BROLUCIZUMAB-DBLL 1 MG Approval required Full clinical review J0180 INJECTION AGALSIDASE BETA 1 MG INJECTION AGALSID REQUIRED INJECTION ASE REQUIRED INJECTION Drug AGALSIDASE BETA C1C PREPITANT 1 MG INJECTION APREPITANT 1 MG No approval required Drug administration J0190 INJECTION BIPERIDEN LACTATE PR. 5 MG INJECTION BIPERIDEN LACTATE PER J0202 INJECTION ALEMTUZUMAB 1 MG INJECTION ALEMTUZUMAB 1 MG Approval Required Drug Administration Full Clinical Review J0205 INJECTION ALGLUCERASE PR. 10 units. ALGLUCERASE INJECTION PO. 10 UNITS No Authorization Required Drug Administration J0207 AMIFOSTINE INJECTION 500 MG AMIFOSTINE INJECTION 500 Drug Review Completed CH0LD INJECTION INJECTION J0207 AMIFOSTINE INJECTION 500 MG TO 250 MG INJECTION METHYLDOPAT HCL DO No Authorization Required Drug Administration 250 MG J0215 INJECTION ALEFACEPT 0.5 MG IN INJECTION ALEPHACEPT 0.5 MG No approval required Drug administration J0220 INJ ALGLUCOSIDASE ALFA 10 MG NOS INJECTION ALGLUCOSIDASE ALFA 10 Required J0220 INJ ALGLUCOSIDASE ALFA 10 MG ASE ALFA 10 MG INJECTION ALGLUCOSIDASE ALFA Approval required Drug administration Full clinical review LUMIZYME 10 MG J0222 INJECTABLE PATISIRAN 0, 1 MG INJECTABLE PATISIRAN 0, 1 MG Authorization Required Full Clinical Review J0256 INJ ALPHA 1-PROTASE-INHIB NOS 10 ATALPHA INJECTION 1PRO Auth. 0 MG J0257 INJ ALPHA 1 PROTEINASE INH 10 MG INJECTION ALPHA 1 PROTEINASE No approval required Drug administration INHIBITOR 10 MG J0270 INJECTION ALPROSTADIL 1.25 MCG INJECTION ALPROSTADIL 1.25 MCG Approval required Drug administration J0270 INJECTION ALPROSTADIL 1.2 5 MCG INJECTION ALPROSTADIL 1 ,25 MCG Medicines Administration approval required J0275HRD Full clinical review ALPROSTAIL STAIL IL URETHRAL SUPPOSITORY Authorization required Drug administration Full clinical review J0278 INJECTION AMIKACIN SULFATE 100 MG INJECTION AMIKACIN SULFATE 100 MG No authorization required Drug administration J0280 INJECTION AMINOPHYLLINE UP TO 250 MG INJECTION AMINOPHYLLINE UP TO 250 No approval required Drug administration INJECTION AMINOPHYLLINE UP TO 250 MG TION AMIODARON No approval required Drug administration HYDROCHLORIDE 30 MG J0285 INJECTION AMPHOTERICIN B 50 MG INJECTION AMPHOTERICIN B 50 MG No approval required Drug administration J0287 INJ AMPHOTERICIN B LIPID CMPLX 10 MG INJECTION AMP HOTERICIN B LIPID Approval it is not necessary to administer the drug COMPLEX 10 mg

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J0288 INJ AMPHOTERICIN B COLESTRYL 10 MG INJ AMPHOTERICIN B COLESTRYL No Authorization Required Drug Administration SULFATE CMPLX 10 MG J0289 INJ AMPHOTERICIN B LIPOSOM 10 MG INJECTION AMPHOTERICIN B LI90MG SUBMISSION NO. AMPICILLIN SODIUM 500 MG INJECTION AMPICILLIN SODIUM 500 MG No approval required Drug administration J0291 INJECTION PLAZOMICIN 5 MG INJECTION PLAZOMICIN 5 MG No approval required J0295 INJ AMPCLLN SODIM/SULBACTAM-1.5 G INJECTION AMPCLLN No approval required Drug administration SO DIUM/SULBACTAM-300AM 1.5 G. UP TO 125 MG INJECTION AMOBARBITAL UP TO 125 No approval required Drug administration MG J0330 INJ SUCCINYLCHOLINE CHLORIDE OP 20MG SUCCINYLCHOLINE CHLORIDE INJECTION No approval required Drug administration UP to 20 MG J0348 INJECTION ANIDULAFUNGIN 1 MG INJECTION AUTH CTION ANIST REPLACEMENT PR. 30 UNITS. ANISTEPLASE INJECTION PO. 30 UNITS No Authorization Required Drug Administration J0360 INJECTION HYDRALAZIN HCL UP TO 20 MG INJECTION HYDRALAZIN HCL UP TO 20 No Authorization Required Drug Administration MG J0364 INJ APOMORPH HYDROCHLORIDE 1 MG INJECTION HYDRALAZIN HCL APPLICATION APUTHOMDROCHlide ADMINISTRATION J 0364 INJ. CTION APROTININ 10000 KIU INJECTION APROTININ 10000 KIU No Auth Required Drug Administration J0380 INJ METARAMINOL BITARTRATE 10 MG INJECTION METARAMINOL BITARTRATE No Auth Required Drug Administration PR. ARBUTAMINE HCL 1 MG INJECTION ARBUTAMINE HCL 1 MG No Approval Required Drug Administration J0400 INJ ARIPIPRAZOLE IM 0.25 MG INJECTION ARIPIPRAZOLE No Approval Required Drug Administration INTRAMUSCULAR 0.25 MG J0401 INJ ARIPIPRAZOLE EXT. RELEASE 1 MG INJECTION ARIPIPRAZOLE EXTRACT 1 MG INJECTION ARIPIPRAZOLE EXTRACT 1 0456 INJECTION AZITHROMYCIN 500 MG INJECTION AZITHROMYCIN 500 MG No. Approval required Drug administration J0461 ATROPIN SULFATE INJECTION 0.01 MG ATROPIN SULFATE INJECTION 0.01 MG No approval required Drug administration J0470 DIMERCAPROL INJECTION PR. 100 MG INJECTION DIMERKAPROL PER. EN 10 mg injection Baclofen 10 mg No approval administration Administration J0476 INJ BACLOFEN 50 mcg Intratec trial injection BACLOFEN 50 mcg for is not required authorization administration intraitecal J0480 injection Basiliximab 20 mg injection Basilixima 20 mg Bela 5 Belacet with a PT 1 MG No authorization required Drug administration J0490 INJECTION BELIMUMAB 10 MG INJECTION BELIMUMAB 10 MG Authorization required Drug administration Full clinical review J0500 DICYCLOMINE HCL INJECTION UP TO 20 MG DICYCLOMINE HCL INJECTION UP TO 20 No authorization required Drug administration MG J0515 INJ BENZLATENTROPIN CLA No authorization required Drug administration 1 MG J0517 INJECTION BENRALIZUMAB 1 MG INJECTION BENRALIZUMAB 1 MG No approval required Drug administration J0520 INJ BETHANECHOL CHLORIDE UP TO 5 MG INJ BETHANECHOL CHLORIDE UP TO 5 No approval required Drug administration G58 IN PRO J0C0N PCN G BENZ PCN G No approval required Drug administration PRO CAINE 100000 UNITS J0561 INJECTION PCN G BENZ 1000 00 UNIT INJECTION PENICILLIN G BENZATHINE No authorization required Drug administration 100000 UNITS J0565 INJECTION BEZLOTOXUMXUMB BEZLOTOXUMXAB 10 Complete application Clinical review J0567 INJECTION CERLIPONASE ALFA 1 MG INJECTION CERLIPONASE ALFA 1 MG Authorization required Drug administration Complete clinical review J 0570 BUPRENORPHINE IMPLANT 74.2 MG BUPRENORPHIN HIN IMPLANT 74.2 MG No authorization required Drug administration J0571 BUPRENORPHINE ORAL 1 MG BUPRENORPHINE ORAL 1 MG BUPRENORPHIN ORAL DRIFT 1 0MG2 BUPRENORPHIN Auth 1 0MG2 B0PNA 0 No authorization required Drug administration MG BUPRENORPHINE J0583 INJECTION B IVALIRUDIN 1 MG INJECTION BIVALIRUDIN 1 MG No approval required drug administration J05 84 INJECTION BUROSUMAB-TWZA 1 MG INJECTION BUROSUMAB-TWZA 1 MG Approval Required Drug Administration Complete clinical examination J0584 INJECTION BUROSUMAB-TWZA TYPE A PR. J0586 INJECTION ABOTULINUMTOXIN 5 UNITS INJECTION ABOTULINUMTOXIN 5 Approval required Drug administration Full clinical examination J0586 J0587 INJ RIMABOTULINUMTOXIN B 100 UNITS INJECTION RIMABOTULINUMTOXIN 5. Approval RIMABOTULINUMTOXIN 5 Approval required IN5. INJECTION INCOBOTULINUMTOXIN 1 UNIT INJECTION INCOBOTULINUMTOXIN A 1 Approval required Drug administration Complete clinical examination UNIT J0592 INJ BUPRENORPHIN HYDROCHLOR 0.1 INJECTION BUPRENORPHIN No approval required Drug administration MG HYDROCHLORIDE 0.1 MG J0593 INJECTION LANADELUMAB-FLY O 1 MG INJECTION LANADELUMAB-FLYOAN NO. MG INJECTION BUSULFAN 1 MG Authorization Required Drug Clinical Review J0595 INJECTION BUTORPHANOL TARTRATE 1 INJECTION BUTORPHANOL TARTRATE 1 No Authorization Required Drug Administration MG MG J0596 INJ C1 ESTERASE INHIB RUCONEST 10 IN INJECTION C1 ESTERASE INHIBITOR Authorization Required Drug Administration IN RU C1CONEST90 Full Review INRU C1CONEST90 B BERINERT 10 U INJ C- 1 ESTERASE INHIB HUMN Approval required Drug use Full clinical review BERINERT 10 UNIT J0598 INJ C1 ESTERASE INHIB CINRYZE 10 U INJECTION C1 ESTERASE INHIBITOR Approval required Drug use Full clinical review CINRYZE 10 UNIT I CINRYZE E19 INJESTER I C- 19 CHISTER E10 CHISTER E19 ASE INHIBITOR 10 Approval required Drug administration Full clinical review UNITS J0600 INJ EDETATE CALCM DISODIM UP TO 1000MG INJECTION EDETATE CALCIUM No approval required Drug administration DISODIUM UP TO 1000 MG J0604 CINACALCET ORALCA 1. Full administration required CINACALCET ORALCA 1. Clinical review J0606 INJECTION ETELCALCETIDE 0.1 MG INJECTION ETELCALCETIDE 0.1 MG Authorization Required Drug Administration Full Clinical Review J0610 INJECTION CALCM GLUCONATE PER 10 ML INJECTION CALCIUM GLUCONATE PER No Authorization Required Drug Administration 10 ML J0620 INJ CALCM GLUCONATE PER. GLYCEROPHOSPHAT&CALCM LACTAT- 10 ML J0630 INJ CALCITONIN SALMON UP TO 400 UNITS INJECTION CALCITONIN SALMON UP Need authorization Drug administration Full clinical examination 400 UNITS J0636 INJECTION CALCITRIOL 0.1 MCG INJECTION CALCITRIOL 0.1 MCG No authorization required Drug Administration INJECTION C7CASTION J0636 636 INJECTION CALCI TRIOL 0 ,1 MCG INJECTION POFUNGIN ACETATE 5 No authorization required Drug administration MG J0638 INJECTION CANAKINUMAB 1 MG INJECTION CANAKINUMAB 1 MG No authorization required Drug administration

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J0640 INJ LEUCOVORIN CALCIUM PER 50 MG INJECTION LEUCOVORIN CALCIUM PER Authorization Required Drug Administration Full Clinical Review 50 MG J0641 INJECTION LEVOLEUCOVORIN NO. INJECTION LEVOLEUCOVORIN 0.5 MG INJECTION LEVOLEUCOVORIN 0.5 MG No approval required J0670 INJECTION MEPIVACAINE HCL PR. 10 ML INJECTION MEPIVACAINE HCL PER. 10 No authorization required Drug administration ML J0690 INJECTION CEFAZOLIN SODIUM 500 MG INJECTION CEFAZOLIN SODIUM 500 MG REQUIRED SITE OF ADMINISTRATION J0600 MG 0 MG INJECTION CEFEPIME HYDROCHLORIDE No authorization required Administration of the drug 500 MG J0694 INJ CEFOXITIN SODIUM 1 GM INJECTION CEFOXITIN SODIUM 1 G No authorization required drug administration J0695 INJ CEFTOLOZANE 50 MG & TAZ 25 MG INJECTION CEFTOLOZANE 50 MG AND No approval required J0695 INJ CEFTOLOZANE 50 MG & TAZ 25 MG INJECTION CEFTOLOZANE 50 MG AND No approval required J0694 INJ CEFTOLOZANE 25 MG INJEC PR. 250 MG INJECTION CEFTRIAXONE SODIUM PER. No Approval Required Drug Administration 250 MG J0697 INJ STERIL CEFUROXIME SODIUM 750 MG INJECTION STERIL CEFUROXIME No Approval Required Drug Administration SODIUM PR. 750 MG J0698 INJECTION CEFOTAXIME SODIUM SOL CEF GAXIME SUBMISSION NO. 02 INJ BETAMETHASONE AC & PHOS 3 MG INJ BETAMETHASONE ACETATE & No Approval Required Drug Administration PHOSPHATE 3 MG J0706 CAFFEINE CITRATE INJECTION 5MG CAFFEINE CITRATE INJECTION 5 MG No Approval Required Drug Administration J0710 INJ CEPHAPIRINE SODIUM TO SEED 1 GM INJECTION IN SEED 1 GM INJECTION 1 J07 12 INJECTION CEFTAROLINE FOSAMIL 10 MG INJECTION CEFTAROLINE FOSAMIL 10 No authorization required Drug administration MG J0713 CEFTAZIDE INJECTION 500 MG CEFTAZIDE INJECTION 500 MG No authorization required Drug administration J0714 INJ CFTAZDM & AVICE/AVICE TM 000 MG. AM No authorization required Drug administration 0.5 G/0.125 G J0715 INJ CEFTIZOXIME SODIUM PR. 500 MG INJECTION CEFTIZOXIM SODIUM PR. No Approval Required Drug Administration 500 MG J0716 INJ CENTRUROIDS IMM FAB2 TO 120 MCI INJECTION CENTRUROIDS REQUIRED IMMUNE I J0AB IMMUNE D J0 AUT F7AB IMMUNE I 0 INJECTION CERTOLIZUMAB PEGOL 1 MG INJECTION CERTOLIZUMAB PEGOL 1 MG Approval Required Drug Use Complete Clinical Review J0720 INJ CHLORMPHNICL SO DIM SUCCNT TWO 1G INJECTION CHLORAMPHENICOL No Approval Required Drug Administration SODIUM SUCCATE FOR 1 G J0725 INJ CHORIONIC GONADOTROPIN-10000 EXPRESSION USP CHLORAMPHENICOL Nored 0 USP UNIT J0735 INJ CLONIDINE HYDROCHLORIDE 1 MG INJECTION CLONIDINE HYDROCHLORIDE No Approval Required Drug Administration 1 MG J0740 INJECTION C IDOFOVIR 375 MG INJECTION CIDOFOVIR 375 MG No Authorization Required Drug Administration J0743 INJ CILASTATIN SODIM USE IMPOVIR 375 MG INJECTION CIDOFOVIR 375 MG No Authorization Required Drug Administration J0743 INJ CILASTATIN SODIM INDICATION ACCOUNT IMPOVIR-2 IMIPENEM PO 250 MG J0744 INJ CI PROFLOXACIN IV INFUS 200 MG INJECTION CIPROFLOXACIN No. approval required Drug administration INTRAVENOUS INFUSE 200 MG J0745 INJ CODEINE PHOSPHATE PO 30 MG INJECTABLE CODEINE PHOSPHATE PER. No approval required Drug administration UP TO 150 MG J0775 INJ COLLAGENASE CHC 0.01 MG INJ COLLAGENASE CLOSTRIDIUM Approval required Drug administration Full clinical review HISTOLYTICUM 0.01 MG J0780 INJ PROCHLORPERAZINE UP TO 10 MG INJ PROCHLORPERAZINE UP TO 10 MG DFLUT NEEDED MEDICINE ADMINISTRATION URGENT J077 10 MG MCG INJ CORTICORELIN OVINE TRIFLUTATE 1 No approval required Drug administration MICROGM J0800 INJECTION CORTICOTROPIN UP TO 40 UNITS INJECTION CORTICTROPIN UP TO 40 Approval required Drug administration Complete clinical review UNITS J0834 INJECTION COSYNTROPIN 0.25 MG INJECTION COSYNTROPIN 0.25 MG INJECTION COSYNTROPIN 0.25 Application of medicine 0.2 5 Medicine no. V IMM FAB UP 1 G INJ CROTALIDAE POLYVALENT IMMUNE No authorization required Application of drug FAB UP TO 1 G J0841 INJECTION CROTALIDAE IMMUNE F120 MG INJECTION CROTALIDAE IMMUNE F120 No authorization required Application of drug MG J0850 INJ CYTOMEGLOVRUS IMMU GLOB IV INJECTION Comp lete Injection CROTALIDAE IMMUNE F120 GLOB IV -CAP J0875 INJECTION DALBAVANCIN 5MG INJECTION DALBAVANCIN 5MG No Authorization Required Administration Drug J0878 INJECTION DAPTOMYCIN 1 MG INJECTION DAPTOMYCIN 1 MG No Authorization Required Administration J0881 INJ DARBEPOETIN ALFA 1 MCG NON-ESRD INJECTION REQUIRED DARBEPO ET DCGIN Administration required authorization DARBEPOET DC GIN USE J0882 INJ DARBEPOETIN ALFA 1 MCG FOR ESRD INJ DARBEPOETIN ALFA 1 MCG FOR No Authorization Required Drug Administration ESRD DIALYSIS J0883 INJ ARGATROBAN 1 MG NON-ESRD USE INJECTION ARGATROBAN 1 MG NON- No Authorization Required Drug Administration ESRD 4BJONS 08GA4BJNES INJECTION ARGATROBAN 1 MG ESRD No approval Drug administration required ON DIALYSIS J0885 INJ EPOETIN ALFA NON-ESRD 1000 UNITS INJECTABLE EPOETIN ALFA DUE TO NON-APPROVAL Drug administration required Full clinical review Always treat medically ESRD 1000 UNITS BEPOETINCTION EPOETINCTION EPOINCTION EPOINCTION EPOINCTION EPOINCTION E POINT TA 1 Approval required Drug administration Full clinical review MICROGRAM J0888 INJECTION EPOETIN BETA 1 MICROGRAM INJECTION EPOE TIN BETA 1 Approval Required Drug Administration Full Clinical Review MICROGRAM J0890 INJECTION PEGINESATIDE 0.1 MG INJECTION 0.1 MG INJECTION 0.1 RELEASE ADMINISTRATION J0.1 DESCRIPTION CITABINE 1 MG DECITABINE INJECTION 1 MG Authorization Required Drug Administration Full Clinical Review J0895 INJ DEFEROXAMINE MESYLATE 500 MG INJECTION DEFEROXAMINE MESYLATE No Authorization Required Drug Administration 500 MG J0897 DENOSUMAB INJECTION 1 MG DENOSUMAB INJECTION 1 MG Approval Required Clinic l Drug Administration B045 Drug Review B045 Drug Administration MG INJECTION BROMPHENIRAMINE No approval required Use of the drug MALEAT PR. 10 MG J1000 INJ DEPO-ESTRADIOL CYPIONATE UP TO 5MG INJECTION DEPO-ESTRADIOL CYPIONATE No approval required Drug administration UP TO 5 MG J1020 INJ METHYLPRDNISOLON ACTATE 20 MG INJECTION DESCRIPTION METHY0 ACUTE. 0 INJ METHYLPRDNISOLON ACTATE 40 MG INJECTION METHYLPRDNISOLON No Approval Required Drug Administration ACETATE 40 MG J1040 INJ METHYLPRDNISOLON ACTATE 80 MG INJECTION METHYLPRDNISOLON No Approval Required Drug Administration ACETATE 80 MG J1050 INJ MEDROXYPROGESTERNIS OLON ACTIVITY None Drug PROGESTERONE ACETATE 1 MG J1071 INJ TEST required OSTERONE CYPIONATE 1 MG INJECTION TESTOSTERONE CYPIONATE 1 No Authorization Required Drug Administration MG J1094 INJECTION DEXAMETHASONE ACTATE 1 MG INJECTION DEXAMETHASONE ACETATE No Authorization Required Drug Administration 1 MG J1095 INJ DEXAMETHASONE 9% IN= IOL 1 MCG INJECTION DEXAMETHASONE REQUIRED Full Authorization DEX REQUIRED AMETHASONE 9% IN= IOL

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J1096 DXAMETHASONE LAC OPHTH INSRT 0.1 DEXAMETHASONE LACRIMAL Drug Approval Required Full Clinical Review MG OPHTHALMIC INSRT 0.1 MG J1097 PHN 10.6&KET 2.88 MG/ML OPH IRR 1MLPHEN/Aquit. red IRR SOL 1 ML J1100 INJ DEXMETHOSON SODIM PHOSHATE 1 INJECTION DEXAMETHOSON SODIUM No approval required for the use of the drug MG PHOSPHAT 1 MG J1110 INJ DIHYDROERGOTAMINE MESYLATE 1 INJECTION No approval required for the use of the drug MG MESYLATE ACCEPT 1AM 0MG IN J 1 1 0 MG 1 1 0 MG ACTION ACETAZOLE MID SODIUM No authorization required Drug use UP TO 500 MG J1130 DICLOFENAC SODIUM INJECTION .5 MG DICLOFENAC SODIUM INJECTION .5 MG No authorization required Drug use J1160 DIGOXIN INJECTION UP TO 0.5 MG DIGOXIN INJECTION UP TO 0.5 MG IN J1IGOVIN DMU U J 11OX DMU INJECTION INJECTION DIGOXIN INJECTION CTION DIGOXIN IMMUNE FAB No approval required Drug administration GET PR. CAP CONNECTOR J1165 INJ PHENYTOIN SODIUM PR. 50 MG INJECTION PHENYTOIN SODIUM PER. 50 No approval needed Drug administration MG J1170 INJECTION HYDROMORPHONE UP TO 4 INJECTION HYDROMORPHONE UP TO 8 Drug administration UP TO 4 D1C Administration required YLLINE UP TO 500 MG INJECTION DYPHYLLINE UP TO 500 MG No approval needed Drug administration J1190 INJ DEXRAZOXANE HCL PR . 250 MG INJECTION DEXRAZOXANE No approval required Drug administration HYDROCHLORIDE PR. drug administration required TO 50 MG J1205 INJ CHLOROTHIAZIDE SODIUM 500 MG INJECTION CHLOROTHIAZIDE SODIUM No approval required Drug administration PR. 500 MG J1212 INJ DMSO DIMETHYL SULFOXIDE 50% 50ML INJECTION DMSO DIMETHYL SULFOXIDE No Authorization Required Drug Administration 50% JUP 0 MLC 50% 0 MG INJECTION METHADONE HCL UP TO 10 No Authorization Required Drug Administration MG J1240 DIMENHYDRINATE INJECTION 50 MG DIMENHYDRINATE INJECTION UP TO 50 None approval required for the use of the drug MG J1245 DIPIRIDAMOLE INJECTION PR. AMIN HCI NA 250 MG INJECTION DOBUTAMINE HCI NA 250 No authorization required drug administration MG J1260 INJECTION DOLASETRON MESYLATE 10 MG INJECTION DOLASETRON MESYLATE 10 No authorization required drug administration MG J1265 INJECTION DOPAMINE HCL 40 MG INJECTION DOPAMINE HCL 40 MG NO . MG INJECTION DORIPENEM 10 MG No authorization required Administration of the drug J1270 INJECTION DOXERCALCIFEROL 1 MCG INJECTION DOXERCALCIFEROL 1 MCG No authorization required Administration of the drug J1290 INJECTION ECALLANTIDE 1 MG INJECTION ECALLANTIDE 1 MG Authorization required Administration of the drug Complete clinical examination J1300 INJEMGIZC UM 1300 10 MG - authorization required Administration Drug Full Clinical Review J1301 INJECTION EDARAVONE 1 MG INJECTION EDARAVONE 1 MG Approval Required Drug Administration Full Clinical Review J1303 INJECTION RAVULIZUMAB-CWVZ 10 MG INJECTION RAVULIZUMAB-CWVZ 10 MG Approval Required Full Clinical Review J1320 INJ UP AMITRIPTY NO. Authorization Required Drug Administration 20 MG J1322 ELOSULFASE ALFA INJECTION 1 MG ELOSULFASE ALFA INJECTION 1 MG No Authorization Required Drug Administration J1324 ENFUVIRTIDE INJECTION 1 MG ENFUVIRTIDE INJECTION 1 MG Authorization Required Drug Administration Full Clinical Review J13025 ELOSULFASE ALFA INJECTION 1 MG 5 MG No Authorization Required Drug Administration J1327 EPTIFIBATIDE INJECTION 5 MG INJECTION EPTIFIBATIDE 5 MG No approval required Drug administration J1330 INJ ERGONOVINE MALEATE UP TO 0.2 MG INJECTION ERGONOVINE MALEATE UP No approval required Drug administration UP TO 0.2 MG J1335 INJECTION INJECTION INJECTION INJEC TION ERGONOVINE MALEATE UP None drug administration approval required TO 0.2 MG required Drug Administration MG J1364 INJECTION ERYTH LACTOBIONATE 500 MG INJECTION ERYTHROMYCIN No drug administration approval required LACTOBIONATE PR. 500 MG J1380 INJ ESTRADIOL VALERATE TO 10 MG INJECTION ESTRADIOL VALERATE TO No Authorization Required Drug Administration 10 MG CONJEGENEST INJECJCJEGRO 500 MG CONJECTION5C D PER No Authorization Required Drug Administration MG 25 MG J1428 INJECTION ETEPLIRSEN 10 MG INJECTION ETEPLIRSEN 10 MG Required Application Authorization Full clinical examination J1430 INJ ETHANOLAMINE OLEATE 100 MG INJECTION ETHANOLAMINE OLEATE 100 No approval required Drug administration INJERMGONE 1435 MG No Approval Required Drug administration J1436 INJ ETIDRONATE 300 MG INJECTION ETIDRONATE DINODIUM PER. No Authorization Required Drug Administration 300 MG J1438 INJECTION ETANERCEPT 25 MG INJECTION ETANERCEPT 25 MG Authorization Required Drug Administration Full Clinical Review J1439 INJECTION CAFERRICTOXRBOX J1439 INJECTION J1439 INJECTION YMALTOSE 1 Authorization Required Drug Administration Full Clinical Review MG J144 2 INJ. FILGRASTIM EXCL BIOSIMLRS 1 MIC INJECTION FILGRASTIM EXCLUSIVE Approval Required Drug Administration Full Clinical Review Always Treated With Medical BIOSIMILARS 1 MIC J1443 INJ FERRICOL PRPP CIT SOL 0.1 MG IRON INJ FERRICOL PRPP 0 CITRATE Drug Req. INJECTION FPC POWDER 0.1 MG IRON INJ FERRI PYROPHOSPHATE CITRATE Approval not required PWD 0.1 MG IRON J1447 INJECTION TBO-FILGRASTIM 1 MICROG INJECTION TBO-FILGRASTIM 1 Approval required Drug Administration Full Clinical Review MICROGRAM J1447 INJECTION F250GRAM J1 1 CONAZOLE 20 0 MG No authorization required Use of the drug J1451 INJECTION FOMEPIZOLE 15 MG INJECTION FOMEPIZOLE 15 MG No authorization required for the use of the drug J1452 INJ FOMIVIRSEN SODIUM IO 1.65 MG INJECTION FOMIVERSEN SODIUM No authorization required for the use of the drug INTRAOCULAR 1.65 INMGFOMCITTION 1453SA INJECTION 1 MG ANT No approval required Drug administration J1454 INJ FOSNETPT 235 MG & PLNST 0.25 MG INJ FOSNETUPITANT 235 MG & No approval required Drug administration PALONOSETRON 0.25 MG J1455 INJECTION FOSCARNET SODIUM 1000 MG INJECTION FOSCARNET SODIUM PER No approval required Drug administration INMG JNITION507 10007ALL INJECTION GALIJ -NITRATE 1 MG No Drug Administration approval required J1458 INJECTION GALSULFASE 1 MG INJECTION GALSULFASE 1 MG Drug administration approval required Full clinical review J1459 INJ IG IV NON-LYOPHILIZED 500 MG INJ IMMUNO GLOBULIN IV Drug administration approval required Full clinical review NON-LYOPHYLIZED INGLOBULIN 500 MG INJECTION GAMMA GLOBULIN No approval required for drug administration INTRAMUSCULAR 1 CC J15 55 INJECTION IMMUNE GLOBULIN 100 MG INJECTION IMMUNE GLOBULIN 100 MG Approval required Drug administration Full clinical examination J1556 INJ IMMUNE GLOBULIN BIVIGAM 500 MG INJECTION Full MG INJECTION CIGLIVIN MG INJECTION AM 500 MG J1557 INJ IG IV NON-LYFOLIZED 500 MG INJ IMMUNE GLOBULIN IV Authorization Required Drug Administration Full Clinical Review NONLYOFILIZED 500 MG J1559 INJECTION IG HIZENTRA 100 MG INJECTION IMMUNE GLOBULIN Authorization Required Drug Administration Full Clinical Review HIZENTRA 100 MG

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J1560 INJECTION GAMMA GLOB IM OVER 10 CC INJECTION GAMMA GLOB No approval required Drug administration INTRAMUSCULAR OVER 10 CC J1561 INJ IG NON-LYOPHILIZED 500 MG INJECTION IMMUNOGLOBULIN GENERAL INJECTION IG VIVAGLOBIN 100 MG INJECTION IMMUNOGLOBULIN Approval required. Full Clinical Review of Drug Application VIVAGLBIN 100 MG J15 66 INJ IG IV LIFILIZED NOSE 500 MG INJ IG IV LIFILIZED NOT OTHER APPROVAL Drug Application Required Full Clinical Review SPEC 500 MG J1568 INJ IG YOOCTOGAM 500 MG INJ IG YOOCTOGAM 5 NONLOCMG IV NONLOCGAM IV. Full clinical review required for drug use 500 MG J1569 INJ IG GAMMAGARD IV NONLYO 500 MG INJ IG GAMMAGARD LIQ IV Drug administration approval required Full clinical review required NON-LYOPHILIZED 500 MG J1570 INJECTION GANCICLOVIR SODIUM 500 MG. J1571 INJ HEP B IG HEPAGAM B IM 0.5 ML INJ HEPATITIS B IG HEPAGAM B IM 0.5 No Authorization Required Drug Administration ML J1572 INJ IG IV NONLYOFILIZED 500 MG INJ IMMUNE GLOBULIN IV Authorization Required Drug Administration Full Clinical Review NONLYOFILIZED JEP500 HEP503 ML INJ HEP B IG HEPAGAM B INTRAVENOUS No authorization required for the use of the drug 0.5 ML J1575 INJ IG/HYALURONIDASE 100 MG IG INJ IMMUNE No authorization required for the use of the drug GLOBULIN/HYALURONIDASE 100 MG IG J1580 INJENTGAMGAM 8CINGRAM INDGAAM AND GENTAMICIN No authorization required Use of the drug UP TO 80 MG J15 95 GLATIRAMACETATE INJECTION 20 MG GLATIRAMER ACETATE INJECTION 20 Approval Required Drug Administration Complete Clinical Review MG J1599 INJ IG IV NON-LYOPHILIZED NOSE 500 MG INJ IG IV NON-LYOPHILLIZED E.g. LIQUID Approval required Drug administration Full clinical review NOS 500 MG J1600 INJ GOLD SODIUM THIOMALATE UP TO 50 MG INJECTIONS GOLD SODIUM THIOMALATE No approval required Drug administration UP TO 50 MG J1602 INJECTION IN GOLIMUMAB US 1602 INJECTION IN GOLIMUMAB 1st line Drug Administration Full clinical review IN TRAVENOUS USE J1610 INJ GLUCAGON HYDROCHLORIDE PER 1 INJECTION GLUCAGON No approval required Drug Administration MG HYDROCHLORIDE PER 1 MG J1620 INJ GONADORELN HYDROCHLORIDE 100 COST INJECTION USE MOROCHLORIDE INJECTION USE MOEDROCHLORIDE INJECTION NO COST 100 MCG J 1626 INJ GRANISETERN HYDROCHLORIDE 100 MCG INJECTION GRANISETRON No approval required Administration HYDROCHLORIDE 100 MCG J1627 INJ GRANISETRON EXT-RLSE 0.1 MG INJECTION GRANISETRON EXTENDED- Authorization Required Drug Administration Full Clinical Review RELEASE 0.1 MG J1628 INJECTION GUSELKUMABTION GUSELKUMABTION 1 GUSEL INJECABTION Drug Administration 1 GUSEL INJECABTION Authorization 1 GUSEL INJECABTION BG. 1630 INJECTION HALOPERIDOL UP TO 5 MG INJECTION HALOPERIDOL UP TO 5 MG No approval required Drug administration J1631 INJ HALOPERIDOL DECANOATE PR. 50 MG INJECTION HALOPERIDOL DECANOATE No approval required Drug administration PR. 50 MG J1640 INJECTION HEMIN HEMIN 4 INJECTION HEPARIN SODIUM 10 UNITS INJECTION HEPARIN SODIUM PER. 10 No approval required Drug administration UNITS J1644 INJ HEPARIN SODIUM PR. 1000 INJECTION UNITS OF HEPARIN SODIUM PO. Clinical examination 2500 IU J1650 INJECTION ENOXAPARIN SODIUM 10 MG INJECTION ENOXAPARIN SODIUM 10 No approval required Drug use MG J1652 INJ FONDAPARINUX SODIUM 0.5 MG INJECTION FONDAPARINUX SODIUM 0.5 No approval required Drug use INJECTION J1655 INJECTION T165 5 PARIN SODIUM 1000 No approval required Application of the drug IU J1670 INJ TETNS IMMUN GLOB HUMAN FOR 250 J. INJECTION TETANUS IMMUNE GLOB No approval required Administration of the drug HUMAN FOR 250 UNITS J1675 INJ HISTRELIN ACTATE 10 MICROGMS INJECTION HISTRELINCTATE 10 No approval required Administration of the drug FOR 250 UNITS 5 INJECTION HYDROCORTISONE ACETATE No. Authorization required Administration of medication UP TO 25 MG J1710 INJ HYDROCORTISON SOD PHOS FOR 50 MG INJ HYDROCORTISON SODIUM No authorization required Drug administration PHOSPHAT FOR 50 MG J1720 INJ HYDROCORTSON SOD SUCC FOR 100 MG INJ HYDROCORTISON SODIUM REQUIRED Auth. 1726 INJECTION HPC 10 MG INJECTION HYDROXYPROGESTERON Approval required Drug administration Full clinical examination CAPROATE 10 MG J1729 INJECTION HPC NOS 10 MG INJECTION HYDROXYPROGESTERON Approval required Drug administration Full clinical examination CAPROATE NOS 10 MG J1730 INJECTION DIAZOXIDE UP TO 300 MEASUREMENT INJEOXID 300 NO NO . Drug Administration J1740 INJECTION IBANDRONATE SODIUM 1 MG INJECTION IBANDRONATE SODIUM 1 No approval required Drug Administration MG J1741 INJECTION IBUPROFEN 100 MG INJECTION IBUPROFEN 100 MG No approval required Administration of drugs J1742 INJ IBUTILIDE FUMARATE 1 MG INJECTION 1 MG INJECTION ACTION IBUPROFEN 100 MG 743 INJECTION ID URSULF ASE 1 MG INJECTION IDURSULFASE 1 MG Authorization Required Drug Clinical Review J1744 INJECTION ICATIBANT 1 MG INJECTION ICATIBANT 1 MG Authorization Required Drug Administration Full Clinical Review J1745 INJ INFLIXIMAB EXCL BIOSIMILR 10 MG INJECTION INFLIXIMAB EXK LIN BIOSIMILR 10 MG INJECTION INFLIXIMAB EXKLIN Drug Administration Full Authorization Drug Administration J1745 INJ INFLIXIMAB EXCL. 1746 IBALIZUMAB-UIYK INJECTION 10 MG IBALIZUMAB-UIYK INJECTION 10 MG Authorization Required Drug Administration Full Clinical Review J1750 IRON DEXTRANE INJECTION 50 MG IRON DEXTRAN INJECTION 50 MG No Authorization Required Drug Administration J1756 IRON SUCHAROSE INJECTION 1 1786 IMIGLUC INJECTION DELETE 10 UNITS IMIGLUCERASE INJECTION 10 UNITS No authorization required Drug administration J1790 INJECTABLE DROPERIDOL UP TO 5 MG INJECTIVE DROPERIDOL UP TO 5 MG No authorization required Drug administration J1800 INJECTABLE PROPRANOLOL HCL TRIAL FOR 1 MG INJECTIVE DROPERIDOL UP TO 5 MG MG J1810 INJECTIVE DROPRIDOL&FENTANYL CITRATE FOR 2 ML INJ DROPERIDOL&FENTANYL CITRATE Fox approval no. Drug administration UP TO 2 ML AMP J1815 INJECTION INSULIN PER. 5 UNITS. INJECTABLE INSULIN PO. 5 UNITS. ADMINISTRATION OF INSULIN THROUGH approval required Drug administration Complete clinical examination DME per 50 units J1826 Injection Interferon Beta-1a 30 MCG Injection Interferon Beta-1a 30 Required approval for drug administration Complete clinical examination MCG J1830 Inj. interferon Beta-1b 0.25 mg Injection Interferon Beta-1b 0.25 Drug administration approval required Full clinical examination MG J1833 INJECTION ISAVUCONAZONIUM 1 MG INJECTION ISAVUCONAZONIUM 1 MG No authorization required Drug administration J1835 INJECTION ITRACONAZOLE 50 MG INJECTION ITRACONAZOLE 50 MG No authorization required Drug administration INJ K184ATE TO K1835 INJECTION ITRACONAZOLE 50 MG INJECTION ITRACONAZOLE 50 MG AMYCIN SULFATE UP TO No approval required Drug administration 500 MG J185 0 INJ KANAMYCIN SULFATE FOR 75 MG INJECTION KANAMYCIN SULFATE UP No approval required Drug administration 75 MG

158

J1885 INJ KETOROLAC TROMETHAMINE 15 MG INJECTION KETOROLAC No approval required Drug administration TROMETHAMINE PR. 15 MG J1890 INJ CEFALOTHIN SODIUM FOR 1 GM INJECTION CEFALOTHIN SODIUM OP No approval required INJEJ1C 0MGRE INJE 3MG1C. TION LANREOTIDE 1 MG No approval required Drug administration J1931 LARONIDASE INJECTION 0.1 MG LARONIDASE INJECTION 0.1 MG Approval required Drug administration Full clinical review J1940 FUROSEMIDE INJECTION UP TO 20 MG FUROSEMIDE INJECTION UP TO 20 MG No approval required AUT. Required Drug Administration J1940 INJECTN FUROSEMIDE TO 20 MG CTION ARIPIPRAZOLE LAUROXIL 1 No Authorization Required Drug Administration MG J1943 INJECTN ARIPIPRAZOLE LAUROXIL 1 MG INJECTION ARIPIPRAZOLE LAUROXIL 1 No Authorization Required MG J1944 INJECTN ARIPIPRAZOLE LAUROXIL 1 MG INJECTION ARIPIPRAZOLE LAUROXIL IL LAU ROXIL LAUROXIL LAUROXIL LAUROXIL 1 No Authin Auth JECTION LEPIRUDIN 50 MG No Authorization Required Drug Administration J1950 INJ LEUPROLIDE ACETATE PR. 3.75 MG INJECTION LEUPROLIDE ACETATE PER No marketing authorization required 3.75 MG J1953 INJECTION LEVETIRACETAM 10 MG INJECTION LEVETIRACETAM 10 MG No marketing authorization required J1955 INJECTION LEVOCARNITINE PO 1 G INJECTION 1 G 9 6 INJECTION LEVOFLOXACIN 2 50 MG INJECTION LEVOFLOXACIN 250 MG No. Authorization Required Drug Administration J1960 INJ LEVORPHANOL TARTRATE FOR 2 MG INJECTION LEVORPHANOL TARTRATE GORE No Authorization Required Drug Administration FOR 2 MG J1980 INJ HYOSCYAMINE SULFATE FOR 0.25 MG INJECTION HYOSCYAMINE FOR 0.25 MG INJECTION HYOSCYAMINE FOR 0.25 MG INJECTION Auth . 0 INJ CHLORDIAZEPOXIDE HCL FOR 100 MG INJECTION CHLORDIAZEPOXIDE HCL UP No approval required Drug use FOR 100 MG J2001 INJECTION LIDO HCL IV INFUS 10 MG INJECTION LIDOCAINE HCL No approval required Drug use INTRAVENOUS INFUS 10 MG J2010 INJECTION LINCOMYC0 IN LINCOMYC0IN FOR 300 INJ No drug approval fox Application MG J2020 INJECTION LINEZOLID 200 MG INJECTION LINEZOLID 200 MG No authorization required for the use of the drug J2060 INJECTION LORAZEPAM 2 MG INJECTION LORAZEPAM 2 MG No authorization required for the use of the drug J2062 LOXAPINE REQUEST FOR INHALATION 1 FOR INHALATION Application Complete clinical review J2150 I INJECTION MANINTOL 25 % I 50 ML INJECTION MANNITOL 25% I 50 ML No authorization required Drug administration J2170 INJECTION MECASERMIN 1 MG INJECTION MECASERMIN 1 MG Authorization required Drug administration Full clinical review J2175 MEPERIDINE HCLIDE INJECTION 100 INJECTION NO. rug Administration MG J2180 INJ MEPRIDINE&PROMTHZIN HCL FOR 50 MG INJECTION No Authorization Required Drug Administration MEPERIDINE&PROMETHAZINE HCL FOR 50 MG J2182 INJECTION MEPOLIZUMAB 1 MG INJECTION MEPOLIZUMAB 1 MG Authorization Required Drug Administration J21 Clinical INJEMG01 Clinical INJEMG01 Clinical Drug INJECTION MEROPENEM 100 MG No Authorization Required Administration of drugs J2186 INJ MEM VABORBACTAM 10 MG/10 MG INJECTION MEROPENEM No authorization required Administration of drugs VABORBACTAM 10 MG/10 MG J2210 INJ METHYLRGONOVINE MALATE TO 0.2 INJECTION METHYLRGONOVINE No Authorization Required MAN METHYLRGONOVINE MALATE 2UPMGY. LNALTREXONE 0.1 MG INJECTION METHYLNALTREXONE 0.1 No Approval Required Drug Administration MG J2248 INJECTION MICAFUNGIN SODIUM 1 MG INJECTION MICAFUNGIN SODIUM 1 MG No Approval Required Drug Administration J2250 INJECTION MIDAZOLAM HCL PR. 1 MG INJECTION MIDAZOLAM HCL PER. 1 MG Required application of the drug J226CIN INJE 50MG INJECT. TION MILRINONE LACTATE 5 MG No Authorization Required Drug Administration J2265 INJECTION MINOCYCLINE HCL 1 MG INJECTION MINOCYCLINE HCL 1 MG No Authorization Required Drug Administration J2270 INJ MORPHINE SULFATE DO 10 MG INJECTION MORPHINE SULFATE DO No Authorization Required INMG20 40 MS2 1 0 MG INJECTION MS PRES - FREE No Approval Required Drug Administration EPID/INTRATHECL USE 10 MG J2278 ZICONOTIDE INJECTION 1 MICROGRAM ZICONOTIDE INJECTION 1 MICROGRAM No Approval Required Drug Administration J2280 INJECTION INJECTION MOXIFLOX0 MOXIFLOX0 MOXIFLOX0 MG Approval Required Drug Administration J2300 INJECTION N ALBUPHINE HCL PR 10 MG INJECTION NALBUPHINE HCL PO . 10 MG No approval required Drug administration J2310 INJECTION NALOXONE HCL PR. 1 MG INJECTION NALOXONE HCL PER. cover Administration MG J2320 INJ NANDROLONE DECANOATE FOR 50 MG INJECTION NANDROLONE DECANOATE No approval required Drug administration UP TO 50 MG J2323 INJECTION NATALIZUMAB 1 MG INJECTION NATALIZUMAB 1 MG Approval required Drug administration Full clinical review INJECTION J2323 INJEC TION 5 MG INJECTION. 0.1 MG No Authorization Required Drug Administration J2326 NUSINERSEN INJECTION 0.1 MG NUSINERSEN INJECTION 0.1 MG Authorization Required Drug Administration Full Clinical Review J2350 OCRELIZUMAB INJECTION 1 MG OCRELIZUMAB INJECTION 1 MG Authorization Required Drug Administration Full Clinical Review J2353 DINJ OCTREOTMG INJ O CTREOTIDE INJ 1 MG J 1 Approval Required Drug Administration Full Clinical Review MG J2354 INJ OCTREOTDE NO-DPOT SUBQ/IV 25MCG INJ OCTREOTIDE NON-DEPOT FORM Authorization Required Drug Administration Full Clinical Review SUBQ/IV INJ 25 MCG J2355 INJECTION OPRELVEKIN 5 MG INJECTION CLAIM 5 MG INJECTION OPRELVEKIN INJECTION 3 D7C SUBMISSION NO. UMAB 5 MG INJECTION OMALIZUMAB 5 MG Approval Required Drug Administration Full Clinical Review J2358 INJ OLANZAPINE LONG-ACTING 1 MG INJECTION OLANZAPINE LONG-ACTING 1 No Approval Required Drug Administration MG J2360 INJ ORPHENADRINE CITRATE CLAIM FOR 60 REQ. Administration UP TO 60 MG J2370 INJECTION PHENYLEPHRINE HCL UP TO 1 ML INJECTION PHENYLEPHRINE HCL UP To No approval required Drug Administration 1 ML J2400 INJ CHLORPROCAIN HCL PR. MG INJECTION ONDANSETRON HCL PR. 1 No authorization required drug administration MG J2407 INJECTION ORITAVANCIN 10 MG INJECTION ORITAVANCIN 10 MG No authorization required drug administration J2410 INJECTION OXYMORPHONE HCL FOR 1 MG INJECTION OXYMORPHONE HCLuth required J2 No D50 SUBMISSION 1 D2C. MICROGRAM INJECTION PALIFERMIN 50 No Auth Required Drug Administration MICROGRAM J2426 INJ PALIPERIDONE PALM EXT RLSE 1 MG INJECTION PALIPERIDONE PALMITATE No Auth Required Drug Administration EXT RLSE 1 MG J2430 INJ PAMIDRONATE DISODIUM PR. TION PAPAVERINE HCL FOR 60 MG INJECTION PAPAVERINE HCL UP TO 60 No Authorization Required Drug Administration MG J2460 INJ OXYTETRACYCLINE HCL FOR 50 MG INJECTION OXYTETRACYCLINE HCL UP No Authorization Required Drug Administration FOR 50 MG J2469 INJECTION PALONOSETRON HCL 25 MCGNO INJECTION ACTION NO.

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J2501 INJECTION PARICALCITOL 1 MCG INJECTION PARICALCITOL 1 MCG No authorization required for the use of the drug J2502 INJ PASIREOTIDE LONG-ACTING 1 MG INJECTION PASIREOTIDE LONG-ACTING 1 No authorization required for the use of the drug MG SO2503 INJECTION J2503 INJECTION J2503 INJECTION J2503 INJECTION. SODIUM 0.3 Approval required Drug administration Full clinical examination MG J2504 INJECTION PEGADEMASE BOVINE 25 IU PEGADEMASE BOVINE INJECTION 25 IU No approval required Drug administration J2505 INJECTION PEGFILGRASTIM 6 MG INJECTION PEGFILGRASTIM 6 PEGFILGRASTIM 6 PEGFILGRASTIM 6 PEGFILGRASTIM 6 PEGFILGRASTIM STIM 6 PEGFILGRAS TEAM 6 MG approval required Drug use Full clinical examination INJECTION J250MG 1 MG No approval required Drug use J2510 INJ PCN G PROCAINE AQUEOUS 600000 U INJECTION PCN G PROCAINE AQUEOUS No approval required Drug administration FOR 600000 UNITS J2513 INJ PENTASTIRCH 10% SOL 100 ML INJECTION PENTASTIRCH 10% No approval required SOLUTION 50000 INJ PENTASTIFICATION INJ PENTASTARCH 5 50 MG INJECTION PENTOBARBITAL SODIUM No approval required Drug use PR. 50 MG J2540 INJECTION PCN G K+ UP TO 600,000 UNITS INJECTION PENICILLIN G POTASSIUM TO No approval required Drug Administration 600,000 UNITS J2543 INJ PIP SOD/TZ SOD 1 G/0.125 G INJOD USE DPITAPER G INJOD AUT. 1 G /0.125 G J2545 PENTAMIDINE ISETHIONATE AND SOL 300 MG PENTAMIDINE ISETHIONATE AND SOL No authorization required Application of drug NONCP UD P 300 MG J2547 INJECTION PERAMIVIR 1 MG INJECTION PERAMIVIR 1 MG INJECTION PERAMIVIR 1 MG INJECTION ADMINISTRATION 1 MG D 5ME Auth. 0 MG INJECTION PROMETHAZINE HCL UP To No Authorization Required Drug Administration 50 MG J2560 INJ PHENOBARBITAL SODIUM UP TO 120 MG INJECTION PHENOBARBITAL SODIUM UP No Authorization Required Drug Administration UP TO 120 MG J2562 INJECTION PLERIXAFOR 1 MG INJECTION REQUEST 1 PLERIXAFOR Drug 9MG INJECTION J2562 DRUG J2562. TOCIN UP TO 10 UNITS INJECTION OXYTOCIN UP TO 10 UNITS No approval required Drug Administration J2597 INJ DESMOPRESIN ACETATE PR. 1 MCG INJECTION DESMOPRESSIN ACETATE No approval required Drug administration PR. TOLAZOLIN HCL UP TO 25 MG INJECTION TOLAZOLIN HCL UP TO 25 No approval required Drug Administration MG J2675 INJECTION PROGESTERONE PR. 50 MG PROGESTERONE INJECTION PER 50 MG No approval required Drug administration J2680 INJ FLUPHENAZINE DECANOATE INJECTION UP TO 50 MG Administration UP TO 25 MG J2690 INJ PROCAINAMIDE HCL UP TO 1 GM INJECTION PROCAINAMIDE HCL UP TO 1 No approval required Drug administration GM J2700 INJ OXACILIN SODIUM UP TO 250 MG INJECTION OXACILIN SODIUM UP TO No Authorization Required Drug Administration 250 INJOFMGOFJE J20POLJE PROJECOL 250 INJ OD MG 250 MG INJECTION MG No Auth Required Drug Administration J2710 INJ NEOSTIGMIN METHYL SULFATE 0.5 MG INJECTION NEOSTIGMINE No Authorization Required Drug Administration METHYL SULFATE TO 0.5 MG J2720 IN J PROTAMIN SULFATE PR. CONC IV HUMAN 10 IU INJECTION PROTEN C CONCENTRATE IV No authorization required Administration of the drug HUMAN 10 IU J2725 INJECTION PROTIRELIN PO 250 MCG INJECTION PROTIRELIN PO 250 MCG No authorization required Administration of the drug J2730 INJ PRALIDOXIM CHLORIDE AT 1 GM INJECTION KLORIDOX D7RED No authorization PRALIDOX 6 0 INJ PHENTOLAMINE MESYLATE FOR 5 MG INJECTION PHENTOLAMINE MESYLATE No authorization required Drug administration UP TO 5 MG J2765 INJ METOCLOPRAMIDE HCL FOR 10 MG INJECTION METOCLOPRAMIDE HCL UP No authorization required Drug administration FOR 10 MG J2770 INJ QUINUOPRISTINJ000 ENVIRONMENTAL ADMINISTRATION INJECTION/5DA0C. NUPRISTIN/DALFOPRISTIN 500 MG J2778 INJECTION RANIBIZUMAB 0.1 MG INJECTION RANIBIZUMAB 0.1 MG Approval Required Drug Administration Full Clinical Review J2780 INJ RANITIDINE HYDROCHLORIDE 25 MG INJECTION RANITIDINE No Approval Required Drug Administration INJ RANITIDINE HYDROCHLORIDE 25 MG INJECTION RASBURICASE 0.1 MG REQUIRED INJECTION .5 MG No authorization required drug administration J2785 REGADENOSON INJECTION 0.1 MG REGADENOSON INJECTION 0.1 MG No authorization required Drug administration J2786 RESLIZUMAB INJECTION 1 MG RESLIZUMAB INJECTION 1 MG authorization required Drug administration Complete clinical review J2787 RIBOFLAVIN 5'-PHO OPTH SOLRIZUMAB 1 MG INJECTION required drug administration Full Clinical examination J278 7 RIBOFLAVIN 5'-PHO OPHTH SOLRIZUMAB 1 MG HALMIC SOL TO 3 ML J2788 INJ RHO DIG HUMAN MINIDOSE 50 MCG INJ RHO D IMMUNE GLOBULIN HUMAN No approval required Drug administration MINIDOSE 50 MCG J2790 INJ RHO DIG HUMN FULL DOSE 300 M CG INJECTION HUMAN DFU 300 MCG INJECTION HUMAN DFU Auth. CG J2791 INJ RHO D IG HUMAN RHOPHYLAC 100 IU INJ RHO D IG HUMAN RHOPHYLAC No Approval Required Drug Administration IM/IV 100 IU J2792 INJ RHO D IMMUE GLOB IV HUMN 100 IU INJ RHO D IMMUE GLOBULIN Application I JU1 GLOBULIN NO. CTION RILONACEPT 1 MG INJECTION RILONACEPT 1 MG No Authorization Required Drug J2794 INJECTION RISPERIDONE 0.5 MG INJECTION RISPERIDONE 0.5 MG No Authorization Required Drug Administration J2795 INJ ROPIVACAINE HYDROCHLORIDONE 1 MG J2796 INJECTION ROMIPLOSTIM 10 MCG INJECTION ROMIPLOSTIM 10 MCG - authorization required Drug Administration Full clinical review J2797 INJECTABLE ROLLAPITANT 0.5 MG INJECTABLE ROLLAPITANT 0.5 MG Approval Required Drug Administration Full Clinical Review J2798 INJECTABLE RISPERIDONE 0.5 MG INJECTABLE RISPERIDONE RISPERIDONE 0.5 MG REQUIRED INJECTION RISPERIDONE 0.5 MG 0.5 MG 0.5 M 10 INJECTION CTION METHOCARBAMOL TO 10 No Approval Required Drug Administration ML ML J2805 INJECTION SINCALIDE 5 MICROGRAM INJECTION SINCALIDE 5 MICROGRAM No Approval Required Drug Administration J2810 INJECTION THEOPHYLLINE PR. CTION SARGRAMOSTIM 50 MCG Approval required Drug administration Full clinical review J2840 INJECTION SEBELIPASE ALFA 1 MG INJECTION SEBELIPASE ALFA 1 MG Approval required Drug administration Full clinical review J2850 INJ SECRETIN SYNTH HUMN 1 MICROGM INJECTION SECRETIN SYNTHETIC No approval required Drug administration HUMAN J2C0MG INJECTION SECRETIN SYNTH HUMAN 1 MG 1 M1C0MG INJECTABLE SILTUXIMAB 10 MG Authorization Required Drug Administration Full Clinical Review J2910 AUROTHIOGLUCOSE INJECTION UP TO 50 MG AUROTHIOGLUCOSE INJECTION DO No Authorization Required Drug Administration 50 MG J2916 INJ SODIM FERRI GLUCONATE 12.5 MG INJ SODIM FER RIC GLUCONATE 2. No Authorization Required CMPLUCRO D2916 INJ. 0 INJ METHYLPRDNISOLON SODIUM FOR 40 INJ METHYLPRDNISOLON SODIUM No Drug Authorization Required MG SUCCNAT FOR 40 MG J2930 INJ METHYLPRDNISLN SODIM FOR 125 MG INJ METHYLPRDNISOLON SODIUM No Drug Authorization Required SUCCNAT FOR 125 MG J2940 INJECTION SOMATREM INJECTION Complete Injection Author 1 SOMATREM INJECTION 4 Required 1 INJECTION SOMATROPIN 1 MG INJECTION SOMATROPIN 1 MG Authorization required Drug administration Full clinical examination J2950 PROMAZINE HCL INJECTION UP TO 25 MG PROMAZINE HCL INJECTION UP TO 25 No authorization required Drug administration MG

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J2993 INJECTION RETEPLASE 18.1 MG INJECTION RETEPLASE 18.1 MG No authorization required Drug use J2995 INJ STREPTOKINASE PR. 250000 IU STREPTOKINASE INJECTION PO ALTEPLASE RECOMBINANT 1 No authorization required Administration of the drug MG J3000 INJECTION STREPTOMYCIN UP TO 1 G INJECTION STREPTOMYCIN UP TO 1 G No authorization required Administration of the drug J3010 INJECTION FENTANYL CITRATE 0.1 MG INJECTION FENTANYL CITRATE 0.1 MG No authorization required Administration of the drug J3 030 INJECTION SUCCINATION SUMATRIPT 6 Authorization required Drug administration Full clinical review MG J3031 INJECTION FREMANEZUMAB-VFRM 1 MG INJECTION FREMANEZUMAB-VFRM 1 authorization required Full clinical review MG J3060 INJECTION TALIGLUCERASE ALFA 10 U INJECTION TALIGLUCERASE ALFA 10 Approval Drug administration Full clinical review required INJECTION 0 MAGAZINE INJE J307 CENT0 UNITS INJE J3 07C. 30 MG No approval required Drug administration J3090 TEDIZOLID PHOSPHATE INJECTION 1 MG TEDIZOLID PHOSPHATE INJECTION 1 MG No approval required Drug administration J3095 TELAVANCIN INJECTION 10 MG TELAVANCIN INJECTION 10 MG No approval required Drug administration J3101 TENECTEP INJECTION 1MG TENE CTEN INJECTION 1MG drug required J3105 INJ TERBUTALINE SULFATE FOR 1 MG INJECTION TERBUTALINE SULFATE OP No approval required Drug administration FOR 1 MG J3110 INJECTION TERIPARATIDE 10 MCG INJECTION TERIPARATIDE 10 MCG Approval required Drug administration Full clinical review J3111 INJECTION ROMOSOZUMAB-AQOS INJECTION 1 AquiGO INJECTION 1 Aqui G MG J3121 INJ TESTOSTERONE ENANTATE 1 MG INJECTION TESTO STERONE ENANTHATE No drug approval required 1 MG J3145 INJ TESTOSTERONE UNDECANOATE 1 MG TESTOSTERONE INJECTION No drug approval required UNDECANOAT 1 MG J3230 INJ CHLOROMAZINE HCL FOR 50 MG INJECTION FOR 50 MGLORP INJECTION DEKVI 50 MG INJECTION FOR 50 MG INJECTION CHROMIUM. J3240 INJ THYROTROPIN .9 MG PROV 1.1 VIAL INJ THYROTROPIN ALPHA 0.9 MG PROV Authorization required Drug administration Full clinical examination 1.1 MG CAP J3243 TIGECYCLINE INJECTION 1 MG TIGECYCLINE INJECTION 1 MG No authorization required Drug administration J3245 TIGECYC LINE INJECTION 1 MG MCABTION 1 MG Management approval required for drugs Full clinical review J3246 INJECTION TIROFIBAN HCI 0.25 MG INJECTION TIROFIBAN HCI 0.25 MG No approval required Drug administration J3250 INJ TRIMETHOBENZAMIDE HCL UP TO 200 MG TRIMETHOBENZAMIDE HCL INJECTION No approval required Drug administration UP TO J3250 INJ TRIMETHOBENZAMIDE HCL. MG INJECTION TOBRAMYCIN SULFATE OP No authorization required Drug administration ZA 80 MG J3262 TOCILIZUMAB INJECTION 1 MG TOCILIZUMAB INJECTION 1 MG No authorization required Drug administration J3265 TORSEMIDE INJECTION 10 MG/ML TORSEMIDE INJECTION 10 MG/ML No authorization required Drug administration INJRA J3 2IEC 0 mg THIETHYLPERAZINE MALEATE No approval required Drug administration UP TO 10 MG J3285 INJECTION TREPROSTINIL 1 MG INJECTION TREPROSTINIL 1 MG No approval required Drug administration J3300 INJ TRIAMCINOLONE ACETONIDE PF 1 MG INJ TRIAMCINOLONE ACETONIDE PRES No approval required Drug administration J3300 INJ TRIAMCINOLONE ACETONIDE P F 1 MG INJ TRIAMCINOLONE ACETONIDE PRES No authorization required Drug administration J3300 INJ TRIAMCINOLON ACETONIDE PF 1 MG 10 MG INJECTION TRIAMCINOLON ACETONIDE No authorization required Drug administration NOS 10 MG J3302 INJ TRIAMCINOLON DIACTATE 5 MG INJECTION TRIAMCINOLON DIACETATE No authorization required Drug administration PR. PF IS MS FORMULATION 1 MG TRIAMCINOLONE ACETONIDE INJECTION PF No approval required Drug administration ER MS F 1 MG J3305 INJ TRIMETREXATE GLUCORONATE 25 MG TRIMETREXATE INJECTION No approval required Drug administration GLUCORONATE PO 25 MG J3310 PERPHENAZINE INJECTION DO 5 Drug administration J3315 INJ TRIPTORELIN PAMOATE 3.75 MG INJECTION TRIPTORELIN PAMOATE 3.75 No approval required Drug administration MG J3316 INJECTION TRIPTORELIN IS 3.75 MG INJECTION TRIPTORELIN EXTENDED- No approval required Drug administration RELEASE 3.70 MGJ3316 INJECT MG3 OMYCIN DIHYDROCHLORIDE No approval required Drug administration GM TO 2 GM J3350 INJECTION UREA OP FOR 40 G INJECTION UREA UP TO 40 G No authorization required Drug administration J3355 INJECTION UROFOLLITROPIN 75 IU INJECTION UROFOLLITROPIN 75 IU Authorization required Drug administration Full clinical review J3350 US FOR 1350 SUBCUTANEOUS Permission required Drug administration Full clinical review INJECTION 1 MG J3358 USTEKINUMAB IN TRAVENOUS INJ 1 MG USTEKINUMAB TO INTRAVENOUS Required approval Drug administration Complete clinical examination INJECTION 1 MG J3360 INJECTION DIAZEPAM UP TO 5 MG INJECTION DIAZEPAM SET INJECTION INJECTION INDIL 4COK INJECTION INJECTION 1 MG J3360 INJECTION DIAZEPAM UP TO 5 MG 5000 IU CAP INJECTION UROKIN SE vial of 5000 IU No approval of the Veterinary Medicines Administration required J3365 INJ IV UROKINASE 250000 IU VIAL INJECTION IV UROKINASE 250000 IU No Approval Required Drug Administration VIAL J3370 INJECTION VANCOMYCIN HCL 500 MG INJECTION HCL VANCOMY0 INJECTION 3 VANCOMY0 INJECTION 3 KTION VEDOLIZUMAB 1 MG INJECTION V EDOLIZUMAB 1 MG Approval Required Drug Administration Complete Clinical Review J3385 I NJ VELAGLUCERASE ALFA 100 UNIT INJECTION VELAGLUCERASE ALFA 100 Approval Required Drug Administration Complete Clinical Review UNIT J3396 INJECTION VERTPORFIN 0.1 MG INJECTION INJECTION INJECTION INJ. 3MG AUT 1 VERTPORFIN D3MG. IDASE ALFA-VJBK 1 MG INJECTION VESTRONIDASE ALFA -VJBK 1 No approval required Drug administration MG J3398 INJ VORETGN NEPARVVC-RZYL 1 B VEC G INJECTION VORETIGENE NEPARVOVEC- No approval required Drug administration RZYL 1 B VEC G INJ AVSX-101-XIOI Drug author Application P -^TO Required D-^TX1 Full Clinical Review J3399 INJ AVSX-101-XIOI P-TX TO 5X10^15VG VCTR GNOMS J3400 INJ TRIFLUPROMAZINE HCL UP TO 20 MG INJECTION TRIFLUPROMAZINE HCL UP No Approval Required Drug Use UP TO 20 MG 20 MG HCLY 20 MG 20 MG 20 MG 20 MG TION HYDROXYZIN HCL UP TO 25 No Drug Authorization Required MG J3411 INJEC TION THIAMINE HCL 100 MG INJECTION THIAMIN HCL 100 MG No Authorization Required Drug Administration J3415 INJECTION PYRIDOXIN HCL 100 MG INJEC TION PYRIDOXINE HCL 100 MG Required Br administration of drugs J3415 INJECTION PYRIDOXIN INE HCL 100 MG INJECTION PYRIDOXINE HCL 100 MG 2 CYNOCOBLMN FOR 1000 MCG INJECTION VIT B-12 CYANOCOBALAMIN No approval required drug administration FOR 1000 MCG J3430 INJECTION PHYTONADIONE PO 1 MG INJECTION PHYTONADIONE PO 1 MG No approval required Drug administration J3465 VORICONADION INJECTION PER. Drug Administration J3470 INJ HYALURONIDASE FOR 150 UNITS INJECTABLE HYALURONIDASE UP TO 150 No Authorization Required Drug Administration UNITS J3471 INE HYALURONIDASE FOR 1 USP IN INE HYALURONIDASE FOR PRES FREE No Authorization Required Drug Administration 1 USP UNIT J3472 INJ HYALURONIDASE FOR IN J000 FREE UINE U000 GET UN WINE PRESS 1 uth Required Drug Administration 1000 USP UNIT J3473 INJ HYALURONIDASE RECOMB 1 USP UNIT INJECTABLE HYALURONIDASE No Approval Required Drug Administration RECOMBINANT 1 USP UNIT

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J3475 INJ MAGNESIUM SULFATE PR. 500 MG INJECTABLE MAGNESIUM SULFATE PER. No approval required Drug administration 500 MG J3480 INJ POTASSIUM CHLORIDE PR. MG INJECTION ZIDOVUDINE 10 MG No authorization required Drug administration J3486 INJ ZIPRASIDONE MESYLATE 10 MG INJECTION ZIPRASIDONE MESYLATE 10 No authorization required Drug administration MG J3489 INJECTION ZOLEDRONIC ACID 1 MG INJECTION ZOLEDRONIC ACID 1 MG No authorization required Drug administration required DRUCLASSIF IGS CLASSIFICATION CLASSIFICATION CLASSIFICATION OF DRUGS Application Full Clinical Review Always handled by physician J3530 INHALATION OF NASAL VACCINE INHALATION OF NASAL VACCINE No approval required J3590 UNCLASSIFIED BIOLOGICAL UNCLASSIFIED BIOLOGICAL Approval required Drug Administration Full Clinical Review Always treated by physician. ESRD on Dialysis J7030 Infus normal physical solution salt 1000 cc infusion normal physical solution is not necessary to approval 1000 cc J7040 infus with ordinary physical rastin salt sterile infusion normal physical solution is required no approval sterile J7042 5% Required physiological solution/7% Dectrose Annore 050 infusion 050 infus. HERB 250 CC INF NORMAL SALT PURCHASE No approval required 250 CC J7060 5% DEXTROSE/WATER 5% DEXTROSE/WATER No approval required J7070 INFUSION D-5-W 1000 CC INFUSION D-5-W 7 DEXTROSE 10000 No approval required 0 ML INFUSION DEXTRANE 40500 ML No Authorization required to administer the drug J7110 INFUSION DEXTRANE 75 500 ML INFUSION DEXTRANE 75500 ML No authorization required to administer the drug J7120 LACTATIN INFUSION RINGS FOR 1000 LACTATIN INFUSION FOR 1000 CLOSED INFUSION 7 121 5% DEXTROSE LR INFUSION FOR 1000 CC 5 % DEXTROSE LACTATE RINGS No approval required INFUSION UP TO 1000 CC J7131 HYPERTONIC SALT 1 ML HYPERTONIC SALT 1 ML No approval required J7170 INJECTION EMICIZUMAB-KXMGWIZ INJEUMC05.WXH 05.HX. uth Medication administration required J7175 INJECTABLE FACTOR X 1 I.U. INJECTION FACTOR X 1 I.U. No Authorization Required Drug Administration J7177 INJ HUMAN FIBRINOGEN CONCENTRATE 1 MG INJECTION HUMAN FIBRINOGEN No Authorization Required Drug Administration CONCENTRATE 1 MG J7178 INJ HUMAN FIBRINOGEN CONC. NOT. 1 MG INJECTION HUMAN FIBRINOGEN CONCENTRATION 1 MG J7178 INJ CONC. TION VWF 1 I.U. VWF:RCO INJECTION VON WILLEBRAND FACTOR 1 No approval required Drug Administration I.U. VWF:RCO J7180 INJECTABLE FACTOR XIII 1 I.U. INJECTION FACTOR XIII 1 I.U. No Approval Required Drug Administration J7181 INJ FACTOR XIII A- SUBUNIT PO IJ INJECTABLE FACTOR XIII A-SUBUNIT PER No Approval Required Drug Administration IU J7182 INJECTABLE FACTOR VIII PER. :RCO INJ VON WILLEBRAND FACTR COMPLEX No approval required Drug Administration WILATE 1 IE:RCO J7185 INJECTABLE FACTOR VIII PR. TJ. INJECTION FACTOR VIII PR. VIII No approval required Drug administration IU J7187 INJ VONWILLBRND FCT CMPLX HUMN IU INJ VONWILLEBRND FACTOR CMPLX No approval required Drug administration HUMN RISTOCETIN IU J7188 INJECTION FACTOR VIII BY I.U. INJECTION FACTOR VIII PER I.U. No marketing authorization required J7189 FACTOR VIIA 1 MICROGRAM FACTOR VIIA 1 MICROGRAM No marketing authorization required J7190 FACTOR VIII AHF HUMAN PER IU FACTOR VIII ANTIHAEMOPHILIC FACTOR No marketing authorization required J71III PO IHFU C ANTIHAEMOPHILIC FACTOR No marketing authorization required PROCINE PER IE J7192 FACTOR VIII PER IE NOS FACTOR VIII PER IE NOT OTHERWISE APPROVAL REQUIRED ADMINISTRATION COMPLETE CLINICAL EXAMINATION SPECIFIED J7193 FACTOR IX AHF PURIFIED NON-RECMB-IU FACTOR IX NED APRUT A RECOMMENDED SUBMISSION NO. IU J7194 COMPLEX FACTOR IX PO IJ COMPLEX FACTOR IX PO IJ No drug administration approval required J7195 INJECTION FACTOR IX PO IJ NOSE INJ FACTOR IX PO IJ NO OTHER No drug administration approval required STATED J7196 INJ 5 INJ. INJECTION ANTITHROMBIN No approval required Application of the medicine RECOMBINANT 50 I.U. J7197 ANTI-THROMBIN III PER IU ANTI-THROMBIN III PER IU No authorization required Drug administration J7198 ANTI-INHIBITOR PER IU ANTI-INHIBITOR PER IU No authorization required Drug administration J7199 HEMOPHILIA COAGULATION FACTOR FACTOR NOC Drug Nocred 200 INJECTION FACTOR IX RIXUBIS PRI IU INJECTION FACTOR IX RIXUBIS PER IU No approval required drug administration J7201 INJ FACTOR IX FC FUS PROTEIN PER IU INJECTION FAC IX FC FUS PROTEIN No approval required drug administration ALPROLIX 1 I.U. J7202 INJ FAC IX AB FUS PRT IDELVN 1 I.U. INJECTION FAC IX ALBUMIN FUS PRT No drug administration approval required IDELVION 1 I.U. J7203 INJ FACTOR IX GLYCOPEGYLYRATED 1 IU INJECTION FACTOR IX No approval required Drug administration GLYCOPEGYLYLATED 1 IU J7205 INJ FACTOR VIII FC FUS PROTEIN IU INJECTION FACTOR VIII FC FUSION No approval required I J7205 INJ FACTOR VIII TED 1 I.U. INJECTABLE FACTOR VIII PEGYLATE 1 No approval required Drug administration I.U. J7208 INJ FACTOR VIII PEGYLATED-AUCL 1 IU INJECTABLE FACTOR VIII PEGYLATED- No approval required AUCL 1 IU J7209 INJECTABLE FACTOR VIII 1 I.U. INJECTION FACTOR VIII 1 I.U. No approval required Drug administration J7210 INJ FACTOR VIII AFSTYLA 1 I.U. INJECTION FACTOR VIII AFFTYLA 1 I.U. Approval Required Drug Administration Full Clinical Review J7211 INJ FACTOR VIII KOVALTRY 1 I.U. INJECTION FACTOR VIII KOVALTRY 1 I.U. Approval Required Drug Administration Full Clinical Review J7296 LNG-RELEASING IU COC SYS 19.5 MG LEVONORGESTREL-RELEASING IU COC No Approval Required SYS 19.5 MG J7301 LNG-RLS INTRAUTERS COC SYS 13.5 INTRAUTERS COC SYS 13.5 INTRAUTERS COC SYS 13 .5 INTRAURMG LEVINERMG 1 3.5 MG J7308 AMINOLEVULINIC ACID HCL TOP 20% 1 U AMINOLEVULINIC ACID HCL TOP ADMN No authorization required Drug administration 20% 1 U DOSAGE J7309 METHYL AMINOLEVULINATE TOP 16.8% 1G METHYL AMINOLEVULINATE MAL TOP Not required authorization Drug administration 163 G.08 16.8% ADMIN 16.8% ADMIN 163 G. 5 MG LONG-ACTING IMPLANT GANCICLOVIR 4.5 MG LONG-ACTING No authorization required Drug use IMPLANT J7311 INJ FA INTRAVTRL IMPL RTSRT 0.01 MG INJECTION FA INTRAVITREAL IMPL Authorization Required Drug Use Full Clinical Review RECITED 0.01 INTRA DJ7C MG TION DEXAMETHASONE Authorization Drug Use Required Full Clinical Review INTRAVITREAL IMPL 0.1 MG J7313 INJ FA INTRAVTRL IMPL ILUVN 0.01 MG INJECTION FA INTRAVITREAL IMPL Authorization Required Drug Use Full Clinical Review ILUVIEN 0.01 MG J7314 INJECT FA INTRAVITREAL IMPL. 0 IMPLVI. 01 Approval required Drug administration Full clinical review MG J7315 MITOMYCIN OPTHALMIC 0 2 MG MITOMYCIN OPTHALMIC 0. 2 MG No approval required Drug administration J7316 INJECTION OCRIPLASMIN 0.125 MG INJECTION OCRIPLASMIN 0.125 MG Approval required Drug administration Full clinical review

162

J7318 HYALN/DERIV DUROLANE IA INJ 1 MG HYALURONAN/DERIVAT DUROLANE Authorization Required Drug Administration Full Clinical Review FOR IA INJ 1 MG J7320 HYALN/DERIV GENVISC 850 IA INJ 1 MGVISC HYALURONAN 80GEN Full Drug Intake Required/HYALURON 8 0GEN Authorization Review IA INJ 1 MG J7321 HYAL HYALGN SUPARTZ/VSCO-3 IA INJ-D HYAL/DERIV HYALGAN SUPARTZ/VISCO- Approval Required Drug Administration Full Clinical Review 3 IA INJ DOSING J7322 HYALURONAN/DRIV HYMOVISIA REQUEST HYMOVISIA SUBMISSION NO. Administration Full Clinical Review INJ 1 MG J7323 HYALURONAN/EUFLEXXA DERIVATIVE IA INJ PD HYALURONAN/EUFLEXXA DERIVATIVE IA Approval Required Drug Administration Full Clinical Review INJ PER DOSE J7324 HYALURONAN/DRIV ORTHOVISC. HYALURONAN/DRIVE ORTHOVISC. red Drug Administration Full Clinical Review PER DOSE J7325 HYALURONAN/DERIV SYNVISC INJ 1 MG HYALURONAN/DERIV SYNVISC/SYNVISC- Approval required Drug Administration Full Clinical Review ONE IA INJ 1 MG J7326 HYAL/DERIV GEL-1 INTRA-ARTIVAL GEL-1 INTRA- ARTIVAL INJUREL-DINOS-TRA - Approval Required Drug Administration Full Clinical Review ARTIC INJ PER DOSE J7327 HYLAN/DERV MONOVISC IA INJ PER DOSE HYALURONAN/DERIVATIVE MONOVISC Approval Required Drug Administration Full Clinical Review IA INJ PER DOSE J7328 HYYAL-3 DERIVAT GELSURY. GELSYN-3 Authorization Required Drug Administration Full Clinical Review FOR IA INJ 0.1 MG J7329 HYALN/DERIV TRIVISC FOR IA INJ 1 MG HYALURONAN/DERIVATIVE TRIVISC FOR Authorization Required Drug Administration Full Clinical Review IA INJ 1 MG 1 DERIV MG J7330 CHULCY CLUG AUTO AUTO. Drug Administration Requested Full Clinical Review CHONDROCYTER IMPLANT J7331 HYAL/DERIV SYNOJOYNT IA INJ 1 MG HYALURONAN/DERIVAT SYNOJOYNT Authorization Full Clinical Review Required IA INJ 1 MG J7332 HYAL/DERIV INJURONIA 1 TRILURONIA TRILURONIA Author Full Clinical Review Required IN J 1 MG J7333 HYALURONAN/DERIV DERIVAT VISCO -3 IA Approval Required Drug Administration Full Clinical Review HYAL/DERIV VISCO-3 IA INJ PR. DOSE INJ PO DOSAGE J7336 CAPSAICIN 8% TABLETS PO. CRBDPA 5 MG/LVDP 20 MG EN SU 100 ML CARBIDPA 5 MG/LEVODPA 20 MG EN No Approval Required Drug Administration SUSP 100 ML J7342 INJECTION CIPRO OTIC SUSPN 6 MG INJECTION CIPROFLOXACIN NO. LA HCL TOP ADMIN 10% GEL 10 MG AMINOLEVULUNIC ACID HCL TOP ADMIN Approval Required Drug Administration Full Clinical Review 10% GEL 10 MG INJECTION BIMATOPROST Drug Administration Full Clinical Review J7351 INJ BIMATOPROST IC IMPLANT 1 MCG IMPLANT 1 MCG IMPLANT REQUIRED 1 JFUIM 1 0S LIST SIN IMPL 10 MOMETASON FUROAT SINUS Approval required Full clinical review MCG IMPLANT 10 MCG J7500 AZATHIOPRINE ORAL 50 MG AZATHIOPRINE ORAL 50 MG No approval required Drug administration J7501 AZATHIOPRINE PARENTERAL 100 MG AZATHIOPRINE ORAL J7501 AZATHIOPRINE PARENTER AL 100 MG AZATHIOPRINE ORAL D7C requires t PARENTERAL 50 MG INE ORAL 100 MG CYCLOSPORINE ORAL 100 MG No Approval Required Drug Administration J7503 TACROLIMUS EXTENDED RELEASE ORAL 0.25 MG TACROLIMUS EXTENDED RELEASE ORAL No Approval Required Drug Administration 0.25 MG J7504 LYMPHCYT GLOB HORSE PARENTAL LYMPHCYT IMMUN GL REQUIRED OB PAR 2MG GLOBAL ADMINISTRATION 5MG 7505 MUROMONAB -CD3 PARENTERAL 5 MG MUROMONAB-CD3 PARENTERAL 5 MG No approval required Drug administration J7507 TACROLIMUS IMMEDIATE RELEASE ORAL 1 MG TACROLIMUS IMMEDIATE RELEASE No approval required Drug administration ORAL 1 MG J7508 TACROLIMUS EXT. RELEASE ORAL 0.1 MG TACROLIMUS RELEASE DEVELOPMENT 7 MG TACROLIMUS EXTEND1. 09 METHYLPREDNISOLONE ORAL PR. 4 MG METHYLPREDNISOLONE ORAL PO. 4 MG No approval required Drug administration J7510 PREDNISOLON ORAL PR. 5 MG PREDNISOLON ORAL PER 5 MG No approval required drug administration J7511 LYMPHCYT GLOB RABBIT PARENTRAL 25MG LYMPHCYT IMMUN GLOB RABBIT J7511 LYMPHCYT GLOB PARENTRAL 25MG IMMEDIATE RLSE/DELAYED RLSE ORAL 1 MG PREDNISONE IMMEDIATE No approval required drug administration RLSE/DELAYED RL SE ORAL 1 MG J7513 DACLIZUMAB PARENTERAL 25 MG DACLIZUM B PARENTERAL 25 MG No authorization required Drug administration J7515 CYCLOSPORINE ORAL 25 CYCLOSPORIN ORAL 25 Administration J7516 CYCLOSPORINE PARENTERAL 250 MG CYCLOSPORINE PARENTERAL 250 MG No authorization required Drug administration J7517 MYCOPHENOLATE MOFETIL ORAL 25 0 MG M YCOPHENOLATE MOFETIL ORAL 250 Not required approval Drug administration MG J 7518 MYCOPHENOLIC ACID ORAL 180 MG 8 MYCOPHEN 5 Submission 20 SIROLIMUS ORAL 1 MG SIROLIMUS ORAL 1 MG No authorization required Drug administration J7525 TACROLIMUS PARENTERAL 5 MG TACROLIMUS PARENTERAL 5 MG No authorization required Drug administration J7527 EVEROLIMUS ORAL 0, 25 MG EVEROLIMUS ORAL 0. 25 MG no Approval required Administration of the drug J7527 EVEROLIMUS ORAL 0.25 MG EVEROLIMUS ORAL 0.25 MG No approval required Administration of the drug J7527 EVEROLIMUS ORAL. UG NOT No Authorization Required Drug Administration OR CLASSIFIED J7604 ACETYLCYSTEIN AND SOL CP PROD UD P G ACETYLCYSTEIN INHAL SOL COMP No Authorization Required Drug Administration PROD UNIT DOSE P G J7605 ARFORMOTEROL AND SOL NONCOMP UD 15 ARFORMOTEROL INHAL SOL NONCOMP No Authorization Required Drug Administration J 7605 UNIT 6 HAL U D 20 FORMOTEROL FUMARATE INHAL SOL U No authorization required drug administration MCG DOSISFORM 20 MCG J7607 LEVALBUTERAL INHAL CP DME 0.5 MG LEVALBUTEROL INHAL CP PROD THRU No authorization required drug administration DME CONC 0.5 MG J7608 ACETYLCONCYSTEIN I SLCOLPERCYSTEIN I STEIN I SOLCPYSTEIN I Medicine does not require approval administration UNIT BOX PER G J7609 ALBUTEROL INHAL CP THRU DME 1 MG ALBUTEROL INHAL CP PROD THRU DME No approval is required Administration of medicine UNIT DOSE 1 MG J7610 ALBUTEROL INHAL ADMIN THRU DME ALBUTEROL INHAL INHAL SOL ADMIN 1 CONT. 1 ALBUTEROL INHAL NON-CP CONC 1 MG ALBUTEROL INHAL NON-CP THRU DME No Authorization Required Drug Administration CONC FORM 1 MG J7612 LEVALBUTROL INHL NON-CP CONC 0.5 MG LEVALBUTEROL INHAL NON-CP THRU No Authorization Required 7015 Drug Administration INHAL. NON-CP U DOSE 1 MG ALBUTEROL INHAL NON-CP PROD THRU No Approval Required Drug Administration DME U DOSE 1 MG J7614 LEVALBUTEROL INHAL NON-CP U 0.5 MG LEVALBUTEROL INHAL NON-CP THRU No Approval Required Drug Administration J0ME U 5 MG . DME unit levalbuterol 0.5 mg levalbuterol inhal sol sol dme no approval required medication administration unit 0.5 mg j7620 albuterol for 2.5 mg IPT for 0.5 mg albuterol for 2.5 mg 2.5 mg 2.5 mg and auth Bretropium 2.5 mg 2.5 mg. OMETAZONE INHAL CP UNIT PO BECLOMETHASOME INHAL CP PROD No approval required Drug administration MG UNIT DOSAGE PO. MG J7624 CONTENT BETAMETHAZONE CP UNIT. MG BETAMETHASONE INHAL CP PROD DME No drug administration authorization required UNIT DOSAGE PR. MG J7626 INHALATION BUDESON INHALATION BUDESON. ON-CP SINGLE DOSAGE No approval required Drug use UP TO 0.5 MG

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J7627 BUDESONIDE INHAL CP UNIT FOR 0.5 MG BUDESONIDE INHAL CP PROD UNIT No Authorization Required Drug Administration DOSAGE UP TO 0.5 MG J7628 BITOLTEROL MESYLATE INHAL CP CONC MG BITOLTEROL MESYLATE INHAL CP RELEASE J7628 BITOLTEROL MESYLATE ADMINISTRATION NO. OL MESYLAT INHAL CP U MG BITOLTEROL MESYLAT INHAL CP UNIT No approval required Application of the drug DOSAGE PR. MG J7631 CROMOLYN NA I SOL NONCP UD P 10 MG CROMOLYN SODIUM INHALATION SOL No authorization required Drug administration NONCP UD P 10 MGOLYN 0 MGOLYN 0 INHAL SOL COMP No authorization required drug administration PROD UD 10 MG J7633 BUDESONIDE INHAL NON-CP CNC 0.25 MG BUDESON IDE INHAL NON-CP CONC No approval required Drug administration SCHEDULE PR. uth required drug Administration DME CONC. 0.25 MG J7635 ATROPINE CONTENT CP CONC. FORM PR. MG ATROPIN INHAL SOL COMP PROD No approval required Drug administration CONC FORM PR. MG J7636 ATROPINE CONTENT CP UNIT DOSAGE PO. J7637 DEXAMETHASON INHAL CP CONC PR. DEXAMETHASONE INHAL COMP PROD No Approval Required Drug Administration MG CONC FORM PER MG J7638 DEXAMETHASONE INHAL CP UNIT PER. MG DEXAMETHASONE INHAL COMP PROD No approval required Drug administration UNIT -MG DORNASE ALFA INHAL SOL NONCOMP No approval required Drug administration UNIT DOSAGE PR. MG J7640 FORMOTEROL INHAL CP U DOSE 12 MCG FORMOTEROL INHAL COMP PROD UNIT No Approval Required Drug DOSAGE FORM 12 MCG J7641 COMPLUNISOLIDE INH FLUNISOLIDE No uth Necessary Drug Administration DOSAGE PR. MG J7642 GLYCOPYRROLATE INCLUDED CP CONC. MG GLYCOPYRROLAT INHAL COMP PROD No approval required Drug administration CONC FORM PR. MG J7643 GLYCOPYRROLATE INCLUDED IN THE DOSAGE BY CONTENT OF MG GLYCOPYRROLATE COMP. 644 IPRATROPIUM BROMIDE INHAL NON-CP IN MG IPRATROPIUM BROMIDE INHAL NON-CP No authorization required Drug use U DOSAGE PO. MG J7645 IPRATROPIUM BROMIDE INHAL U PER MG IPRATROPIUM BROMIDE INHAL THRU No approval required Drug Administration DME U DOSAGE PER. HCL INHAL CP PROD THRU No approval required Drug administration DME PER MG J7648 ISOETHARINE HCI INH NON-CP CONC MG ISOETHARINE HCI INHAL NON-CP CONC No approval required Drug administration SHEMA PER MG J7649 ISOETHARINE HCI HCI NON-CP UMG -Comp Unit No Author Required drug dosage form per Mg J7650 isoetherin HCI inhalation U dose per Mg isoetherin HCI inhalation through DME no copyright required unit dose of drug administration per Mg J7657 isoproterenol HCI inhal CP DME mg isoproterenol HCI inhal CP Administration THROUGH DME PO MG J7658 ISOPROTERENOL HCI INH NON-CP CONC MG ISOPROTERENOL HCI INHAL NON-CP No approval required Drug administration CONC FORM PO MG J7659 ISOPROTERENOL HCI INH NON-CP IN MG ISOPROTERENOL HCI DRU INHAL AUT administration required DOSIS PR. MG J7660 ISOPROTERENOL HCI CONTENT UNITS PO. MG ISOPROTERENOL HCI INHAL THRU DME No approval required Drug administration U DOSE PR. MG J7665 MANNITOL ADMINISTERED THROUGH INHALER 5 MANNITOL ADMINISTERED THROUGH MG 7 TO 5 SUBMISSION ON OTHERS Auth. TERENOL SULF INHAL CP 10 MG METAPROTERENOL SULFATE INHAL CP No authorization required Drug use PROD CONC 10 MG J7668 METAPROTERNOL INH NON-CP CONC 10 METAPROTERENOL SULF INHAL NON-CP No authorization required Drug use MG CONC PER 10 MGPROTERENOL J766 CONC. SULF INHAL NOT -CP No approval required drug administration MG UNIT DOSAGE 10 MG J7670 METAPROTERENOL SULFATE INHAL 10 MG METAPROTERENOL SULFATE INHAL No approval required drug administration THROUGH DME PR. 10 MG J7674 METAPROTERENOL SULFATE INHAL INHAL order Drug administration THROUGH NEB PR 1 MG J7676 PENTAMIDINE ISETHIONATE AND SL 300 MG PENTAMIDINE ISETHIONATE AND SOL CP No authorization required Drug administration PROD U D 300 MG J7677 REVEFENACIN I SOL NONCP DME 1 MCG REVE PHENACIN REVEVENACIN REQUIRED NO. BUTALINE SULFATE INH CP CONC MG TERBUTALINE SULFATE INHAL COMP No Approval Required Drug Administration CONC FORM PER MG J7681 TERBUTALINE SULFATE INH COMP U DOSE MG TERBUTALINE SULFATE INHAL COMP No Approval Required Drug Administration UNIT DOSAGE PER. uth Necessary drug administration DOSAGE PO. 300 MG J7683 TRIAMCINOLON CONTENT CP CONC PR. MG TRIAMCINOLON INHAL COMP PROD No approval required Drug administration CONC FORM PR. MG J7684 TRIAMCINOLON CONTENT CP UNIT. MGH COMP PROD J 685 TOBRAMYCIN INHAL CP THRU DME 300 TOBRAMYCIN INHAL CP PROD THRU No authorization required Drug administration MG DME U DOSAGE 300 MG J7686 TREPROSTINIL INHAL UNIT DOSE 1.74 MG TREPROSTINIL INHAL UNIT SOLUTION No authorization required DRUG 1768 6 SUBMISSION NO. ADMINISTERED THROUGH DME NOC INHALATION SOLUTION No Approval Required Administering Drug ADMINISTERED VIA DME J7799 NOC RX NOT INHALED RX ADMINISTERED VIA NOC RX EXCEPT INHALATION RX No Approval Required Administering Drug DME ADMINISTERED VIA DME J7999 COMPOUND DRUG NOC COMPOUND DRUG NOT REQUIRED Drug A8 READY DRUG A8 EMETIC Rectal/Supp Nose Anti -Emetic Medicinal drug does not need administration administration rectal/suppositor nose J8501 APPITENT Oral 5 mg Aprepitant oral 5 mg no approval of administration of medication J8510 Busulfan orally 2 MGUH BUSULFAN Oral 2 mguth Busulfan 5 mg orally 5 mg ORAL 1 50 MG No authorization required Drug administration J8521 CAPECITABINE ORAL 500 MG CAPECITABINE ORAL 500 MG No authorization required Drug administration J8530 CYCLOFOSHAMIDE ORAL 25 MG CYCLOFOSHAMIDE ORAL 25 MG 25 MG Auth. Mg dexamethasone oral 0.25 mg No approval Medical use required J8560 ETOPOSIDE ORAL 50 MG ETOPOSIDE ORAL 50 MG No approval Medical use required J8562 Fludarabine phosphate oral 10 mg Fludarabine phosphate oral 10 mg No approval OTHER SPECIFIC J8600 MELPHALAN ORAL 2 MG MELPHALAN ORAL 2 MG No authorization required for the use of the drug J8610 METHOTREXATE ORAL 2.5 MG METHOTREXATE ORAL 2.5 MG No authorization required for the use of the drug J8650 NABILONE ORAL 1 MG NABILONE ORAL 1 MG No authorization required for the use of the drug

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J8655 NETUPT 300 MG & PALONOST 0.5 MG ORL NETUPITANT 300 MG & no approval required Drug Administration PALONOSETRON 0.5 MG ORAL J8670 ROLLAPITANT ORAL 1 MG ROLLAPITANT ORAL 1 MG0 Drug Administration 5 MG0 0.5 MG ORAL J8670 ROLLAPITANT ORAL 1 MG MOZOLOMIDE O RAL 5 MG No authorization required Drug administration J8705 TOPOTECAN ORAL 0.25 MG TOPOTECAN ORAL 0.25 MG No authorization required Drug administration J8999 PRSC DRUG ORAL CHEMOTHERAPEUTIC NO. OXORUBICIN HCL 10 MG No approval required Drug administration J9015 INJ ALDESLEUKIN PR. FOR SINGLE USE DROP INJECTION BUBBLE ALDESLEUKIN PER. SINGLE Approval required Drug administration Full clinical review USE VIAL J9017 ARSENIC TRIOXIDE INJECTION 1 MG ARSENIC TRIOXIDE INJECTION 1 MG Approval required Drug administration Full clinical review J90AGINAZE INJER0CUINJER0CUINJER0CU ERWINAZE Approval required Drug administration Full clinical review 1000 IU J9020 ASPARAGINA INJECTION 10000 INJECTION UNITS FOR 10000 UNITS Authorization required Drug administration Full clinical review J9022 INJECTION ATEZOLIZUMAB 10 MG INJECTION ATEZOLIZUMAB 10000 UNITS Full AV3MG authorization J9022 INJECTION ATEZOLIZUMAB 10 MG INJECTION ATEZOLIZUMAB 10 10 MG INJECTION AVELUMAB 10 MG authorization required Drug use Full clinical review J9025 INJECTION AZACITIDINE 1 MG INJECTION AZAC ITIDINE 1 MG Authority Drug Administration Required Full Clinical Review J9027 INJECTION CLOFARBINE 1 MG INJECTION CLOFARABINE 1 MG Authorization Required Drug Administration Full Clinical Review J9027 INJECTION CLOFARABINE 1 MG INJECTION CLOFARABINE 1 MG Authorization Required Drug Administration Full Clinical Review INCGALVICAL INCGALVES INCGALVICAL LIVEINSTRAB ALES INCG1030 INSTILATION 1 Authorization Required Full Clinical review MG J9031 BCG PR. INSTALLATION BCG PER INSTALLATION Authorization required Drug administration Full clinical review J9032 INJECTION BELINOSTAT 10 MG INJECTION BELINOSTAT 10 MG Authorization required Drug administration Full clinical review J9033 INJ BENDAMUSTIN BENDAMUSTIN BCLAM TRENDA Full administration 10 MG INJECTION BELINOSTAT 10 MG Clinical review TRENDA 1 MG J9034 INJ BENDAMUSTINE HCL BENDAM 1 mg BENDAM AUNDAM AUSTIN HCL Required administration approval of the drug complete clinical examination of the Bendeka 1 mg J9035 injection Bevacizumab 10 mg injection Bevacizumab 10 mg required approval injenam0361 injerochlinical examination of an injanam0361 injection of the Bendamustine approval. J9039 Injection BlinaTumomab 1 injection BLINA TUMOMAB 1 Approval Required Drug Administration Full Clinical Review MICROGRAM MICROGRAM J9040 INJECTION BLEOMYCIN SULFATE 15 UNITS INJECTION BLEOMYCIN SULFATE J9040 INJECTION INJECTION BLEOMYCIN SULFATE J9040 INJECTION Full Review D4 TION BORTEZOMIB 0.1 MG INJECTION BORTEZOMIB 0.1 MG Appr oval Required Drug Administration Full Clinical review J9042 INJECTION BRENTUXIMAB VEDOTIN 1 MG INJECTION BRENTUXIMAB VEDOTIN 1 authorization required Drug administration Full clinical review MG J9043 INJECTION CABAZITAXEL 1 MG INJECTION CABAZITAXEL 1 MG. MG9. Approval required for the drug C4C. .1 MG INJECTION BORTEZOMIB NOS 0.1 MG Authorization required Drug administration Full clinical review J9045 INJECTION CARBOPLATIN 50 MG INJECTION CARBOPLATIN 50 MG No authorization required Drug administration J9047 INJECTION CARFILZOMIB 1 MG INJECTION CARFILZOMIB 1 MG Authorization required Drug administration INJE C0500 Full clinical review J9047 INJECTION INE 100 MG- authorization required Drug administration Full clinical review J9055 INJECTION CETUXIMAB 10 MG INJECTION CETUXIMAB 10 MG authorization required drug administration Full clinical review J9057 INJECTION COPANLISIB 1 MG INJECTION COPANLISIB 1 MG authorization required drug administration Full clinical review J9057 INJECTION COPANLISIB 1 MG INJECTION COPANLISIB 1 MG approval required drug administration Complete clinical examination J9055 INJECTION COPANLISIB 1 MG PLATINUM POWDER OR No approval required drug administration SOLUTION 10 MG J9065 CLADRIBINE INJECTION PR. 1 MG CLADRIBINE INJECTION PER Approval required 1 MG Drug administration Full clinical review J9070 CYCLOPHOSPHAMIDE 100 MG CYCLOPHOSPHAMIDE 100 MG No approval required 9CYTA Drug administration INJE1 CYTARABINE INJECTION LIPOSOM 10 Approval required Drug administration Full clinical review MG J9100 CYTARABINE INJECTION 100 MG INJECTABLE CYTARABINE 100 MG Required approval Drug Administration Full Clinical Review J9118 INJECTION CALASPARGASE PEGOL-MKNL 10 U INJECTION CALASPARGASE PEGOL- Approval Required J9118 Full CALASPARGASE PEGOL-MKNL -RWLC 1 MG INJECTION CEMIPLIMAB-RWLC 1 MG Approval Required Full Clinical Review J9120 INJECTION DACTINOMYCIN 0.5 MG INJECTION DACTINOMYCIN 0.5 MG Authorization required Full drug administration clinical review J9130 DACARBAZINE 100 MG DACARBAZINE 100 MG authorization required DACTINOMYCIN 0.5 MG authorization Full CJ140MU Drug Administration J9130 DACARBAZINE 100 MG DACARBAZINE 100 MG CTION DARATUMUMAB 10 MG authorization required Drug Administration Full clinical review J9150 INJECTION YES UNORUBICIN 10 MG IN INJECTION DAUNORUBICIN 10 MG Approval required Drug Administration Full Clinical Review J9151 INJ DAUNORUBICIN CITRATE LIP 10 MG INJ DAUNORUBICIN CITRATE Approval required Drug Administration LIPOS JOMG 10 MG 10 MAG 10 MG 100 1000 1 MG DNR & 2.27 MG CA INJECTION LIPOSOMAL 1 MG DNR & Approval Required Drug Administration Full Clinical Application Review 2.27 MG CA J9155 INJECTION DEGARELIX 1 MG INJECTION DEGARELIX 1 MG Approval Required Drug Administration Full Clinical Review J9160 INJ DENILEUKINE DIFTITOX 300 MCG CLAIM INJECTION 300 MCG CLAIM INJECTION 300 MCG CLAIM INJECTION 0 MCG J9165 INJ DIETHYLSTILBESTEROL 250 MG IN INJECTION DIETHYLSTILBESTEROL Drug Authorization Required Administration Full Clinical Review DIPHOSPHAT 250 MG J9171 DOCETAXEL INJECTION 1 MG INJECTION DOCETAXEL 1 MG Authorization Required Drug Administration Full Clinical Review J9173 INJECABTION DOCETAXEL DOCETAXEL 1 MG Approval Required Drug Administration Full clinical review J9175 INJECTION ELLIOTTS' B SOLUTION 1 ML INJECTION ELLIOTTS B SOLUTION 1 ML Approval Required Veterinarian Drug Use Full Clinical Review J9176 INJECTION ELOTUZUMAB 1 MG INJECTION ELOTZUMAB 1 MG Approval Required Drug Use Full Clinical Review J9178 INJECTION INJECTION EPIR 2C 2MG Drug administration required Full Clinical Review J9179 ERIBULIN MESYLATE INJECTION 0.1 MG INJEC TION ERIBULIN MESYLATE 0.1 MG Approval Required Drug Administration Full Clinical Review J9181 ETOPOSIDE INJECTION 10 MG ETOPOSIDE INJECTION 10 MG Approval Required C8BJUDD Full Study J9181 FLUDARABINE PHOSPHATE INJECTION Approval Required Drug Administration Full Clinical review 50 MG J9190 INJECTION FLUOROURACIL 500 MG INJECTION FLUOROURACIL 500 MG No approval required Drug administration J9199 INJ GEMCITABINE HCL INFUGEM 200 MG INJECTION GEMCITABINE HCL INFUGEM REQUIRED Full review CFLCITABINE INFUGEM J200 Clinical review J9200 500 MG INJECTION FLOXURIDINE 500 MG Approval required Drug administration Full clinical examination J9201 INJ GEMCITABINE HCL NOS 200 MG INJECTION GEMCITABINE HCL NOS 200 Approval required Drug administration Full clinical examination MG J9202 GOSERELIN ACETATE IMPLANT 3.6 MG REQUIRED IMPLANTING GOSERELIN ACETATE J920 Completed drug administration 3.6 Drug administration J9202 Drug administration 3.6 NEEDED. UMAB OZOGAMICIN 0.1 MG INJECTION GEMTUZUMAB OZOGAMICIN Drug Administration Approval Required Full Clinical Review 0.1 MG J9204 MOGAMULIZUMAB-KPKC INJECTION 1 MG MOGAMULIZUMAB-KPKC INJECTION 1 Approval Required Full Clinical Review MG J9205 IRINOTECAN INJECTION LIPOSO ME 1 RequiPOSE LIPOSOME 1 R Equipment MG J9206 INJECTION IRINOTECAN 20 MG INJECTION IRINOTECAN 20 MG No authorization required Administer J9207 INJECTION IXABEPILONE 1 MG INJECTION IXABEPILONE 1 MG Authorization required Administer Full clinical review J9208 INJECTION IFOSFAMIDE 1 G INJECTION IFOSFAMIDE 1 G INJECTION IFOSFAMIDE DJE2C permission required 1 G2C permission M9C 0 0 mg INJECTION MEAT 200 MG Authorization Required Full Clinical Review J9210 INJECTION EMAPALUMAB-LZSG 1 MG INJECTION EMAPALUMAB-LZSG 1 MG Authorization Required Full Clinical Review J9211 INJECTION IDARUBICIN HCL 5 MG INJECTION IDARUBICIN HCL 5 MG INJECTION IDARUBICIN HCL JFUL 5 MG INJECTION INJECTION INJECTION AL2MG HCL 5 AL2MG FACON -1 RECOMB 1 MCG INJECTION INTERFERON ALFACON-1 requires authorization drug use Full clinical review RECOMBINANT 1 MCG J9213 INJ INTERFERON ALFA-2A RECOM 3 M U INJECTION INTERFERON ALFA-2A requires authorization drug use Full clinical review RECOMBINANT 3 M U J92 RECOMBINANT 3 M U J92 RECOMBINANT 3 M U J92 INTERFERON ALFA-2B Approval required Drug administration Complete clinical examination RECOMBINANT 1 M U

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J9215 INJ INTERFERON ALFA-N3 250,000 IU INJECTION INTERFERON ALFA-N3 authorization required Drug administration Full clinical review 250,000 IU J9216 INJ INTERFERON GAMMA-1B 3 MILLION U INJECTION INTERFERON GAMMA authorization C1BION GAMMA authorization C1BION GAMMA authorization C1BIN GAMMA 3 M9 1 7 LEUPROLIDE ACETATE 7 .5 MG LEUPROLID ACETATE 7.5 MG No approval required Drug administration J9218 LEUPROLID ACETATE PO 1 MG LEUPROLIDE ACETATE PO 1 MG Approval required Drug administration Full clinical review J9219 LEUPROLID ACETATE IMPLANT 65 MG LEUPROLID ACETATE 5 MG Review J9225 HISTRELIN IMPLANT VANTAS 50 MG HISTRELIN IMPLANT VANTAS 50 MG Authorization required drug use Full clinical review J9226 HISTRELIN IMPL SUPPRELIN LA 50 MG HISTRELIN IMPLANT SUPPRELIN LA 50 authorization required drug use Full clinical review IP28IMMG J92CTION IP28IMMG J92M 1 MG authorization needed Drug use Full clinical review J9229 INJECT INOTUZUMAB OZOGAMICIN 0.1 INJECTION INOTUZUMAB OZ OGAM Medicine Needs Approval ICIN Administration Full Clinical Review MG 0.1 MG J9230 INJECTION MECHLORETHAMINE HCL 10 INJECTION MECHLORETHAMINE HCL 10 INJECTION MECHLORETHAMINE Authorization J9229 Full Clinical Review MG 0.1 MG J9230 INJECTION MECHLORETHAMINE HCL 10 INJECTION MECHLORETHAMINE INJECTION MELPHALAN HCL 5 0 mg INJECTION MELIN INJECTION MELPHALAN Authorization Required Drug Administration Full Clinical Review HCL 50 MG J9250 METHOTREXATE SODIUM 5 MG METHOTREXATE SODIUM 5 MG Authorization Required Drug Clinical Review J9260 METHOTREXATE SODIUM 50 MG METHOTREXATE SODIUM 50 MG Authorization Required Drug Administration INJECINE Full Clinical Review 50 MG LARABINE 50 MG Authorization Required Drug Administration Full Clinical Review Review J9262 INJ OMACETAXIN MEPESUCCINATE .01 MG INJECTION OMACETAXINE Authorization Required Drug Administration Full Clinical Review MEPESUCCINATE 0.01 MG J9263 INJECTION OXALIPLATIN 0.5 MG INJECTION OXALIPLATIN 0.5 MG INJECTION OXALIP JROV ADMINISTRATION J9263 INJECTION OXALIP 5UUT. CLITAXEL PROTBND PARTICLE 1 MG INJECTION PACLITAXEL PROTEINBOUND Approval Required Drug Administration Full Clinical Review PARTICLE 1 MG J9266 INJ PEGASPARGASE SINGLE DOSE CAP INJECTION PEGASPARGASE PR. J9267 INJECTION PACLITAXEL 1 MG INJECTION PACLITAXEL None J9267 INJECTION PACLITAXEL 1 MG INJECTION PACLITAXEL None P8MGIN ADMINISTRATION J12CENT Administration Required 10 MG INJECTION PENTOSTATIN 10 MG Authorization Required Drug Administration Complete Clinical Review J9269 INJECTION TAGRAXOFUSP-ERZS 10 MCG INJECTION TAGRAX OFUSP-ERZS 10 MCG approval required Full Clinical Review J9270 INJECTION PLICAMYCIN 2.5 MG INJECTION PLICAMYCIN Authorization PLICAMYCIN D1270 INJECTION PLICAMYCIN Authorization D1270 INJECTION PLICAMYCIN C.7MG INJECTION PLICAMYCIN C.7MG INJECTION PEMBROLIZUMAB 1 MG INJECTION PEMBROLIZUMAB 1 Approval Required MG Drug Administration Full Clinical Review J9280 INJECTION MITOMYCIN 5 MG INJECTION MITO MYCIN 5 Necessary approval MG Drug Administration Full Clinical Review J9285 INJECTION OLARATUMAB 10 MG INJECTION OLARATUMAB 10 MG authorization required INJEPER 5 MG 5 MG INJECTION MITOXANTRONE HCL PER 5 Authorization required Drug Administration Full Clinical Review MG J9295 INJECTION NECITUMUMAB 1 MG INJECTION NECITUMUMAB 1 Drug approval required MG administration Full Clinical Review J9299 INJECTION NIVOLUMAB 1 MG INJECTION NIVOLUMAB 1 MG9 Authorization INJECTION INJECTION Full Clin10Z Drug Review J9299 POTEBNA INJECTION MG INJECTION OBINUTUSUMAB 10 MG Authorization Required Drug Administration Full Clinical Review J9302 INJECTION OFATUMUMAB 10 MG INJEC TION OFATUMUMAB 10 MG Authorization Required Drug Administration Full Clinical Review J9303 PANITUZUMAB INJECTION 10 MG PANITUZUMAB INJECTION 10 MG9 INJECTION Full Drug Approval C05 JEXECTION 10 MG9 THREAD JEXETRIN SURGERY MG INJECTION PEMETREXED 10 MG Approval Required Drug Administration Full Clinical Review J9306 PERTUZUMAB INJECTION 1 MG PE RTUZUMAB INJECTION 1 MG Approval Required Drug Administration Full Clinical Review review J9307 INJECTION PRALATREXATE 1 MG INJECTION PRALATREXATE 1 MG Authorization required Drug administration J9307 INJECTION PRALATREXATE 1 MG INJECTION PRALATREXATE 1 MG Authorization required Drug administration J9307 Full clinical review 5 UCIRUMAB 5 MG Authorization needed Drug administration Full clinical review J9309 INJ GEMCITABINE HCL N OS 200 MG POLATUZUMAB VEDOTIN INJECTION - Authorization Required Full Clinical Review PIIQ 1 MG J9311 INJ RITUXIMAB 10 MG & HYALURONIDASE INJECTION Authorization RITUXIMAB 10 CRIMGAL REVIEW Full Treatment J9MGAL REVIEW 10 C1MGAL NOTE. 2 INJECTION RITUXIMAB 10 MG INJECTION RITUXIMAB 10 MG Approval Required Drug Administration Full Clinical Review J9313 INJ MOXTUMOMB PASUDOTX-TDFK 0.01 INJECTION MOXETUMOMAB Approval Required Full Clinical Review MG PASUDOTOX-TDFK 0.01 MG J9315 INJECTION ROMIDEPSIN REQUIRED INJECTION 1 MG INJECTION 1 INJECTION DMG 1 ROMIDE C2 INJECTION STREPTOZOCIN 1 G INJECTION STREPTOZOCIN 1 G Authorization required drug administration Complete clinical examination J9325 Inj. T-VEC per 1 m plate form unit Inj Talimogene laherparepvec per Needs approval drug administration Full clinical review 1 m Plate F U J9328 Injection Temozolomide 1 mg Injection Temozolomide 1 Mg Needs approval drug administration Full clinical review J9330 INJECTION TEMSIROLIMUS 1 MG INJECTION TEMSIROLIMUS 1 MG needed authorization of drug use Full clinical review J9340 INJECTION THIOTEPA 15 MG INJECTION THIOTE PA 15 MG approval required drug administration Full clinical review J9340 INJECTION THIOTEPA 15 MG INJECTION THIOTEPA 15 MG authorization required drug administration J9330 INJECTION T50CTION. AN 0.1 MG Drug Administration Required Full Clinical Review J9352 INJECTION TRABECTEDIN 0.1 MG INJECTION TRABECTEDIN 0.1 MG Drug Administration Required Full Clinical Review J9354 INJ ADO-TRASTUZUMAB EMTANSINE 1 MG INJ ADO-TRASTUZUMAB EMTANSINE 1 Required approval for full clinical review of drug use I NJEXUZUMMG J9CMG TRABECTEDIN 1 MG TION TRASTUSUMAB EXCLUDES Required approval Drug administration Full clinical review BIOSIMILAR 10 MG J9356 INJ TRA 10 MG & HYALURONIDASE-OYSK INJECTION TRASTUZUMAB 10 MG and required approval Full clinical review HYALURONIDASE-OYSK J9357 INJ VALRUBICIN INTRAVICIN INTRAVESIKRIG IN TR AVICAL INTRA-SAFE INTERNAL red Drug administration Full clinical review 200 MG J9360 INJECTION VINBLASTINE SULFATE 1 MG INJECTION VINBLASTINE SULFATE 1 MG authorization required Drug administration Full clinical review J9370 VINCRISTINE SULFATE 1 MG VINCRISTINE SULFATE 1 MG authorization required Drug administration Full clinical review J9371 INJ VINCRISTINE SULFATE LIPOS IST approval VINCRISTINE SULFATE D 1LF LIPOSIST Full Clinical Review LIPOSOM 1 MG J9390 INJ VINORELBIN TARTRATE 10 MG INJECTION VINORELBINE TARTRATE 10 Approval Required Drug Administration Full Clinical Review MG J9395 INJECTION FULVESTRAN 25 MG INJECTION FULVESTRANT 25 MG Approval Required INAFJEBERTION Drug Administration INAFJEBERTION J 94CLI-1 INJECTION ZIV-AFLIBERCEPT 1 MG Veterinarian Approval Required Drug Administration Full Clinical Review J9600 INJECTION PORFIMER SODIUM 75 MG INJECTION PORFIMER SODIUM 75 MG Authorization Required Drug Administration Full Clinical Review J9999 NOT ANOTHER CLASS ANTINEOPLSTC NOT ELSE CLASSIFIED Approval Required Medication administration Full clinical examination CLINICAL0 DRUG CLINICAL0 1 STANDARD WHEEL AIR STANDARD Wheelchair authorization DME full clinical examination required K 0002 STANDARD HEMI WHEELCHAIR STANDARD HEMI WHEELCHAIR Authorization DME full clinical examination required K0003 LIGHTWEIGHT WHEELLIGHT WHEELCHAIR Approval DME full clinical examination required K0004 HIGH STRENGTH LENGTH Approval LIGHTWEIGHT WGHTRHDENGTH Full clinical review WHEELCHAIR K000 5 ULTRALIGHT WHEELCHAIR ULTRALIGHT WHEELCHAIR Approval required DME Full Clinical review K0006 HEAVY WHEELCHAIR Approval required DME HEAVY WHEELCHAIR Full clinical review K0007 EXTRA HEAVY WHEELCHAIR Approval required EXTRA HEAVY WHEELCHAIR DME Full Clinical K0007 AL WHEELCHAIR/BASE No authorization required K0009 SECOND MANUAL WHEELCHAIR/BASE SECOND MANUAL WHEELCHAIR/BASE No approval required K0010 STD -WT FRME MOTORIZED/PWR WHEELCHAIR STANDARD WEIGHT FRAME Approval required DME Full Clinical Examination MOTORIZED/MOBILE WHEELCHAIR WHEELCHAIR SILENT/MOTORIZED/MOVED WHEELCHAIR-1 WT FRME MOTORIZED/PWR Authorization Required DME Full Clinical Examination WHEELCHAIR M /PROG CNTRL K0012 LGHTWT PRTBLE MOTORIZED/PWR LIGHTWEIGHT PORTABLE Authorization Required DME Full Clinical Examination WHEELCHAIR MOTORIZED/ELECTRIC WHEELCHAIR K0013 MOTORIZED BASE WHEELCHAIR BOWLED MOTRIZD/PWR

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K0014 Other Motorized/Electric Wheelchair Other Motorized/Electric Wheelchair No Approval Required Basic Wheelchair Basque K0015 Non-Adjustable HT Armrest Removable Non-Adjustable Height No Approval Required EA Armrest For Each K0B0BLE Set Each K0B0BLE Adjust HT Armrest REPL EA K0018 DTACH ADJ HT ARMREST UP PRTN REPLACE EA DATACHBLE ADJUST HT ARMREST UP No authorization required PRTN REPL ONLY EA K0019 ARM CUSHION REPLACEMENT EACH ARM CUSHION REPLACEMENT EACH ONLY No authorization required K0020 FIXED AIR ADJUSTABLE ADJUSTABLE Authorization required PAIR K0037 FLIP FOR HIGH MOUNTING - ABOVE FOOTREST EACH HIGH PLATED FLIP-UP FOOTREST EACH No approval required K0038 BENSEM EACH FEET ROOM EACH No approval required K0039 FEET ROOM H STYLE EACH FEET ROOM H STYLE EACH No approval required ADJUSTER K0040AB. OT BOARD EACH No authorization required K0041 OVERSIZE BASE BOARD EACH BASE BOARD EACH No authorization required K0042 REPLACEMENT STANDARD SIZE BASE BOARD EA ONLY STANDARD SIZE BASE BOARD No authorization required REPLACE EACH ONLY K0043 EXTLOON EXTLO ESTTUBEST EXTTRE ENS ION TUBE No authorization required EA REPLACEMENT ONLY K004 4 Foot Legs UPR Hgr BRKT Replacement EA Foot Posted Top Hanging Brackets No Approval Required Replaced Each Only k0045 Barry Cmpl Collection Replacement Only EA FOOT COMPLEX No Approval Required Replacement Only Each k0046 eGrest EGrest Feel Leg Lift Aging Leg No Approval No Approval Required ONLY BRACKET REPL EA K0050 CLAW ONLY ASSEMBLY REPLACE CLAW REPLACE No approval R0LSGRETS ON EPL. CAM RLS ASSEMBLY FOOTREST/FOOTREST No. Authority Required REPLACE ONLY EACH K0052 SWNGAWAY DOTCHBLE FTRSTS RPL ONLY LOCKABLE DETACHABLE STEEL STEEL No Approval Required E REPL EACH ONLY K0053 RAISED FOOTREST ARTICULATING EA RAISED FOOTREST EquiAT2 1 IN LTWT/ULTRLT TOILET SEAT HT21 IN No Approval Required LTWT / ULTRALTWT RHLSTOL K0065 SPOKE GUARDS FOR EACH SPOKE Each No Approval Required K0069 RW ASM CMPL SOLID T SPKE/MLD RPL EA REAR WHL ASM CMPL SLD TIRES No Approval Required SPKE/MLD REPL ONLY RPNW ASPKE CMPON/EPLD WHL ASM COMP PNEUM TIRES No Approval Oval Required SPKS/ MLD RPL E ONLY K0071 FRT C ASM COMPL PN TIRE REPLACEMENT ONLY E FRONT WHEEL ASSEMBLY COMPLETE PN No approval required TIRE ONLY REPL EA K0072 FRT C ASM CMPL SEMIPN AS FRONT COMPLETE TEMPL. SEMI NEW No Approval Required TIRES ONLY REPL E K0073 WHEEL LOCK EACH WHEEL LOCK EACH No Approval Required K0077 FRT C ASM CMPL SLD TIRE REPLACEMENT ONLY E FRONT WHEEL ASSEMBLY COMPL. SLD No approval required EDRIVE K0 BE ONLY DRIVE BELT FOR ELECTRIC WHEELCHAIR No approval required JUST REPLACEMENT K0105 IV BENCH EACH IV BENCH NO Approval required K0108 TOILET COMPONENT/ACCESSORIES NO. OTHER ACCESSORIES Approval not required K0195 ELEVATING FLOATING BENCHES PAIR OF 4 K5 REQUIRED RAISING READING OTHER PAIR PUMP UNTRPT PARENTRAL WITH INFUSION PUMP CONTINUOUS Approval not required PARENTERAL ADMIN S K0462 TEMP REPL PT EQUIP REPR ANY TYPE TEMP REPL PT EQUIPMENT ER OWNED None authorization required REPR ANY TYPE K05 52 SPL EX N-INS RX INF PMP SYR CRT S- E SPL EXT IN NUT Medicine Cart Supplies Required STERL EA Administration K0553 SPL ALLOW TX CGM1 MO SPL = 1 IN SRVC ALLOW ALLOW TX CGM1 MO SPL = Authorization Required General Medicine - Complete Clinical Examination 1 U OF SERVICE Health & Behavioral Assessment/Intervention DEDICATERIVER DEDICATERIVER SYS RECEIVER INTENDED FOR USE Authorization Required General Medicine - Complete Clinical Examination W/THERAPEUTIC GCM SYS Health & Behavioral Assessment/Intervention K0601 REPL BATTERY SILVER OXIDE 1.5 V EA REPL BATTERY EXT INFUS PUMP SILVER No approval required Supplies for drug administration 5 VOX 2 1,600 REPL BATTERY SILVER OXIDE 3 V EA REPL BATTERY EXT INFUS PUMP SILVER No approval required supplies for drug administration OXIDE 3 V EA K0603 REPL BATTERY PUMP ALKALINE 1.5 V EA REPL BATTERY EXT INFUS PUMPLINE Supplies Auth. PL BATTERY PUMP LITHIUM 3.6 V EA REPL BATTERY EXT INFUS PUMP No approval required consumables for medicine LITHIUM 3.6 VOLT EA Administration K0605 REPL BATTERY PUMP LITHIUM 4.5 V EA REPL BATTERY EXT INFUS PUMP No. 0606 AED w/ INTGR EKG ANALYSIS GARMNT TYPE AUTO EXT DEFIB W/INTGR EKG ANALY authorization required DME Full clinical exam CLOTHES TYPE K0607 REPLACE BATTERY AUTO EXT DEFIB EA REPLACE BATTERY AUTO EXT DEFIB GARMNT No authorization required REPLACE ONLY TYPE K0608 REPL EA K0608 AC INSTRUCTIONS FOR USE W/AUTO No Approval Required EXTERNAL DEFIB EA K0609 REPL ELECTRODE W/AUTO EXT DEFIB EA REPL ELEC W/AUTO EXT DEFIB GARMNT Approval Required DME Full Clinical Exam ONLY TYPE EA K0669 TOILET ACCESS TOILET DK TOILET ACCESS DCC SEAT ACCESS /BACK CUSHION No approval required NO DME PDAC K0672 ADD LOW EXTERNAL ORTHOSIS REPLACE ANY ADD LOW EXTERNAL ORTHOSIS REMV Soft No approval required INTERFACE REPL EA K0730 CNTRL DOSE INHAL RX DELERY CONTENT CONTROLLED K07 SYSTEM CONTROLLED DOSE 3 WR WC 12 - 24 AMP HR LEAD BATTERY EACH PWR WC 12 -24 AMP HR SEALED LEAD No Approval Required ACID BATTERY EA K0738 GAS CONNECTION O2 SYSTEM RNTL;HOM PORTABLE GAS FOR O2 SYSTEM BEARING; DME Approval Required Full Clinical Exam COMPRS HOME COMPRESSOR K0739 REPR/SRVC DME NO O2 PER 15 MIN. REPR/SRVC DME NOT O2 RQR TECH No approval required CMPNT PER 15 MIN. K0743 SX PUMP HOME MDL APUMP CONNECTOR REQUIRED AGAINST AUT. FOR USE ON WOUNDS

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K0744 ABSRB WD DR H MDL PAD 16 SQ IN/MINDER ABSORB WD DR HOM MDL PRTBLE PAD No approval required SZ 16 SQ IN/MINDER K0745 ABS WD DR PAD>16 SQ IN16 No approval required SQ IN48 WND SQ IN PRTBRBOM No approval required PAD SZ > 48 SQ IN K0800 PWR OP VEH GRP 1 STD PT TO 300 LBS PWR OP VEH GRP 1 STD PT WT CAP TO DME approval required Full clinical exam & INCL 300 LBS K0801 PWR1 OP VEH GRP-1 450 LBS PWR OP VEH GRP 1 HEAVY DUTY PT 301 DME Approval Required Full Clinical Exam UP TO 450 LBS K0802 PWR OP VEH GRP 1 HVY PT 451-600 LBS PWR OP VEH GRP 1 VERY HEAVY GRP 1 VERY HEAVY 5 Required Required 1 LBS K0806 PWR OP VEH G RP 2 STD PT Up to 300 lbs pwr ops gret GRP 2 STD PT WT cap for authorization DME COLL required Clinical exam and incled 300 lbs K0807 PWR OP GRP 2 HVY PT 301-4 OP50 LVEHRPY WEED PT 301 FAMILIES DME FULL CLINICAL EXAM OP VEH GRP 2 PT 451 -600 LBS PWR UP VEH GRP 2 VERY HEAVY DUTY DME Approval Required Full Clinical Examination PT 451-600 LBS OPERATTE1 LBS VEHICLE NOT DME Approval Required Full Clinical Examination OR CLASSIFIED K0813 PWR WC GRP 1 SLING SEAT PT TO 300 PWR WC GRP 1 STD PORT SLING SEAT Requires DME Approval Full Clinical Examination PT UP TO 300 LBS K0814 PWR WC0 GRP PWRC 1 STD PORT CAPT CHAIR Requires DME Approval Full Clinical Examination PT UP TO 300 LBS K0815 PWR WC GRP 1 SLING PT UP TO 300 PWR WC GRP 1 STD SLING SEAT PT UP DME Approval Required Full Clinical Examination TO &= 300 LBS K08 GRP CAPT CHAIR PT TO 300 PWR WC GRP 1 STD CAPTAINS CHAIR PT Authorization DME Full Clinical Examination TO &=300 LBS K0820 PWR WC GRP 2 SLING SEAT PT FOR 300 PWR WC GRP 2 STD PORT SLING SEAT Approval Required DME Full Inspection DME &=300 LBS K0821 PWR WC GRP 2 CAPT CHAIR FOR 300 PWR WC GRP 2 STD PORT CAPT CHAIR Authorization Required DME Full Clinical Inspection PT FOR & =300 LBS K0822 PWR WC GRP 2 SLING SEAT PT TO 300 PWR ST WC GRP PT TO Authorization Required DME Full Clinical Examination &=300 LBS K0823 PWR WC GRP 2 CAPT CHAIR PT TO 300 PWR WC GRP 2 STD CAPITANS CHAIR PT Authorization Required DME Full Clinical Examination TO &=300 LBS K0824 PWR 3 WC SE GRP 2 -450 PWR WC GRP 2 HEVY DUTY SLING SEAT DME approval required Full clinical examination PT 301-450 LBS K0825 PWR WC GRP 2 CAPT CHAIR PT 301-450 PWR WC GRP 2 HEVY DUTY CAPT CHAIR Clin DET 4 authorization required 11 0 LBS K0826 PWR WC GRP 2 CROWN SEAT PT 451-600 PWR WC GRP 2 VRY HVY DTY SLNG SEAT authorization required DME Full clinical examination PT 451-600 LB K0827 PWR WC GRP 2 CAPT CHAIR PT 451-600 WCHRY PT 451-600 CAPT CHR Required DME approval Full clinical examination PT 451-600 LBS K0828 PWR WC GRP 2 SLING SEAT PT 601/> PWR WC GRP 2 XTRA HVY DUTY SLING DME approval required Full clinical examination SEAT PT 601LB9 2X K0 CHR PT 601/> > PWR WC GRP 2 XTRA HVY WORK CHAIR DME Approval Required Full Clinical Exam PT 601 LBS/> K0830 PWR WC 2 SEAT STUDENT RAT PT TO 300 PWR WC GRP 2 STD SEAT STUDENT RAT Pending Authorization Clinical Exam DME &= 300 LBS K0831 PWR WC 2 SEAT ELEV CAPT PT TO 300 PWR WC GRP 2 STD SEAT EVIS CAP CHR Approval Required DME Full Clinical Examination PT TO 300 LB K0835 PWR WC GRP 2 1 PWR SLING PT TO 3RP100 PWR SLING SEAT Approval Required DME Full Clinical Examination Review PT TO 300 LBS K0836 PWR WC 2 1 PWR CAPT CHAIR PT UP TO 300 PWR WC GRP 2 STD 1 PWR CAPT CHAIR DME approval required Full clinical examination PT UP TO 300 LBS 2 WC GWR PWR SLING PT 301-450 PWR WC GRP 2 HVY 1 PWR Sling SITUIZATION CLINICAL EXAMINATION REQUIRED PT 301-450 -450 LBS K0838 PWR WC 2 1 PWR CAPT CHR PT 301-450 PWR WC GRP 2 REQUIRED CH1 Author PWR WC GRP 2 required CH1 Clinical Examination PT 301-450 LBS K0839 PWR WC 2 1 PWR SLNG SEAT PT 451-600 PWR WC GRP 2 VRY HVY 1 PWR SLING DME approval required Full clinical examination PT 451-600 LBS K0840 PWR 0C 1 PWR WC 1 > PWR WC GRP 2 XTRA HVY 1 PWR SLING DME approval required Full clinical examination PT 601 LBS/ > K0841 PWR WC GRP 2 MX PWR SLING PT UP TO 300 PWR WC GRP 2 MX PWR SLING SEAT PT DME Approval Required & Full Clinical 300 LBS K0842 PWR WC 2 MX PWR CAPT CHR PT UP TO 300 PWR WC GRP 2 STD MX PWR CAPT CHR -DME Authorization Required Full Clinical examination PT TO &=300 LBS K0843 PWR WC 2 MX PWR SLING PT 301-4 MX PWR SLNG Authorization required DME Full clinical examination SEAT PT 301-450 LBS K0848 PWR WC GRP 3 SLING SEAT PT TO & =300 PWR WC GRP 3 STD SLING SEAT PT ON & Approval Required DME Full Clinical Examination = 300 LBS K0C 3 CAPT CHAIR PT ON &=300 PWR WC GRP 3 STD CAPTAIN CHAIR PT Approval Required DME Full Clinical Examination TO & = 300 lbs K0850 PWR WC GRP 3 Sling Seat PT 301-450 PWR WC GRP Authorization 3 HVY duty required seatme Clinical examination PT 301-450 lbs K0851 PWR WC GRP 3 CAPT PT 301-450 PWR WC GRP 3 HVY TEN CHAIR Approval required DME Full clinical examination PT 301-450 LBS K0852 PWR SLING WC SE GRP-6 PWR0 GRP 3 V HVY DUTY SLING SEAT Requires DME Approval Full Clinical Examination PT 451-600 LB K0853 PWR WC GRP 3 CAPT CHAIR PT 451-600 PWR WC GRP 3 HVY DUTY CAPT CHAIR Requires DME Approval Full KWR-4BS5 K0853 650 KWR-650 WC GRP 3 SLING SEAT PT 601 LB/> PWR WC GRP 3 XTRA HVY DTY SLNG DME Approval Required Full Clinical Examination SEAT PT 601 LBS/> K0855 PWR WC GRP 3 CAPT CHAIR PT 601 LB/> PWRX WCHV GRP 3 WT Approval Required DME Full Clinical Examination CAP 601 LB/> K0856 PWR WC 3 1 PWR SLING SEAT PT TO 300 PWR WC GRP 3 STD 1 PWR SLING SEAT Approval Required DME Full Clinical Examination PT TO &=300 LB K0857 PWR CAPT CHAIR PT TO 300 PWR WC GRP 3 STD 1 PWR CAPT CHAIR Approval required DME Full clinical examination PT TO &=300 LB K0858 PWR WC 3 1 PWR SLNG SEAT PT 301-450 PWR REQUIRED WC author GRP 3 HD 1 PWR SLING Full clinical examination PT 301-450 450 LBS K0859 PWR WC 3 1 CAP CHAIR PT 301-450 PWR WC GRP 3 HD 1 PWR CAPT CHAIR DME approval required Full clinical examination PT 301-450 LBS K0860 PWR 1 WC 4 SLNG 600 PWR WC GRP 3 V HD 1 PWR SLING SEAT DME Approval Required Full Clinical Review PT 451-600 LB K0861 PWR WC 3 MX PWR SLNG SEAT PT TO 300 PWR WC GRP 3 STD MX PWR SLNG SEAT Authorization DME Full Clinical License Review &=300 LB K0862 PWR WC 3 MX PWR SLNG SEAT PT TO 300 PWR SLNG SEAT -450 PWR WC GRP 3 HD MX PWR SLING SEAT Approval required DME Full Clinical Examination PT 301-450 LBS K0863 PWR WC 3 MX PWR SLING PT 4 PWR1-6C0RP05 PWR V HD MX PWR SLNG - Authorization required DME Full Clinical Examination SEAT PT 451 -600 LB K0864 PWR WC 3 MX PWR SLNG SEAT PT 601/> PWR WC GRP 3 XTR HD MX PWR SLNG authorization required DME Full Clinical Examination/>60 SEAT PT

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K0868 PWR WC GRP 4 BELTED PT TO &=300 PWR WC GRP 4 STD SLING SEAT PT TO & DME Approval Required Full Clinical Exam = 300 LBS K0869 PWR WC GRP 4 CAPT CHAIR PT TO &=300 PWR WC GRPAIN CHAIR PT DME Approval Required Full Clinical Exam TO & = 300 LBS K0870 PWR WC GRP 4 SLING SEAT PT 301-450 PWR WC GRP 4 HVY DUTY SLING SEAT DME Approval Required Full Clinical Exam PT 301-450 PWR SLING SECPT 451-600 PWR WC GRP 4 HVY DUTY SLING SEAT Authorization required for SLING SEAT DME Full clinical examination PT 451-600 LB K0877 PWR WC 4 1 PWR SLING SEAT PT TO 300 PWR WC GRP 4 STD 1 PWR Authorization required for SLING SEAT TO &=300 LB K0878 PWR WC 4 1 PWR CAPT CHAIR PT TO 300 PWR WC GRP 4 STD 1 PWR CAPT CHAIR DME approval required Full clinical PT TO &=300 LB K0879 PWR WC 4 1 PWR SLNG SEAT 4 PWR01-4 PT5 WC GRP 4 HD 1 PWR SLING SEAT DME approval required Full clinical review PT 301-450 LBS K0880 PWR WC 4 1 PWR SLNG SEAT PT 451-600 PWR WC GRP 4 V HD 1 PWR SLING SEAT Authorization required DME Full C451 Review 600 LB K0884 PWR WC 4 MX PWR SLNG SEAT PT DO 300 PWR WC GRP 4 STD MX PWR SLNG SEAT Authorization Required DME Full Clinical Examination PT TO &=300 LB K0885 PWR WC 4 MX PWR CAP GRP PT 4 STWR PT MX PWR CAPT CHR Authorization Required DME Full Clinical Examination PT TO &=300 LBS K0886 PWR WC 4 MX PWR SLING PT 301-450 PWR WC GRP 4 HD MX PWR SLING SEAT Approval required DME Full clinical examination PT 301-4890 L 5 PED 1 PWR SLING PT TO 125 PWR WC GRP 5 PED 1 PWR SLING SEAT Approval required DME Full clinical examination PT TO &=125 LB K0891 PWR WC 5 PED MX PWR SLING PT TO 125 PWR WC GRP 5 PED SEATWR DME Approval Required Full Clinical Exam PT TO &=125 LB K0898 ELECTRIC WHEELCHAIR NOC ELECTRIC WHEELCHAIR NO SECONDARY Authorization Required DME Full Clinical review CLASSIFIED K 0899 PWR MOBILTY DEVC NOT CODED DME PWR MOBILTY DVC DVC Fully CODED NOPDAC DME Review author CRIT K0900 CUSTOM DME EXCEPT CUSTOM DME EXCEPT No authorization required DRIVER'S CHAIR DRIVER'S CHAIR K1001 ELEC POSIT OBS INC SLEEP APNEA TX SENS ELECTRONIC POSITION OBSTACLE IVE SLEEP Required authorization SPNLESS 2 ANY T CES SYS INCLUDES ALL RECORDS & Full Clinical Exam Required ACCESSORIES ANY TYPE K1003 WHIRLPOOL BAR GOES IN PORTABLE PORTABLE TANK PORTABLE Authorization Required Full Clinical Exam K1004 LOW FREQUENCY U/S DIA TX DVC HOME USE LWIA FRQ USL Authorization LWIA FRQ US Clinical Review CMPNT & ACCESS K1005 DISP COLL & STRG BAG BM ANY SZ T EA SINGLE COLL & STRG BAG BM ANY No Approval Required SIZE ANY T EA L0112 CRANIL CERV ORTHOS CONGN TORTICOLLI CRANIL CERTY ORTOS Authorization Full Authorization CERME ORTHOS. Om L0113 CRANIL CERV ORTHOS TOTICOLLI PRFB CRANIAL CERVL ORTHOSE TOTICOLLIS NO CHANCING NOT APPLICATION PREFAB L0120 CERVICAL FLEX INDEPENDENT PRAFAB CERVICA FLAXIBALLY NEED APPEPPLY NO APPLICATION PREFAB-LLX COFLV3 R Form PT CERV flexibly Termoplastic Termopy Vical Semi -circular adjustable cervical SEMI-RIGID ADJUSTABLE No approval required L0150 CERV SEMI-RIGID ADJUSTABLE CHIN CUP CERVICAL SEMI-RIGID ADJUSTABLE No approval required CAST CHIN CUP L0160 CERV SEMI-RIGID OCCIP/MALE PREF REQUIRED OCCIP/MALE PREFAB. /MALE ASSEMBLY L0170 CERV COLLAR MOLDED PATIENT MODEL CERVICAL COLLAR PATIENT MOLDED CERVICAL COLLAR Required DME Authorization Full Clinical Examination MODEL L0172 CERVICAL COLLAR SEMI-RIGID FOAM PREFAB CERVICAL COLLAR SEMI-RIGID FOAM No approval required P017 SE 2-PIN FOAM XT PREFAB CERVICAL COLLAR SEMI-RIGID FOAM Not required approval THOR EXT PREFAB L0180 CERV MX POST COLLR SUPPS ADJ CERV MX POST COLLAR OCCIP/MAN No approval required BRACKETS ADJUSTBL L0190 CERV MX POST COLLR ADJ CERV OCC BARS CERME CERME View complete SUPP ADJ CERV BARS L0200 CERV COL LR ADJ CERV BARS&THOR EXT CERV MX POST COLLR OCCIP/MAN ADJ No Approval Required CERV&THOR EXT L0220 THORACIC RIB BELT TRUSTOM FABRICATED ACRUSTOM L4SOFLK SUPP UP THOR PREFAB TLSO FLEXIBLE TRUNK SUPP UP THOR No Approval Required REGION PREFAB L0452 TLSO FLEX TRUNK SUPP UP THOR CUSTOM TLSO FLEXIBLE TRUNK SUPP UP THOR No Authorization Required CUSTOM REGION L0454 TLSO FLEX SC JUNC T-9 PRFAB JUSTOM TO TEF OM FIT L0455 TLSO FLEX SC JUNC TO T-9 ASSEMBLY TLSO FLEXIBLE SC JUNCT TO T-9 ASSEMBLY No Authorization Required OFF THE SHELF L0456 TLSO FLEX SC SCAP SPN PRFAB CUSTOM TLSO FLEXIBLE SC JUNCT SCAP SPINEAB Full Approval CTL SCAP RYGGAB Required CTL5 CFLX JUNC TRM INF SCAP SPINE TLSO FLX SC JUNC TERM INF TO SCAP Authorization Required DME Full Clinical Review SPINE PREFAB L0458 TLSO TRIPLANR 2 SHELL ANT-XIP HOID TLSO TRIPLANR 2 RIGD SHELL ANT TO Approval Required PR-REFAB L0458 TLSO TRIPLANR 2 SHELL ANT-XIPHOID TLSO TRIPLANR 2 RIGD SHELL ANT TO Approval Required DME Full L2SOID 0 SHALL MYRE- STERNL TLSO TRIPLANAR 2 SHELL ANT TO Authorization Required DME Clinical Examination AFT Full PRFAB L0462 TLSO TRIPLANR 3 SHELL ANT-STERNL TLSO TRIPLANAR 3 SHELL ANT TO Approval Required DME Full Clinical Review STERNL NOTCH PRFAB L4SO NOTCH PRFAB L4SO NOTCH 4TL0RL LANAR 4 SHELL ANT TIL Approval Required DME Full Clinical Review STERNL NOTCH PRFAB L046 6 TLSO SAGITTAL CONTROL PREFAB CUSTOM TLSO SAGITTAL CONTROL RIGID FRME No approval required ASSEMBLY CUSTOM CUSTOM L0467 TLSO SAGITTAL CONTROL RIGID SAGITTAL CONTROL RIGID PREF SHELF L0468 TLSO SAGITTAL-CORONAL ASSEMBLY TLSO SAGITTAL-CORONAL CONTROL No approval required CUSTOM PREFAB CUSTOM CUSTOM L0469 TLSO SAG ITTAL-CORONAL CONTROL A MOUNTING TLSO SAGITTAL- CORONAL CONTROL No approval required RIGID FRAME PREFAB L0470 TLSO-CORONAL CONTROL PREFAB TLSO SAGITTAL-CORONAL CONTROL DME approval required Full clinical review APRON W/STRAP PRFAB L0472 TLSO TRIPLANAR HYPREXT RIGD FRME TLSO TRIPLANAR HYPREXT RIGD No approval required ANT&LA T FRME PRFAB L0480 TLSO TRIPLANR 1 PC WITHOUT INTERFACE CSTM TLSO TRIPLANAR CRIPLANAR REQUIRED INTERFME 1 PC. 482 TLSO TRIPLANAR 1 PC W /INTERFCE CSTM TLSO TRIPLANAR 1 PC W/INTERFCE DME Approval Required Full Clinical Examination LINER CSTM

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L0484 TLSO TRIPLANR 2 PC NO INTERFACE CSTM TLSO TRIPLANAR 2 PARTS U/O INTERFCE Authorization Required DME Full Clinical Review LINER CSTM L0486 TLSO TRIPLANR 2 PC W/INTERFCE CSTM TLSO TRIPLANAR 2 PARTS TM CINTERFME LINE Authorization W/4 PARTS REQUIRED Review L8 8 TLSO TRIPLANR 1 PCS W/INTERFCE PRFAB TLSO TRIPLANAR 1 PCS W/INTERFCE Authorization Required DME Full Clinical Review LINER PRFAB L0490 TLSO SAGIT-CORONAL ENHANCEMENT PRFAB TLSO SAGIT-CORONAL W/OVRLAP W/OVRLAP REQUIRED No approval 29 RTLID REQUIRED FOR PLANT IC SHELLS PREFA B TLSO TWO RIGID PLASTIC SHELLS Requires DME authorization Full clinical examination ASSEMBLY L0492 TLSO 3 RIGID PLASTIC SHELLS ASSEMBLY TLSO THREE RIGID PLASTIC SHELLS ASSEMBLY No approval required ASSEMBLY L0621 SACROILIS FLACTROFLACHO SACROILIS FLACROIL IBLE No approval required ASSEMBLY L0622 SACROILIC ORTHOSIS FLEXIBLE CUSTOM SACROIL STRENGTH ORTHOSIS FLEXIBLE No approval required CUSTOMIZED L0623 SACROILIAL ORTHOSIS RIGID MOUNTING SACROILIAL ORTHOSIS RIGID/Semi- No approval required RIGID PANL PREFAB L0624 SACROILIAL ORTHOSIS RIGID SACROILIAL ORTHOSIS CUSTOM not required C6 AUT 5 LUMBAR ORTHOSIS FLEXIBLE MOUNTING LUMBAR ORTHOSIS FLEXIBLE No approval required MOUNTING SHELF L 0626 LUMB ORTHOS RIGID POST PREFAB CUSTM LUMB ORTHOS SAGIT CNTRL RIGID No authorization required POST PANL PREFAB L0627 LUMBAR ORTHOSIS RIGD A&P PNL PRFAB LUMBAR ORTHOSIS SAGIT CNTRL RIGID TM L0P required TM AUTSO PFLIBEL Auth LE PREFAB HYLDEN LUMBAR-SACRAL ORTHOSIS FLEXIBLE Item no. Approval required PREFAB HAIRED L0629 LSO FLEXIBLE CUSTOM LUMBAR-SACRAL ORTHOSIS FLEXIBLE No approval required CUSTOM FAB L0630 LSO SAGIT CONTROLLER RIGID CAST ASSEMBLY LUMBAR-SACRAL ORTHOSIS STRAPLESS LEAF SAGIT SAGIT SAGIT SAGIT IT CNTRL RIGID POST CUSTOM LUMBAR -SACRAL ORTHOSIS SAGIT CNTRL DME authorization required Full Clinical Review STIV A&P PREFAB L0632 LSO SAGIT CNTRL STIV A&P CUSTOM LUMB-SACRAL ORTHOS SAGIT CNTRL No approval required STIV A&P CUSTOM L0633 LSO SAG-COR CNTRL CNTRL CNTRL RL No approval required RIGD POST PREFAB L0634 LSO SAG-COR CNTRL STIV P OST CUSTOM LUMB -SAC ORTHOS SAGIT-COR CNTRL No approval required RIGD POST CUSTOM L0635 LSO SAG-COR CNTRL LUMB FLEX PREFAB LSO SAGIT-COR CNTRL Full View CAGITTAL-COFLIG PREFABET PREFABET PREFLIG CORRED EFAB L0636 LSO SAG-COR CNL EFAB L0638 LSO S AG- COR COR CNTRL RIGID A&P CUSTOM LUMB-SACRAL ORTHOS SAG-COR CNTRL Approval Required DME Full Clinical Review RIGD A&P CUSTOM L0639 LSO SAG-COR CNTRL RIGD SHELL PREFAB LUMB-SAG-CORTHO Full Review LUMB-SAC-CORTHO CORTHO SHELL PREFAB L0640 LSO SAG - COR CNTRL RIGD SHELL CUSTOM LSO SAGITTAL-CORONAL RIGID Approval Required DME Full Clinical Review SHELL/PANEL CUSTM FAB L0641 LUMB ORTHOS SAGIT CTRL RIGD PST PNL LUMBIT PREFTAL A PHOSTL LUMBIT PREF. AB L0642 LUMB ORTHOS SAGITAL CTRL ANT POST PNL LUMB ORTHOS SAGITTAL CTRL RIGD No approval required ANT POST PANELS L0643 LSO SAGITTAL CNTRL RIGID POST PANEL LSO SAGITTAL CONTROL RIGID STOP No approval required PANELS PREFAB L0648 PRLOST POST SAGITANT LSO SAGITTAL CNTRL POST authorization required DME full Clinical Overview of PREFAB PANELS L0649 LSO SAGITAL-CORNL CNTRL RIGD PST PANL LSO SAGITTAL-CORONL CONTROL RIGD No approval required POST PANELS L0650 LSO SAGIT-CORNL CNTRL ANT PST PANL LSO SAGITTAL-CORONL CONTROL RIGD LSO SAGITTAL-CORONAL CONTROL RIGD P065 1 LSO SAGIT - CORN Clinical Required CNTRL RIGD SHLL/PNL LSO SAGITTAL-CORONAL CONTROL RIGD Authorization Required DME Full Clinical Review SHELLS/PANELS L0700 CTLSO ANT-POST-LAT CNTRL FORM PT CTLSO ANT-POSTERIOR-LAT MOLD CONTROL Full Review Clin0 L7 MODEL Authorization Required CTLSO-MOLD PT INTERFACE MATERIAL CTLSO ANT-POST-LAT CNTRL MOLD PT- Authorization Required DME Full Clinical Exam INTRFCE MATL L0810 HALO PROC CERV HALO AND JACKET HALO PROC CERV HALO INCLUDED IN J0C Authorization C0C REQUIRED Full Authorization C0C CERV HALO-PLAST BDY JACKET HALO PROC CERV HALO INC I PLASTR Approval Required DME Full Clinical Review BDY JACKET L0830 HALO PROC CERV HALO-MLWAKEE HALO PROC CERV HALO INC IN Approval Required DME Full Clinical Review 8WAORTHO MLPHOORT 5 INS ADD HALO PROC MRI COMPAT SYS Approval Required DME Full Clinical Review R INGS & PINS ANY MATL L0861 ADD HALO PROC REPLCMT LINER/INTERFC ADD HALO PROC REPLCMT No Approval Required LINER/INTERFCE MATERIAL L0970 TLSO CORSET FRONT TLSO CORSET LSO CORSET LSO CORSET FREDE LSO CORSET SET FRONT No Approval Required L0974 TLSO FULL C ORSET TLSO FULL CORSET None approval required L0976 LSO FULL CORSET LSO FULL CORSET No approval required L0978 AXIAL EXTENSION FOR CRUTCHES AXIAL EXTENSION FOR CRUTCHES No approval required PREFALL STRAP PO L09AB STRAP D OFF No approval required PAIR OF SHELVES L0982 GRIP FOR SUPPORT BAG ASSEMBLY SET 4 GRIP FOR BAG SUPPORT PREFAB No Needs approval Hyl De- set 4 L0984 Protective socks Mounting excludes Not required Approval Shelf Each L0999 not needed for spine Other Spinal L1000 CTLSO INCLUSE INCLUSIVE MURNING INIT The author IMPORTED DVME Full Clinical review ORTHOS INCL MDL L1001 CTLS IMMOBILIZER INFANT SZ PREFAB CERV THOR LUMB SACRAL IMMOBLIZR No Authorization Required DILUTION B0SDSION B0DSION TCOSSION TCOSSION TCOSSION TCOSSION 1 SCOLIOSIS Authorization Required DME Full Clinical Review ORTHOSIS & ACCESSORIES L1010 ADD CTLSO/SCOLIO ORTH OS AX SLEEVE ADD CTLSO/ORTHOSIS FOR SCOLIOSIS No approval required AXILLA SLINGER L1020 ADD CTLSO/SCO LIO ORTHOSIS KYPHOS PAD ADD CTLSO/SCOLIOSIS ORTHOSIS No approval required KYPHOSIS

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L1025 ADD CTLSO/SCOLIO ORTHOS KYPHOS PAD ADD CTLSO/SCOLIO ORTHOS KYPHOS Not required authorization PLUTAJUĆI PAD L1030 ADD CTLSO/SCOLIO ORTHOS LUMB PAD DODAJ CTLSO/SCOLIO ORTHOSIS ORTHOS Not required L1030 Auth ORTH LU MB/RIB PAD DODAJ CTLSO /SCOLIOS ORTHOSIS I don't have any breast cancer LUMB/LUMB RIB PAD L1050 ADD CTLSO/SCOLIOSIS ORTHOS STERNL PAD ADD ZA CTLSO/SCOLIOSIS No posterior oesophageal STERNAL ORTHOSIS PAD L1060 PADLI CTLOSTLISTHOS/ ORTH OSIS No posterior oesophageal TORACIC PAD L1070 ADD CTLSO/SCOLIO ORTH TRPEZUS SLNG ADD CTLSO/SCO LEO ORTOZA br foals orthodontic TRAPEZIUS SLING L1080 ADD CTLSO/SCOLIOS ORTHOS OUTRIG DODATAK CTLSO/SCOLIOS ORTHOSES Nije foals orthodontic/ADD CTLVRISOUT OUTRIG CAR - br. Possible authorization VERTICL EXT L1090 DODAJ CTLSO/SCOLIOS ORTHOS LUMB SLING ADDIT CTLSO/SCOLIOS ORTHES No posterior eardrum /KOŽA L1110 ADD CTLSO/ SCOLIOS RINGFORM PT MDL ADD CTLSO/SCOLIOSIS ORTHES No Authos Required SO SCOL IO ORTH COVR UPRT OF ADDITION CTLSO SCOLIOSIS ORTHOSES NO Auth Required COVER UPRT EA L1200 TLSO INCL SUBMIT ONLY INIT ORTHOS TLSO UKLJUČUJUĆI NAMJEŠTAJ INITI Potrebno odobrenje AL Potpuni DME clinical pregled ORTHROAS 10 STEPS SAME ORTHESES ILI SPEEDS 2ND 1ST TLSO LATERALNI L1220 DODATAK TLSO ANT TORAKALNI EXT DODATAK AND TLSO PREDNJI No backpack oven MILWAUKEE TIP SUPERSTRCT DODATAK TLSO MILWAUKEE TIP Baby oven DME Full Clinica l Pregled SUPERSTRUCTURE L1240 DODATAK TLSO LUMBAR DEROTACTION DODAJ JELSE AND TLSO LUMBAR DEROTACTION EROTATION EXAMPLE DODATAK TLSO PREDNJI TORAKALNI DEROTACIONI EXAMPLE L1270 TRBUŠNI EXAMPLE TLSO LAT TROHANTERNI EXAMPLE Nije potrebno odobranch NA TLSO LATERAL DONJI Niche posterior odorant TROHANTERNI JASTUČAK L1300 OTH SCOLIOSIS PROC BDY JACKT MOLD DISC JACKT MOLD Authorization Through go MOLDED Pt Model L1310 Oth Scoliosis Proc Postop BDY Jackt Oth Scoliosis Proc Postoperative Authorization Required red DME Full Clinical Review Body Jacket L1499 Mental Orthotics Br . . . . SEKSIBLJIVA MONTAŽNA L1620 Orthotic cock otmicu flex public test test cock Orthotic abduction flex public base ovlaštenja potrebna harness prefab l1630 amortict conftrxho h. od hip gentle polu-a odobrenje potrebno flex cstm fabl l1640 hip orthosis-pel bend / sprdr bar orthose-pel bar bar bel potrebno odobrenje THI MANCHTER FAB L1650 HIP ORTHOSIS ABDUCT CNTRL-STATC ADJ HIP ORTHOSIS ABDUCT ST ADJ-ABDUCT NO. 2 HIP ORTHOS CAR DEAD CUFF ADLT PRFAB HIP ORTHOS CAR DEAD CUFF ADLT SZ Niche Footbridge Earbridge PRFAB ANY TYPE L1660 HIP OR THOS ABDUCT CNTRL-STATC PLSTC HIP ORTHOS ABDUCT CNTRL STAT PLSTC Niche Footbridge Earbridge PRFAB-FITAD J IP ORTHOS DYN PELV CONTROL Thigh author izacija potreban DME Potpuni clinical pregled CLEAN CSTM FAB L1685 HIP ORTHOS POSTOP HIP ABDCT CSTM H IP ORTHOS ABDCT CNTRL POSTOP HIP Back authorization DME Potpuni clinical pregled ABDCT CSTM L1686 HIP ORTHOS ABD ORTH ABDCT POSTOP RIGHT Potreban author DME potreban DME DEM ll Clinic pregled CSTM CUSTOM FAB L1720 BEN PERTHES ORDER TRILAT TACHDIJAN LEG PERTHES ORDER TRILAT Potrebno odobranje DME Potpuni pregled clinic TACHDIJAN CSTM FAB L1730 LEGG PERTHES ORTHOZE SCOTTISH RITE LEGG PERTHES ORTHOZE RITE CUSTOM FAB L1 755 LEGG HOTTES PERTHES Backpack or breastfeeding D ME Potpuni pregled clinic DNO CSTM FAB L1810 HEEL ELASTIC LEDS PREFAB HEADGEAR ELASTIC LED PREFAB No Back Breaker CUSTOM FIT L1812 ELASTIC EAR STORE W/JNTS PREFAB ELASTIC EAR STORE WITH GLOBOOUT No Back Breaker B L1820 PREFAB L1820 PARK LOAD W/CONTROLL W/CONDLE W/CONDLE DYLR PADS&JNT Nije potrebno earphones PRFAB IN CL FIT&ADJ L1830 EARS PREFAB EARS L THE HONOR I don't want earphones LONGTUDNL PREFAB L1831 EARS ZAKLJUČAK EARS JNT PSTN ORTO Z ZA COLLEGE COLLEGE JNT POTREBNO PRFABTNNE JNT 3 COLLEGE 2 R PRILAGODBA PREFAB BREAST BED DME Potpuni clinic pregled LED DESIDE PREFAB L1833 PRILAGODBA KNEE EARS JNT RIGD SUPP KNEE EARS GLOB Bedroom outdoor DME Potpuni clinic pregled led RIGD SUPP PREFAB L1834 NO AS ZGLOB COLLEGE RIGID CUSTOM FAB NO AS ZGLOB COLLEGE ZGLOB COLLEGE CliDIG RIGID CliD authorization F6 RIGID U/U JOINT PREFAB CROSS COLLEGE ORTHOS BR. ZGLOB Nije rear oar brake PREFABRIC L1840 NON MED-LAT ACL DEROTACTION CSTM FAB NON MEDIAL-LATERAL ACL DEROTACTION Rear oar brake DME Potpuni clinically pregled CUSTOM FAB

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L1843 KNEE ORTHOSIS 1 UPRT THI&KAL ASSEMBLY KNEE ORTHOSIS SINGLE THIGH CREATION DME Approval Required Full Clinical Review & CALF PREFAB L1844 KNEE ORTHOSIS 1 UPRT THI&KAL CUSTOM KNEE ORTHOSIS SOME REQUIREMENTS NEEDED Full Review L1 845 KNEE ORTHOSIS DBL UPRT THI &CALF PRFAB KNEE ORTHOS DOUBLE UP CORRECTED authorization required DME full clinical review PREFAB L1846 KNEE ORTHOSIS DBL UPRT THI&CALF CUSTM KNEE ORTHOSIS DOUBLE UP CORRECTED approval required DME full clinical review CUSTOM ORTHOSIS THIGH AND CALF BUTT L1 ORTHOSIS DOUBLE UPRT AIR DME required full clinical review PREFAB CUSTOM L1848 KNEE OR THOS DBL UPRT AIR SUPPORT PRFAB KNEE ORTHOSIS JU STERABLE COMMON AIR DME approval required Complete clinical examination SUPP PREFAB L1850 KNEE ORTHOSIS SWEDISH TYPE PREFAB KNEE ORTHOSIS NEAR WEIGHT LF L1851 KNEE ORTHOSIS SNG UPRT THIGH AND CALF SINGLE UPRT THIGH ORTHOSIS Authorization required DME Full clinical examination I CALF L1852 KN EE ORTHOSIS DBLE UPRT ORTHOSIS FOR Thighs and knees to BBELT UPGRADE Authorization required DME full clinical examination ORTHOS FOR THIGH AND FIELD L1860 PRACONDYLR Authorization required DME full clinical examination CSTM PROS SOCKT CSTM FAB L1900 AFO SPRNG WIRE DORSIFLX ASST CSTM AFO SPRNG WIRE DORSIFLX ASST CAL F No approval required BAND CSTM FAB L1902 ANK ORTH ANK GAUNTLT/SIM PREFAB OTS ANKLE GAUTH Aquid Aquid F L1904 ANK ORTH ANK GAUNTLT/SIM CUSTOM ANKLE ORTH ANKLE GAUNTLT/SIMILAR No approval required FAB CUSTOM FAB L1906 AFO MX-LIGAMENT ANK SUPT PREFB OTS ANK FT ORTHOS MX- LIG ANK SUPT No Approval Required PREFLARUPB 190 SORTLE ALFRAM 190 SORTH ALF HOSIS SUPRAMALLEOLAR Approval Required DME Full Clinical Examination ADJUSTABLE WITH TAPES CUSTOMIZED L1910 AFO SHOES WITH CLAMP 1 BAR AFO SHOES FOR CLAMP ATTACHMENT POST 1 BAR No approval required COUNTER PRFAB L19 20 AFO 1 UPRT M/STAT /ADJ STOP CSTA FAB Auth. Stop Required CSTM FAB L1930 AFO PLASTION/OTHER MATERIAL PRFAB AFO RIGD ANTHOSE PASTIAL/OTH OTHO Approval Required MATL Prefab L1932 AFO RIGD ANT TIBL CARKIL VICE/AFO AFO RIGD ANT ANT TIBL TIBL OPERATED MATLIN Operation Tibl Tilled required Matlin TIBL 1940 ANK FT ORTHOS PLSTC/OTH MATL CSTM ANK FT ORTHOS PLASTIC/OTH No approval required MATERIAL CUSTOM FAB L1945 AFO MOLD PLSTC RIGD ANT TIBL CSTM AFO MOLD PT MDL PLSTC RIGD ANT Authorization SlinECTical Review DME Complete TM L CPLIR SP10 USE FAB An kle Plastic approval required for foot orthosis Spiral plastic DME Full Clinical Review Custom-Fab L1951 ANK FT Orthos Spiral PLSTC/OTH MATL ANK FT ORTHOS SPIRAL PLSTC/OTH Authorization DME Full Clinical Review MATL PRFAB W/FIT L1960 AFO POST SAMID ANK PLSTC CSTM FAB AFO POSTERIOR SOLID ANK PLASTIC No approval required CUSTOM FAB L1970 AFO PLASTIC W/ANK JOINT CUSTOM FAB AFO PLASTIC WITH ANKLE JOINT DME approval required Full clinical examination CUSTOM FABRICATED L1971 ANK FTABLE PLASTIC/ANKLE JOINT MACHINES PST. TL No Authorization Required W/ANK JNT PREFAB L1980 AFO 1 UPRT DORSIFLX SLID STIRUP FAB AFO 1 UPRT FREE PLANTR DORSIFLX No Authorization Required SOLID STIRUP FAB L1990 AFO DBL UPRT DORSIFLX STIRUP CSTM AFO DBL UPPL STIRU UPPL STIRU 0 Puth. 0 KAFO 1 UPRT SOLID STIRUP CSTM KAFO 1 UPRT FREE KNEEE FREE ANK Authorization required DME Full clinical examination SOLID STIRUP CSTM L2005 KAFO ANY MATL AUTO RLS ANK JNT CSTM KAFO ANY MATL AUTO LOCK&SWNG Authorization required DME Full clinical examination RLSE W/ANK LADY JNT 0 C JNT 6. KAF DVC ADAPTABILITY OF ANY MATERIAL Approval required Full clinical examination CUSTOM FAB L2010 KAFO 1 UPRT STIRUP NO KNEE JNT CSTM KAFO 1 UPRT SOLID STIRUP IN/IN KNEE Approval required DME Full clinical examination JNT CSTM FAB STIFKA L20 DBL20 BL UPRT QUICK STIRUP Approval Required THI&CALF DME Full Clinical Examination CSTM FAB L2030 KAFO DBL UPRT STIRUP NO KNEE JNT KAFO DBL UPRT SOLID STIRUP U/O Approval Required DME Full Clinical Examination KNEE JNT CSTM L2034 KAFOCS TM L2034 KAFO PLSTC S LFLATKA CFONT CPLAT RL Approval Request ed DME Full Clinical Review CSTM FAB L2035 KAFO FULL PLSTC STAT PED SZ PRFAB KAFO FULL PLSTC STAT PED U/O FREE No MOT approval required ANK PRFAB L2036 KAFO FULL PLSTC DBL UPRT CSTM FAB PLFO KAFO REQUIRED Full DME FAB PLFO KAFO REQUEST CSTM FAB L2037 KAFO FULL PLSTC 1 UPRIGHT CSTM FAB KAFO FULL PLASTIC SINGLE CREATED authorization required DME Full Clinical Review CUSTOM FAB L2038 KAFO FULL PLSTC MX-AXIS ANKLE CSTM KAFO FULL PLASTIC DEM MX-0 40 HKAFO TORSN CNTRL CAR ROTATE STRAPS HKAFO TORSION CNTRL CAR ROTAT TRAKE Not required approval CSTM L2050 HKAFO BIL TORSION CABLES CSTM FAB HKAFO TORSION CNTRL BIL TORSION No approval required CABLES CSTM FAB L2060 HKAFO BIL TORSION Purchased DME Full clinical examination BALL BEAR CSTM L2070 HKAFO UNI ROTAT STRAPS CSTM FAB HKAFO TORSION CNTRL UNI ROTAT No approval required STRAPS CSTM FAB L2080 HKAFO UNI TORSION CABLE CSTM FAB HKAFO TORSION CNTRL UNI TORSION No approval required KABEL LFOCS TM BSN FO UNI TORSION CABLE KUGLEBJØREN No approval required CSTM L2106 AFO TIB FX CAST THERMOPLSTC CSTM AFO FX ORTHOSIS TIB FX CAST authorization required DME Full clinical examination THERMOPLSTC CSTM FAB L21 08 AFO TIB FX CAST ORTHS CSTM AFO FX HOIS REQUEST Full Review CSTM AFO FX CHOIS CSTM FAB L2112 AFO TIB FX ORTHOS SFT PRFAB FIT AFO FX ORTHO TIB FX ORTHO SFT No Approval Required PRFAB W/FIT & ADJ L2114 AFO TIBL FX ORTHOS SEMI -KRUT PRFAB AFO TIBL FX ORTHOS DME SEMI-RIGD Authorization Required W/Full PRFB Review & ADJ L2116 AFO TIB FX ORTHOS RIGD PRFAB FIT AFO TIB FX ORTHOSE RIGID PRFAB Authorization Required DME Full Clinical Review W/FIT & ADJ L2126 KAFO FEM FX CAST THERMOPLSTC CSTM Authorization KAFO FEM FXME CAST CORTHOS Full Review L2126 KAFO FEM FX CAST TERMOPLSTC CSTM KAFO FEM FXME CAST REQUIRED Full L2116 DME FXME CAST CORTHOS. 128 KAFO FEM FX CAST ORTHOSIS CSTM FAB KAFO FX ORTHOSIS FEM FX CAST Approval required DME Full clinical examination ORTHOSIS CSTM FAB

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L2132 KAFO FEM FX CAST ORTHOS SFT PRFAB KAFO FEM FX CAST ORTHOS SFT Approval Required DME Full Clinical Review PRFAB W/FIT & ADJ L2134 KAFO FEM FX CAST SEMI-RIGD PRFAB KAFO FEM FX FX CAST ORTHOS Full Review DME CAST ORTHOS SELF FIT&ADJ L2136 KA FO FEM FX CAST ORTHOSIS RIGD PRFAB KAFO FEM FX CAST ORTHOSIS RIGD Approval Required DME Full Clinical Review PRFAB W/FIT & ADJ L2180 ADD LW EXTRM ORTH PLSTC SHOE INSRT ADD LOW Required AUT. JNT L2182 ADD LW EXTRM ORTH DROP LOCK KNEEE JNT ADD LOW EXTREM FX ORTHOSIS DROP No Authorization Required LOCK KNEEE L2184 ADD LW EXTRM RIGHT LTD OPPOSITE KNEEE JNT ADD LOW EXTREM FX ORTHOSIS LTD L K2 AD18 E 6 Auth. KNEE JNT ADD LW EXT FX ORTH ADJ MOT KNEE No approval required JNT LERMAN TYPE L2188 ADD LW EXT FX ORTHOSIS QUADRILAT BRIM ADD LOW EXTERM ORTHOSIS USE No approval required QUADRILAT BRIM L2190 ADD LOW FX AD EXTRELT LOW EXTRELT E No approval required ORT HOSE BELT L2192 TO ADD LW EXT NORTH HIP JNT THI FLNGE ADD LW EXT HIP ORTHOSIS JNT THI No Approval Required FLNGE&PELV BELT L2200 ADD LOW EXTRM LTD ANK MOTION EA JNT ADD LOWER EXTREMITY LTD ANK No Approval Required ADD L2 EA JTREAST MOTION L21EXO DFL NT ADD LEATHER EXTREM DORSIFLEX No Approval Required ASSIST EA JOINT L2220 ADD LW EXT DRSFLX&PLNTR ASST EA JNT ADD LW EXTRM DORSIFLX&PLANTR No Approval Required ASST/RSIST EA JNT L2230 ADD LW EXT SPLIT STIRXT EFLAT RELEASED RELEASED EFLAT AFL KEYS & PLATE Required L2232 A DD LOW EXT ORTHOS ROCKR BOTTM EYE LOW EXT ORTHOS ROCKR BOTTOM No approval required CSTM TOT CNTC CSTM L2240 ADD LW EXT ROUND CALIPER&PLAT ATTCH ADD LOW EXT ROUND No approval required CALIPER & PLATE EATTACH AA L2240 MONT. DD Low Extreme FT Plate Form PT No approval required Mdl Stirup Atch L2260 Add LW Ext Force Solid Stirup Addition Bottom Extremely Reinforced No approval required Solid Stirup L2265 Add Low Extreme Long -length Length addition Lower Extremely Necessary Long 2 XT Varus/Valgus Corr strap Add LW Ext VARUS/VALGUS CORR No Approval Required STRAP PAD/LINE PAD L2275 ADD LW EXT VARUS/VULGUS CORR PLSTC ADD LW EXTRM VARUS/VULGUS CORR No Approval Required PLSTC MOD PADD/LN L2280 ADD LW IND EXTREM BOUT ADD LOW IN EXTREM BOUTH Required MOLDED INNER BOOT L2300 ADD LW EXTRM ABDUCT BAR JNTED ADJ. ADDITION LOW EXTREM ABDUCT BAR No approval required JOINTED ADJUSTBAR L2310 ADD LOW EXTERM ABDUCT BAR STRAIGHT ADD LOW EXTREM ABDUCT BAR L2310 ADD LOW EXTREM ABDUCT BAR STRAIGHT ADD LOW EXTREMITY BAR L3 MOLD LACER CSTM ADD LOW EXT NOT MOLD L ACER CSTM No approval required FAB ONLY ORTHOS L2330 ADD LOW EXT LACER MODE PT CSTM ONLY ADD LOW EXT LACER MODE PT MDL No approval required CSTM ONLY ORTHOS L2335 ADD LOW EXTREM ANT SWING NOT REQUIRED EXTRA ANT SWING SWING BAND L2340 ADD LW EXTRM PRETIBL SWING SHAPE PT ADD LOW EX TREM PRETIBL NO NEED approve required CAST PT MODEL L2350 ADD LW EXT PROSTH TYPE SCKT CAST PT ADD LOW EXTREME PROSTHETIC TYPE DME approval required Full clinical examination PT ADTREKTM L2LD3 SOC L2LD3 HANDLE ADD TO LOWER EXTREMITY No approval required EXTENDED STEEL BRACKET L2370 ADD LOWER EXTREME PAT TERRAIN TO ADD LOWER EXTREMITY No Approval Required DNO PATTERN DNO L2375 ADD LW EXTREME TORSION CNTRL ANK JNT ADD LW EXTREME NO. ADD LW EXT TORSN CNTRL STRAIT KNEEE ADD LW EXT TORSION CNTRL STRAIT No approval required KNEEE JNT EA JNT L2385 ADD LW EXTREM STRAIT KNEEE JNT HD EA ADD LOW EXTREM STRAIT KNEEE JNT No approval required HEVY DUTY EA JNT L2387 ADD LW EXTRIC KNEEFOLI LW EXTRI C EXT POLY E JNT No authorization required CSTM KAFO EA JNT L2390 ADD LW EXTRM OFFSET KLENE JNT EA JNT ADDITION LOWER EXTREM OFFSET No authorization required KNEE JOINT EA-LED L2395 ADD LW EXTRM OFFSET KNEEE JNT HD EA JOFFSET LOW EXTREM LEAF 2397 ADD LOW EXTERM ORT HOSE SUSP SLEEVE ACCESSORY LOWER EXTERM ORTHOSIS No approval required MOLLE SUSPENSION L2405 ADDITIONAL KNEE DROP LOCK EACH KNEE ACCESSORY LED DROP LOCK No approval required EACH L24ETEA 5 LOCK W/INTEGRATED RLSE No approval required MECH MATL EA JNT L2425 ADD KNEE JNT DISC/ DIAL LOCK EA JNT ADD KN Eh JNT DISC/DIAL LOCK ADJ No approval required KNEE FLX EA JNT L2430 ADD KNEE JNT RATCHT LOCK EXT EA JNT ADD KNEE Equint L 4 92 ADD KNEEE LOOP DROP LOCK RING ADD KNEEE LOOP No approval required DROP LOCK RING L2500 ADD LW EXTRM THIGH/WT BEAR RING ADD LW EXTRM THI/WT BEAR No Approval Required GLUTL/IDD EXTRM TWT L2500 TWD WT BEAR MOLD PT ADD LW EXTRM THI/WT BEAR QUADRI- Approval Required DME Full Clinical Review LAT BRIM MOLD PT L2520 ADD LW EXT RM THI/WT BEAR CSTM ADD LW EXTRM THI/WT BEAR QUADRI- No Approval Required LAT BRIM2 EXT ISCH M-L BRIM MOLD PT ADD LW EXTRM ISCH M-L BRIM MOLD Approval Required DME Full Clinical Examination PT MDL L2526 ADD LW EXTRM ISCH M-L BRIM CSTM F IT DOD LW EXTRM ISCH M-L CIRCLE CSTM Approval required DMEIT Full Clinical EXTRM EXTRM ADD LW EXTRM WT BEAR LACR ADD LOW EXTREM BETRA/WEIGHT No approval required NOT CAST BEAR NOT LACER FORM L2540 ADD LW EXT THI/WT BEAR LACR FORM PT ADD LOW EXT THI/ WEIGHT BEAR No approval required LACER MOLLD5 PT THI LWT PT THI/WT ROLLER HAND ADD LOW EXTREME THIG/WEIGHT No approval required BEAR HIGH ROLL CUFF L2570 ADD LW EXT PELV HIP JNT CLEVIS ADD LW EXT PELV HIP JNT CLEVIS TIP Approval required DME Full Clinical Review TO PSTN JNT

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L2580 ADD LOW EXTRM PELV CNTRL PELV SLING ADDITION LOWER EXTREM PELV Authorization Required DME Full Clinical Review CONTROL PELV SLING L2600 ADD LW EXT PELV THRUST BEAR FREE ADD LW EXT BELVHIP JNT No Approval Required CLEVIS EXTEAR/FREETHRUST BEAR THRUST B1 LOCK ADD LW EXT PELV HIP JNT No Approval Required CLEVIS/TRUST BEAR LOCK L2620 ADD LW EXT PLV HIP JNT HEVY-DUTY EA ADD LOW EXTERM PELV CNTRL HIP No Approval Required JOINT HEVY-DUTY EA L262NT EXTEA AFL ADD LOW EXTRM PELV CNTRL HIP JNT No Approval Required ADJUSTBL FLX EA L2624 ADD LW EXTRM PELV HIP JNT FLX EXT ADD LW EXTRM PELV HIP JNT ADJ FLX No Approval Required EXT ABDUCT EA L2627 ADD LW EXTRM EXT PELV A LW PLSTC MOLD PT MDL Approval Required DME Full Clinical Exam HIP JNT&CABLES L2628 ADD LW EXT PELV METL FRME CABLES ADD LW EXT PELV METL FRME RECIP HIP Authorization required DME Full clinical examination JNT&CABLES L2630 PELV CONTROL ADD LW EXTRE BAND EXTRE uth BAND & BELT required UNI L2640 ADD LW EXTRM PELV BAND & BELT CAR ADDITION LOW EXTREME BELT CONTROL No approval required BAND & BELT BIL L2650 ADD LW EXTRM PELV&THOR GLUTL PAD ADD LOW EXTRM PELV&THOR THOR CONTROL ADRET L6 THOR CNTRL THOR ADD LOWER EXTREM THOR No Approval Required BAND CONTROL THOR BAND L2670 ADD LW EXTRM THOR CNTRL PARASP ADD LOW EXTREME THOR CONTROL No Approval Required UPRT PARA SPINE SUPPORT L 2680 ADD LW EXTRM THOR CNTRL CNTRL LEX Approval required BRACKETS BRACKET L2750 ADD LW EXT ORTHOS PLAT ADD LOW EXTREME ORTHO PLATE No approval required CHROME/NICKEL CHROME/NICKEL-BAR L2755 ADD LOW EXTREME ORTHOS PR. SEG CSTM ADD LOW EXTREME ORTHOSIS HYBRID TM AUTPER STREG 0 REQUIRED L2755 IS EXT-EXT- BAR ADDITION LOW EXTREME ORTHOSE EXT No approval required PO EXT PO BAR L2768 ORTHOTIC SIDE BAR DISCNCT DEVC-BAR ORTHOTIC SIDE BAR DISCONNECT No approval required UNIT PER. BAR L2780 ADD LW EXTORTRO DELIVERED. red NON CORROSIVE END BAR L2785 ADD LW EXT ORTHOSIS DROP LOCK RETN EA ADD LOW EXTREME ORTHOSIS No approval required DROP LOCK RETAIN EA L2795 ADD LW EXT NORTH KNEE NTRL FULL CAP ADD LOW EXTERM ORTHOSIS KNEE No approval required LX KNEE0S ADD LW EXTERNAL ORTHOSIS KNEE NTRL . NEE CAP CSTM ADD LOW EXT ORTHOS KNEE CNTRL No approval required KNEE CAP CSTM ONLY L2810 ADD LW EXT NORTH KNEE CNDYLR PAD ADD LOW EXTERM KNEE ORTHOSIS No approval required CONTROL CONDYLR PAD L2820 ADD LW EXT ORTH SFT KNEXT INTRCEDD A Quit red BELW KONE L 2830 ADD LW EXT ORTH SFT INTRFC ABV KNEEE ADD LW EXT ORTHOSIS SOFT INTERFCE No Auth Required MOLD ABVE KNEEE L2840 ADD LW EXT ORTHOS TIB LEN SOCK FX/= ADD LOW EXTREM ORTHOS TIB= Auth Required LW EXTREM ORTHOS LENGTH/LENGTH 8 FEM. L EN SOCK FX/= ADD ORTHOSIS FOR LOWER EXTREMITIES FEM No approval required L2999 ORTHOSIS FOR LOWER EXTREMITIES NO. ORTHOSIS FOR THE LOWER EXTREMITIES IS NOT. No Authorization Required OTHER SPECIFIED L3000 FT INSRT MODEL UCB REQUIRED SHELL TYPE REQUIRED MCB TYPE REQUIRED DME Full Clinical Examination BERKLY SHELL EA L3001 FOOT INSRT REMV MOLD PT SPENCO EA FOOD INSTALLATION Removable Cast PT Authorization Required DME Full Clinical Examination MODEL SPENCO EA L3002 FT INSRT REMV MÖMME PLASTAZOTE/= EA FOOT INSERT KRAV MDL PLAST. EA L3003 FOOT INSRT REMV MOLD SILCON GEL EA FOOT INSERT REMV MOLDED PT MODEL Approval required DME Full Clinical Review SILICONE GEL EA L3010 FT INSRT MODEL LNGTUDNL ARCH SUPP EA FT INSRT REMV MOLD PT MDL Approval required LSUNLARPPEA 3 INSRT REMV M OLD LNGTUDNL SUPP EA INSERT FOR FOOT REMV MOLD PT MDL Approval Required DME Full Clinical Review LNGTUDNL/MT SUPP EA L3030 FOOT INSERT REMV FORMED PT FT EA FOOT INSERT REMOVABLE FORM Required DME Approval Full Clinical REMVAT 3030 REMWORTHY Clinical ADD LW EXT ORS FOOT INSRT/PLAT REMV A DD LW EXT Authorization Full DME Clinical Review Required ORTHOS HI STRGTH L3040 FOOT ARCH SUPP PREMOLD LNGTUDNL EA FOOT ARCH SUPPORT REMV DME Approval Required Full Clinical Review L3040 FOOT ARCH SUPP PREMOLD LNGTUDNL EA FOOD ARCH SUPPORT REMV DME Approval Required Full Clinical Review L3005 PREMOLD L300D 0 PREMODLED L3 MT EA FOOT ARCH SUPPORT REMOVABLE authorization required DME Full Clinical Examination PREMOLDED MT EA L3060 FT ARCH SUPP PREMOLD LNGTUDNL/MT FOD ARCH SUPPORT REMV Authorization required DME Full Clinical Examination EA PREMOLDED LONGTUDNL/MT EA L3070 FONGREFOOT N MV ONREMV ATTCH Authorization required DME Full Clinical Review EA SHOE LNGTUDNL EA L3080 FT ARCH SUPP NONREMV ATTCH SHOE MT FOOT ARCH SUPPLE NON-RECHATABLE Authorization Required DME Full Clinical Review ATTCH HOE MT EA L3090 FT ARCH SUPP NONREMV SUPPTUDNL. Full Clinical Review EA CIPEL LNGTUDNL/ MT EA L3100 HALLUS-VALGUS NAT DYN SPLNT PRFAB HALLUS-VALGUS NAT DYNAMIC No approval required MOUNTING SPLINTS L3140 ROTARY FOOT ABDUCTION BAND INCLUDING ROTARY FOOT ABDUCTION BAND SHOE DME Authorization required Full CFO ABDUD1 R0 Review NO FOOT ABDUCTIONS SHOE ROTARY BAR Requires DME Authorization Full Clinical Exam NO SHOE L3160 FOOT ADJUSTMENT BL SHOE STYLE PSTN DEVC FOOT ADJUSTABLE SHOE STYLE Authorization Required DME Full Clinical Exam POSITIONING DEVICE L3170 FOOT PLASTIC STABLE STABLE FOOT SIL ILIZER Requires DME Approval Full Clinical Exam PREFAB EACH L32 01 ORTHOPED SHOES OXFRD SUPINATR INFNT ORTHOPED SHOES OXFORD Authorization Required DME Full Clinical Examination W/SUPINATOR/PRONATOR INFNT L3202 ORTHOPED SHOES OXFRD W/SUPINATR SHOES REQUEST Full Authorization WORTHOPED SHOE/SHOES REQUEST/SUPINATR REQUEST. PRONATOR CHILD L3203 ORTHOPEDIC SHOES OXFRD W/SUPINATR JR ORTHOPEDIC SHOES OXFORD Approval Required DME Full Clinical Review W/SUPINATOR/PRONATOR JR L3204 ORTHOPEDIC SHOES HITOP SUPINATR INFNT ORTHOPEDIC SHOES HIGHTOP Required DME Approval Full Clinical Review W/SUPINA TR W/SUPINATOR W/ SUPINATR W /SUPINATOR W/SUPINATR. SUPINATR ORTHOPEDIC HIGHTOP SHOES Required DME Approval Full Clinical Examination CHLD W/SUPINATOR/PRONATOR BARN

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L3207 HITOP ORTHOPEDIC SHOE W/SUPINATR JR ORTHOPEDIC HIGHTOP SHOE Required DME Approval Full Clinical Exam W/SUPINATOR/PRONATOR JR L3208 SURGICAL BOOT EACH SURGICAL BREASTFEEDING BOOT EACH SURGICAL SURGICAL BOLG REQUIRED FOR EACH CHILD No application roval Required L 3211 SURGICAL BOOT H VER JUNIOR SURGICAL BOOT EACH JUNIOR Approval not required L3212 BENESCH BOOTS PAIR FOR KIDS BENESCH BOOTS PAIR CHILDREN'S PAIR Approval not required L3213 BENESCH PAIR BOOTS CHILD BENESCH PAIR BOOTS CHILD Approval not required P BENESCHUNI BOOTS L3214 P BENESCH JAIRBOOT Approval required L3224 ORTHO FTWEAR WOMAN OXFRD DIO ORTHOPEDIC FOOTWEAR WOMAN Authorization required DME Full Clinical Review STILER SHOES OXFRD DEL STÖMMER L3225 ORTHO FTWEAR MAN OXFRD DEL STÖMMER ORTHOPEDIC MEN'S SHOES Approval required DME Full Clinical Review OXFORD DIO STÖMMER L3225 FORD 23 DEL STYLER LNLTHORTHO DIO 0 OPEL FOOTWEAR CUSTOM Approval request ed DME Full Clinical Review SHOE DEPTH INSERTS EACH L3250 ORTHOPED FOOTWEAR CSTM MOLD ORTOPED FTWEAR CSTM MOLD REMV Authorization required DME full clinical review PROSTH INNR MOLD PROSTH L3251 FOOT HOE MOLD PT SILK SHOES EA MOLD MODEL REQUIRED DME full clinical review SHOES EA L3252 FOOT SHOE MOLD PT PLASTAZO TE CSTM SHOE MOLD PT MDL Authorization Full Clinical Required DME Review PLASTAZOTE CSTM FABR EA L3253 PLASTAZOTE FOOTWEAR CSTM FIT FOOT MOLDED SHOE PLASTAZOTEUSTOM Full Authorization CFISTON REQUIRED D3TTOG L3TT5 LEARN WEAR D3 SIZE OR WIDTH NON-STANDARD SIZE OR WIDTH Requires DME Authorization Full Clinical Review L32 55 NON-STANDARD Size or length non -standard size or length de approval DME complete clinical inspection L3257 orthopedic shoes Add chrg Split orthopedic shoes additionally required DME Full Charze Bo outfits L3257 ORTOPED FOOTWEAR ADD CHRG orthopedic Footwear Additionally Required DME Full Charze Boles / SHOES EACH DME authorization required Full clinical examination L3265 PLASTAZ OTE SANDAL EACH PLASTAZOTE SANDAL EACH DME authorization required Full clinical examination L3300 TAPERED HEEL LIFT MTS PER INCH TAPERED HEEL LIFT Approval required DME full CLIFT L3300 L3300 TAPERED HEEL LIFT MTS PO. And Only Neoprene Inch Heel Height Lift And Only Authorization Required DME Full Clinical Exam Neoprene Per Inch L3320 Lift Lift Heel & File Cap Per Inch Height Heel Fittings & Cap Authorization Required DME Full Clinical Exam Per Inch L3330 Metal Lift Metal Lift Metal metal metal metal metal metal metal EXTENSION 3 332 LIFT EVEL IN Shoe tapered to 1/2 in lift lift jump inside shoe taper required approval DME full clinical examination half inch L3334 Heel lift by. Inch heel lift per inch No authorization required L3340 Heel Wedge Sach Heel Wedge SACH DME full clinical examination required L3350 HEEL WEDGE HEEL WEDGE authorization required DME full clinical examination L3360 SOLE WEDGE OUTSIDE JON SOLE WEDGE OUTSIDE SOLE Authorization required DME full clinical examination L3370 SO LE WEDGE BETWEEN ONE WEDGE BETWEEN ONE WEDGE BETWEEN THEM ONE Authorization C80B Full Review C3370 Full Clinical Review OT WEDGE Required DME Approval Full Clinical Review L3390 OUTFLARE WEDGE OUTFLARE WEDGE No Approval Required L3400 METATARSAL BAR WEDGE ROCKER METATARSAL BAR WEDGE ROCKER DME Approval Required Full Clinical Review L3410 METATARSAL BAR WEDGE BETWEEN DONATE META TARSAL BAR WEDLE SO 2 SO REQUIRED BAR WEDLE L3 WEDGE BETWEEN BOTTOM ENTIRE BOTTOM AND HEEL BETWEEN NO approval required DON L3430 HEEL NUT PLASTIC REINFORCED HEEL COVER PLASTIC REINFORCED approval required DME Full Clinical Review L 3440 INSTRUCTIONAL HEEL LEATHER REINFORCED HEEL CONTROL LEATHER REINFORCEMENT KET 3 TYPES OF HEEL CUSHION SACH DME approval required Full clinical examination L3455 HEEL NEW STANDARD LEATHER SOLE NEW STANDARD LEATHER DME approval required Full clinical examination L3460 HEEL NEW STANDARD RUBBER HEEL NEW STANDARD RUBBER Approval required DME Full Clinical Review L3 465 HEEL THOMAS HEEL WITH NORTH WIND Author Review L3470 HEEL THOMAS EXTENDED ON BALL HEEL THOMAS EXTENDED ON BALL Authorization required DME Full Clinical Review L3480 CUSHION AND DEPRESSION FOR BACKUP CUSHION AND DEPRESSION FOR BACKUP Authorization required DME Full Clinical Review L3485 CUSHION REMOVED FOR SPURMO NEEDED CUSHION RED L3 ORTHOPEDIC SHOE DOD INSOLE LEATHER ORTHOPEDIC ACCESSORY SHOE INSOLE Need DME Approval Full Clinical Exam LEATHER L3510 ORTHOPEDIC SHOES ADD INSOLE RUBBER ORTHOPEDIC ACCESSORY SHOE INSOLE Need DME Approval Full Clinical Exam RADI 20 RUBBER L35RUPICA RUBBER L35RUPICA ED ADDED K SHOES INSOLE DME approval required Full clinical examination SUEDE COVER WITH LEATHER L3530 ORTHOPEDIC SHOES ACCESSORIES SO L ORTHOPEDIC SHOES HALF SHOES ACCESSORY Sole DME approval required Full clinical examination POLA L3540 ORTHOPEDIC SHOES ACCESSORIES FULL ORTHOPEDIC DLE SHOES COMPLETE ORTHOPEDIC SHOES ACCESSORIES DLEME 3 LFU 5. ED SHOES ADD TOE TAP STANDARD ORTHOPEDIC SHOES ADD TOE TAP approval required DME Full clinical examination STANDARD L3560 ORTHOPEDIC SHOE ADD TOE TAP ORTHOPEDIC SHOE ADDIT TOE TAP approval required DME Full clinical examination HORSE SHOO HORSE SHOE L3570 ORTHOPEDIC SHOE ADD SPCL ADDISTED Obtained Obtained Linical Review EXT INSTEP L3580 ORTHO CIPEL ADD CNVRT INSTP -VELC CLO ORTHOPED SHOE ADD CONVERT FIRM Authorization Required DME Full Clinical Review VELCRO CLOS L359 0 ORTHO SHOES ADD CONVERT FIRM TO ORTHO SHO ADD CONVRT FIRM Authorization Required DME Full Clinical Review SOFTER COUNTSHOP 5 COUNT 5 COUNT 5 COUNTER 5 CH BAR ORTHOPEDIC SHOES SUPPLEMENT MARCH DME Approval Required Full Clinical Review Review BAR L3600 TRF ORTHOS 1 SHO-ANR CALIP PL EXST TRANSF ORTHOS 1 SHOES FOR OTHER DME Approval Required Full Clinical Review CALIP PLATE EXISTS L3610 TX ORTHOS TONSHOS 1 TRNSHOSHOS 1 TRNSHOSHOS DME Authorization Required Full Clinical Examination CALIP PLATE NEW L3620 TRF OR TA 1 SHOE - ANOTHER SLD STIR EX TRANS ORTHOS 1 SHOE-OTHER SLD DME Authorization Required Full Clinical Examination CHAIR EXISTING L3630 TRNS ORTHOS ANDRE SKOTHOS 1 TRANS ORTHOS 1 SKOTH ANDRE SHORTHOS 1 WRITING Required DME Full Clinical Examination SOLID STEMEN NEW L3640 TRNS ORTHOS SHOES DENNS BRWNE TRNS ORTHOS SHOES FOR ANOTH DENNIS Authorization Required DME Full Clinical Examination B BRWNE BTH SHOES L3649 ORTHOPED SHOES AGAIND ADD/ REQUIRED Author Full Clinical Examination Examination NOS APPENDIX / TRANSFER NO . L3650 SHOULDER ORTHOSIS FIGURE 8 ABDUCT ASSEMBLY SHOULDER ORTHOSIS FIGURE 8 ABDUCT No approval required HOLDER PREFAB L3660 SHOULDER ORTHOSIS FIGURE 8 CANVAS ASSEMBLY SHOULDER ORTHOSIS FIGURE 3BBULHO TRIAL NO. S ACROMIO/CLAV SHOULDER ORTHOSIS No Approval Required PREFAB ACROMIO /CLAVICULAR PREFAB L3671 SO JOINT DESIGN U/O JOINT CUSTOM SHOULDER ORTHOSIS JOINT DESIGN Approval Required DME Full Clinical Review W/O JNTS CUSTOM L3674 SHOULDER ORTHOSIS ABDUCT PSTN CSTM SHOULDER AB DUCT Author Complete ORAL CLINICAL REQUIREMENTS

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L3675 SHLDR VEST ABDUCT RESTRAINR PREFAB SHOULDER ORTHOSE VEST ABDUCT No approval required RESTRAINER PREFAB L3677 SHLDR ORTOS JNT DSGN PREFAB SHOULDER ORTHOSE JNT DSGN NR No approval required CUSTOM JNTHL PREFABNT JUSTOM JNTHL PREFGNNT JNTSH NO. AB SHOULDER ORTHOSIS DESIGN DESIGN NO No authorization required LED MOUNTED L3702 EO U/U ASSEMBLIES CUSTOM ALBUERTOSE U/U ASSEMBLIES CUSTOM No authorization required FACTORY L3710 ELB ORTOS ELASTIC METAL JNTS PREFAB ALBUERTOSE ELASTIC V/2 REQUIRED JU2 DUP 0. /MANCHET FREE MOT. CSTM EO DBL UPRT W/FOREARM/HAND CUFF Requires DME Approval Full Clinical Exam FREE MOT CSTM FAB L3730 EO DBL UPRT-CUFF EXT/FLX ASST CSTM EO DBL UPRT W/MANCHET EXT/FLX ASST Requires DME Approval Full Clinical Exam CSTM FABEO L37 W /CUFF ADJ LOCK CSTM EO DBL UPRT W/CUFF ADJ LOCK Authorization Required DME Full Clinical Exam W/ACTV CNTRL CSTM L3760 EO ADJ POS LOCKING JNT PREFAB ITEM ELBUUE ORTHOSE ADJ POS LOCKING No LINT 7 ITEM ADJ 6 POINTS PREFAB OTS ELBUE Required ORTHOSIS ADJ POS LOCK No Authorization Required General Medicine - MOUNTING OTS JOINTS Health and Behavioral Assessment/Intervention L3762 ELBOW ORTHOSIS RIGID U/O LED MOUNTING ELBOW ORTHOSIS RIGID U/O LED not required L3762 ELBOW ORTHOSIS RIGID NO LEG JOINTS CUSTOM FAB EWHO RIGID U/O JOINTS CUSTOM authorization required DME full clinical examination FABRICATED L3764 EWHO 1/> NONTORSION JNTS CSTM FAB EWHO INCL 1/MORE NONTORSION authorization required DME full clinical examination JOIDS TM FINTHOO WINTS 6 R USE FAB EWHFO RIGID U/O JOINTS CUSTOM required authorization DME full clinical examination MANUFACTURED L3766 EWHFO 1/> NONTORSION JNTS CSTM FAB EWHFO INCL 1/MORE NONTORSION Authorization required DME full clinical examination JOINTS INCL CSTM FAB ADJUSTOM FJ. USE OF MANUFACTURING INCLUDING No Approval Required FITTING & FITTING L3807 WHF ORTOS NO JNT PRFAB CUSTOM FIT FINGER ORTOS U/O JNT No Approval Required PREFAB CSTM FIT L3808 WHF ORTOS STIFF NO JNT; CUSTOM FINGER ORTHOSIS, RIGID No approval required without JNT; CUSTOM L3809 WHF ORTHO NO JOINTS ASSEMBLY ANY TYPE MANUAL MANUAL WIRELESS No approval required ASSEMBLY ANY TYPE L3900 WHFO DYN FLX HNG WRST WOODEN CSTM WHFO DYN FLEXIBLE HINGES DME WRST REQUIRED Full Review DME WRST/Required Flin 901 WHFO DYN FLX HNG CABLE DRIVE CSTM WHFO DYN FLEXOR HINGE CABLE Authorization Required DME Full Clinical Review DRIVEN CSTM FAB L3904 WHFO EXTERNAL POWER ELEC CSTM FAB WHFO EXTERNAL DRIVEN ELECTRICAL Approval Required CME Full CHOD F0LIN/5 Review DME Full L3S2N/5 ION JOINTS CSTM FAB AS INCLUDING 1 /NO MORE TORSION Authorization required DME Full Clinical Review COLLECTIONS CSTM FAB L3906 WHO U/O JOINT STRAP CSTM FAB WHO WITHOUT JNT CAN INCLUDE SFT INTRFCE No approval required TAPE CSTM FAB L3908 WRST-HNTRL KOORTHOS- EXTRL-KORTHUS CONTROL No approval required PRFAB COCK-UP PREFAB L3912 HAND FINGR ORTHOS FINGR CNTRL PRFAB HAND FINGER ORTHOSIS FLEX GLOVE No approval required FINGR CNTRL PRFAB L3913 HFO U/O JOINTS MADE TO ORDER CNTHOT HAND Nored L3915 WH ORTHOS 1/>NONTRSN PRFAB CSTM HAND ORTHOSIS No approval required FIT 1/>NONTORSION JNT PR FAB CSTM L3916 WH ORTHOS 1/> NONTORSN JOINT HAND ORTHOSIS 1/> No approval required PREFAB 9 PREFAB 9 PRONTOR EFAB CSTM FIT HAND ORTHOSIS METACARPAL FX No approval required PREFAB CUSTOM FIT L3918 HAND ORTHOSIS METACARPL FX HAND ORTHOSIS METACARPAL FX No approval required ORTHOSIS ORTHO SE PREFAB L3919 ARM ORTHOSIS U/O JOUSTOM JOINTS Cut required FAB FABRIC L3921 HFO 1/> NONTORSION JOINTS CSTM FAB HFO INCLUDED 1/MULTI NONTORSION JOINTS No approval required CUSTOM FAB L3923 HF JOINTLESS ORTHOSIS PRFAB CSTM FIT ARM ORTHOSIS- FINGER U/O JOINT No approval required PREFAB CUSTOM FIT HORTHOS FINGER W-FINGER/HINTO WRAP L3924 SIS NO Approval required JOINTS PREFAB L3925 FINGER ORTHOSIS NON TORSION JNT PREFAB FINGER ORTHOSIS PIP/DIP No approval required NON TORSION JOINT PREFAB L3927 FINGER ORTHOSIS U/O JOINT PREFAB FINGER/ DIP NEEDED No L3929 HF ORTHOSIS 1 /> Nontrsn Jnt Prfab CStm Finger Orthosis 1/> No author CUSTOM & No approval needed CUSTOM L3933 FINGER ORTHOSIS U/U WIRING CSTM FAB FINGER ORTHOSIS U/ O ASSEMBLIES CUSTOM No approval required FACTORY L3935 FO NONTORSION ASSEMBLY USER MANUAL F AB N -9 ORDHOIS Obtained A L5 DD JNT OP EXTREME ORTHOS MATL; JNT ADD JNT UPPER EXTERNAL ORTHOSIS ANY No approval required MATERIAL; JNT L3960 SEWHO ABDUCT PSTN AIRPLANE DESIGN SEWHO ABDUCT PSTN AIRPLANE DESN Authorization Required DME Full Clinical Review PREFAB W/FIT&ADJ L3961 SEWHO SHLDR CAP DESN NR JNTS CSTM SEWHO SHOULDER CAP DESIGN ClinS Full Review Required DME CAP DESIGN ClinS 962 SE WHO ABDUCT PSTN ERBS PALS DESIGN SEWHO ABDUCT PSTN ERBS PALS DESN Authorization Required DME Full Clinical Exam PRFAB W/FIT&ADJ L3967 SEWHO ABDUCT PSTN U/O JNTS CSTM SEWHO ABDUCT POSITIONING U/O Authorization Required DME Full Clinical Exam L3967 SEWHO ABDUCT PSTN U/O JNTS CSTM SEWHO ABDUCT POSITIONING U/O Approval Required DME Full Clinical Exam L3967 GN CSTM FAB SEWHO CAP DESIGN CSTM Approval Required DME Full Clinical Exam FAB L3973 SEWHO ABDUCT POSITION CSTM FAB SEWHO ABDUKT PSTN THOR Approval Required DME Full Clinical Exam CMPNT&SUPP BAR CSTM FAB L3975 CAPHFOSN SHUL DECSTM SHUL SIGN U /O authorization required DME full clinical examination JOINTS CSTM FAB L3976 SEWHFO ABDUCT PSTN U/O JNTS CUS FAB SEWHFO ABDUCT PSTN THOR CMPNT authorization required DME full clinical examination U/O JOINTS CUS FAB

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L3977 SEWHFO NEEDS CAP DESIGN CUSTOMIZED SEWHFO NEEDS CAP DESIGN CUSTOMIZED Approval Required DME Full Clinical Review FAB FAB ELASTIC BAND L3978 SEWHFO ABDUCTION POSITION CSTM FAB SEWHFO ABDUCTION PSTN & nbsp; 80 UP EXT FX ORTHOSIS HUM PRFAB-FIT&ADJ UP EXTREM FX ORTHOSIS HUM No Approval Required PREFABR INCL FIT&ADJ L3981 UE FX ORTHOSIS HUMERAL PREF TRACK UPPER EXTREMITY FX ORTHOSIS Approval Required DME Full Clinical Review HUMERAL PREF TRACK EUPHRMUSB FX UPARM FX ORTHOSIS FX ORTHO RADUS/ULNAR No Approval Required PREFAB M/FIT&ADJ L3984 UP EXTRM FX ORTHOS WRST PRFAB UP EXTREM FX ORTHOSIS WRST PREFAB No Approval Required INCL FIT & ADJ L3995 ADD EXTREM ORTHOS SOCK FX/= EA ADD UPPER FIT AFR EXTREM Auth EA L3999 UPPER LIMB ORTH OSIS NOSE ORTHOSIS FOR UPPER LIMBS NO OTHER Approval Required SPECIFIED L4000 REPLACEMENT BELT FOR SPINE ORTHOSIS REPLACEMENT BELT FOR SPINE ORTHOSIS DME Approval Required Full Clinical Examination CTLSO OR SO L4002 REPLACEMENT BELT FOR ANY PLORTHOSE PNTS No Approval Required ANY LENGTH TYPE L4010 REPLACEMENT MENT TRILATERAL SOCKET BRIM REPLACEMENT TRILATERAL SOCKET BRIM Authorization required fox DME Full Clinical Exam L4020 REPLACE QUADRILAT BRIMM SOCKET MOLD PT REPLACE QUADRILAT SOCKET TRIM Authorization required DME Full Clinical Exam MOLDED PT MODEL L403CS REPLACE SQUADRILAT REPLACE AL SOCKET BRIM No approval required L4040 REPLACE MOLDED THI LACER CSTM ONLY REPLACE MOLDED T HI LACER CSTM FAB No approval required ORTHOSIS ONLY L4045 REPLACEMENT NOT CAST THI LACER CSTM REPLACEMENT ONLY NOT NICE THI LACER CSTM No approval required L4045 REPL NOT CAST ONLY THI LACER CSTM REPLACEMENT ONLY NOT CAST THI LACER CSTM No approval required L4045 REPL NO CAST ONLY T HI LACER CSTM REPLACE ONLY NOT CAST THI LACER CSTM No Approval Required L4045 REPL NOT NICE THI LACER CSTM REPLACE ONLY NOT NICE THI LACER CSTM No Approval Required L4045 REPL NOT NICE THI LACER CSTM REPLACE ONLY NOT NICE THI LACER CSTM No Approval Required L4045 REPL NO REPLACEMENT MOLD ONLY MOLDED CALF LACER CSTM No Authorization Required FAB ORTOS ONLY L4055 REPLACEMENT NO MOLDED CALF LACER CSTM REPLACEMENT NO RELEASED CALF LACER CSTM No Authorization Required FAB ORTOS ONLY L4060 REPLACEMENT HIGH ROLLER CUFF REQUIRED HIGH ROLLER CUFF L4 PRO APRIST REPLACEMENT NO. PLACE PROXIMALLY AND DISTAL Approval not required CREATE FOR KAFO L4080 REPLACEMENT METAL BAND KAFO PROX REPLACEMENT METAL BAND FOR Thigh KAFO No approval required PROXIMAL THIGH L4090 REPLACEMENT METAL BAND KAFO-AFO KAFO/THI REPLACEMENT METAL BAND KAFO-AFO No approval required CALF/DIS HIGH THIGH L4100 REPLACEMENT KAFO CUFF No approval required PROXIMAL HIGH L4110 REPLACEMENT SKIN CUFF KAFO-AFO CALF/THI REPLACEMENT SKIN CUFF KAFO-AFO No approval required POSTERIOR/DISTAL THIGH L4130 REPLACEMENT PRETIBIAL SHELL REPLACEMENT PRETIBIAL SHELL REQUIRED full authorization C5PR C5 PR REQUIRED NT 15 MIN REPAIR ORTHOTICS DEVC WORK Approval not required fox COMPONENTS PO . 15 MINUTES L4210 REP ORTHOT DEVC REP/REPL MINOR PART REPAIR ORTHOTIC DEVC No approval required REPAIR/REPLACEMENT OF MINOR PARTS. AB L4360 Pneumatic i/ VAC Pneumatic pneumatic pneumatic i/ no auth SUTM Pneumatic i/ no auth required CURSM vacuum prefab CUSTM FIT L4361 Pneumatic pneumatic pneumatic pneumatic pneumatic pneumatic pneumatic i/ or walking vacuum and or no auth required prefab L4361 L4370 eg . SPLINT ASSEMBLY No approval required ON SHELF L4386 WALKING BOOT NON-PNEUMATIC ASSEMBLY WALKING BOOT NON-PNEUMATIC No authorization required CSTM ASSEMBLY BOOT CUSTOMIZATION L4387 WALKING BOOT NON-PNEUMATIC ASSEMBLY WALKING BOOT NON-PNEUMATIC No authorization required L4387 W ALKING BOOT NON-PNEUMATIC ASSEMBLY WALKING NON-PNEUMATIC MATSKI BOOT No authorization required L4386 PREFABCE ST FO REPLACEMENT SOFT INTERFACE No authorization required MATERIAL STATIC AFO L4394 REPL SFT INTRFCE MATL FT DROP SPLNT REPLACEMENT MATERIAL MEKAG INTERFACE No authorization required FOOTDROP SPLINT L4396 STAT/DYN ANK FT ORTH OS PREFAB CSTM STATIC/DYNAMIC FOOTEM STATIC/DYNAMIC FOOTDROP TM F3 ATIC/DYNAMIC AFO MIN ABM PREFAB STATIC/DYNAMIC ANKLE ORTHOSIS FOOT No approval required MIN AMB PREFAB L4398 FOOT SPLINT SUPPOSED POS PRFAB SPLIT FOOT SUPPOSED No approval required POSITIONING PRE FAB L4631 AFO WALK BOOC BOOC WALK BOOC OTTM authorization required DME full clinical examination CSTM ANT TIB SHELL CSTM L5000 PART FT SHOE INSRT W/LNGTUDNL ARCH PART FT SHOE INSERT W/LONGTUDNL authorization required DME full clinical exam ARCH TOE FILLER L5010 PART FT MOLD SOCKT ANK HT W/TOE FILE PARTIAL EXAM SO CLIFT FILE PARTIAL DME REQUIFT HEIGHT W/TOE FILER L5020 PART FT CAST SHIP TUBERKEL HT PART FT CAST SUPPORT TIB TUBERKEL Approval Required DME Full Clinical Review HT W/TOE FILE L5050 ANKLE SYMES CAST SOCKET SACH MONKLE SOFOTO Full Review DME ANKLE SYPHO DO Full Clinical Review OT L5060 ANK SYMS METL FRME MOLD LEATHR ANK SYMES METL FRME MOLD LEATHR Authorization Required DME Full Clinical Review SCKT SOCKT ARTIC ANK L5100 BEW KLENE MOLD SOCKT SHIN SACH FOOT BEOW KNELE MOLD SOCKET SHIN SCOTT SHIN Full Review P5 KONE SHIN D5 SCKT JNT&TH I LACER SACH FT BELOW THE KNEE PLSTC SOCKT JNT&THI Approval Required DME Full Clinical Review LACER SACH FOOT L5150 KNEE DISRTC FORM SCKT EXT KNEE JNT KNEE DISRTC FORM SOCKT EXT KNEE Approval Required DME Full Clinical Review JNT KNESHENT B NO KNEE DISARTIC FORM SOCKT BENDED KNEE Approval Required DME Full Clinical Review EXT KNEEE JNT L5200 AK SHAPE SOCKET 1 AXIS CONSTANT FRICTION OVER KNEE MEASUREMENT SOCKET 1 AXIS Approval required DME Full Clinical Examination CONSTANT FRICTION L5210 AK SHRTEAN PROSTH - NO KONE JENSH Authorization required DME Full Clinical Examination JNT NO ANK JNT EA L5220 AK SHRT PROSTH M /ARTIC ANK/FOOT DYN OVER KNEE SHORT PROSTH M/ARTIC Approval Required DME Full Clinical Review ANK/FOOT DYN L5230 AK PROX FEM FOCAL DEFOT PROFIC FEM FOCAL Approval Required DME Full Clinical Review DEFIC SACH FOOT L5250 HIP DISRTC CANADIAN; MULD SCKT HIP HIP DISARTIC CANADIAN TYPE; MULD Authorization Required DME Full Clinical Examination SOCKT HIP JNT L5270 HIP DISRTC TLT TABL; MOLD SCKT LOCK HIP DISRTC TILT TABLE; MOLD SCKT authorization required DME Full clinical examination LOCK HIP JNT

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L5280 HEMIPELVECT CANADIAN; SWITCH SHAPE HEMIPELVECT CANADIAN TYPE; MOLD Authorization Required DME Full Clinical Review SOCKT HIP JNT L5301 BK MOLD SCKT SHIN SACH FT ENDO SYS BELOW KNEEE MOLD SHIN SACH Authorization Required DME Full Clinical Review FT ENDOSKEL SYS L5312 KNEE DISART 1 KNEE DISART MOLDAXIS IS Authorization Required DME Full Clinical Review KNEEE SACH FOOT L5321 AK OPEN END SACH FT ENDO SYS 1 OS OVER KONE OPEN END SACH FT ENDO Authorization Required DME Full Clinical Examination SYS 1 OS KNEE L5331 SINGLE AXIS JOINT KONE Squired DME Full Clinical Examination L5341 SINGLE AXIS KNEE SACH FOOT SINGLE AXIS KNEE SACH FOOT Author Required ization DME Full Clinical Review L5400 IMMED POSTSURG RIGD DRSG W/1 CHG IMMED PSTSRG/ERLY FIT APPLY RIGDME Full ClinSS W1K/BG0 Review Required IMMED POSTSURG RIGD DRS BK-EA CAST IMMD POSTSURG APPL RIGD DRS BK No Approval Required W/EA ADD CAST CHG L5420 IMMED POSTSURG RIGD DRSG 1 CHG AK IMMED POSTSURG INIT DRESS 1 Full Approval C4K0 I CH50 Review Required RG RIGD DRSG AK EA CAST IMMED POSTSURG INIT DRSG AK AK No Approval Required EA ADD CAST CHG L5450 IMMED POSTSURG NONWT BEAR RIGD BK IMMED POSTSURG APPLICATION NONWT No Authorization Required BEAR RIGD BELW MMED POSTSURG APPLIC NONWT Authorization Required DME Full Clinical Review BEAR RIGD ABOVE KNEE L5500 INIT BK PTB SCKT NON-ALIGN DIR FORM INIT BELOW KNEE PTB SOCKET NON- Authorization Required DME Full Clinical Review ALIGN DIR FORMED L5505 INIT AK -DISRTC ISCH LEVEL AND NOT POSSIBLE- Authorization Required DME Full Clinical Examination SOCKT NON-ALIGN L5510 PREP BK PTB SCKT NON-ALIGN MODEL MDL PREP BELOW THE KNEE PTB SOCKET NON- Authorization Required DME Full Clinical Examination ALIGN MOLD MODEL L5520 PREP BK N PTBDK THERMOPLSTCON -ALIGN Authorization required DME Full clinical examination THERMOPLSTC/=DIR FORM L5530 PREP BK PTB THERMOPLSTC/=MOLD PREP BK PTB SCKT NON-ALIGN Authorization required DME Full clinical examination MODEL THERMOPLSTC/=MOLD MDL L5535 PREP ADSCEN PKTTB JP BELOW THE KNEE PTB NON-ALIGN -ALIGN Authorization required DME Full clinical examination PRFAB ADJ OPEN END L5540 PREP BK PTB LAMINATED SCKT MOLD MDL PREP BK PTB SCKT NON-ALIGN Authorization required DME Full clinical examination LAMNATD SCAKKT-MOLD PREPLA-MOLD P5-6DIS-MOLD PREP LAMNATD SCAKSTER -MOLD 0 MODEL PREPLA. AK-DISRTC ISCH LEVL PLASTER Authorization required DME Full clinical examination SOCKET MOLD MDL L5570 PREP AK-DISRTC THRMOPLSTC/=DIR FORM PREP AK-DISRTC ISCH LEVL Authorization required DME Full clinical examination THERMOPLSTC/=DIR FORMED PREP 580 PREP AK-DISRTC/= DIR FORMED LEVL5 MOLD PREP AK DISARTIC NON-ALIGN Authorization required DME Full clinical examination THERMOPLSTC/=MOLD MDL L5585 PREP AK-DISARTIC PRFAB ADJ OPEN END PREP AK-DISARTC NON-ALIGN PRFAB Authorization required DME Full clinical examination ADJ OPN END 5 -90SCKT LAMINATD SCKT MOLD PREP AK-DISARTIC NON-ALIGN Authorization Required DME Full Clinical Review LAMINATED SOCKET MODE L5595 PREP HIP DISARTC THERMOPLSTC/=MOLD PREP HIP DISARTIC-HEMIPELVECT Authorization Required DME Full Clinical Review L5595 THERMOPPLSTC L5595 PREP HIP DISARTC HIP DISARTC FORM PREPARATION- HEMIPELVECT DME Approval Required Full Clinical Review LAMINATD SCKT MOLD L5610 ADD LOW EXTRM ENDO AK ADD LW EXTRM ENDO SYS ABVE KNEE DME Approval Required Full Clinical Review HYDRACADENCE HYDRACADENCE HYDRACADENCE 1XT ADDRIKADENCE LW6X1111 SYS-LW1 X11 ADD-5 LW EXTRM ENDO AK-DISRTC 4-BAR DME Approval Required Full Clinical Review LINK W/FRICT L5613 ADD LW EXT AK-DSRTC W/HYDRAUL ADD LOW EXTRM ENDO AK-DISARTIC 4- DME Approval Required Full Clinical Review CNTRL BAR W/HYDRAUL L5W EXTRA AK-DSRTC W/ PNEUMAT ADD LOW EXT EXOSKEL SYS AK-DISARTC Authorization Required DME Full Clinical Examination CNTRL 4-BAR PNEUMAT L5616 ADD LOW EXT AK UNIVRSL MXPLX FRICT ADD LOW EKSRM ENDO AK UNIVERSAL Authorization CNTRL 4-BAR PNEUMAT L5616 ADD LOW EX. LW EXTREMELY FAST CHANGE AK/BK ADD LOW EXTREME TEST SOCKT SYMES ADD TO LOW EXTREMITY TEST SO L5ET 0M TEST REGUID L5ET 0UTM TEST SO LOW EXTREM. SOCKT BELW KNEE ADDING LOWER EXTREMITY TEST No approval required SOCKET BELOW KNEE L5622 ADD LW EXTRM TST SOCKT KNEEE DISARTC ADDING LOWER EXTREM TEST SUPORT No approval required KNEE DISARTIC L5624 ADD LOW KNEE ADDIT TEST LOW SEXTREM No approval required SOCKET ABOVE KNEE L5 626 ADD LW EXTRM TST SOCK HIP DISARTIC ADDITION LOWER EXTREME TEST SOCKET No approval required HIP DISARTIC L5628 ADD LOW EXTRM TST SOCKT ADDITION LOWER EXTREME TEST SOCKET CONTROL No approval required HEMIPELVECT HEMIPELVECTOMY ADD LW6CNECTOMY LW628 ADD L5 LOWER EXTREME BELOW THE KNEE No approval required ACRYLIC PERFORMANCE L5630 ADD EYE LW EXT SYMS TYPE XPND WALL SCKT ADD LOW EXT SYMES TYPE No approval required EXPANDABLE WALL SOCKET L5631 ADD LW EXT BELOW KONE/DISARTC ACRYLC ADD LOW EXT BELOW KONE/KNEE/DISARTC ACRYLC ADD LOW EXT BELOW KONE/KNEE/KNEE/KNEE LEAF L 5 AKNE EKS2 Auth6 SYMS PTB BRIM DESN SOCKT ADD LOW EXTREME SYMES TYPE PTB No authorization required BRIM DESIGN SOCKT L5634 ADD LW EXT SYMS POST OPENING SOCKT ADD LOW EXTREME SYMES TYPE POST No authorization required OPENING SOCKT L5636 SOCKTMS LW EX T SYMS ADD WITH OPENING SOCKT L5637 ADD LOW EXTREME BELV KONE TOTAL ADD LOWER EXTREME BELOW No Approval Required CNTC KONE TOTAL CONTKT L5638 ADD LW EXTRM BEW KNEEE LEATHER ADDIT LOWER EXTREME BELOW KNEE SWEET L3 KONE Required L5 BEW KNEEE WOOD ADDITION LOWER EXTREME Authorization Required DME Full Clinical Examination KNEE BUMP L5640 ADD LW EXT KNEEE DISARTC LOWER EXTREM KNEEE ADDITION LOWER EXTREM KNEEE Authorization required DME Full Clinical Review DISARTIC LEATHR SOCKT L5642 ADD LW EXTRMATHR SCKT ADDING REQUIRED red DME Full Clinical Review LOWER SOCKET L5643 ADD LW EXT HIP DISRTC FLX EXT FRAME ADD L W EXT HIP DISARTC FLX INNR Required DME Approval Full Clinical Examination SOCKT EXT FRAME L5644 ADD LOWER EXTRECK ABOVE KNEE WOOD ADD LOWER EXTRECK FLX INNR. 5 ADD LOW EXTRM BK FLX INNR EXT FRME ADD LW EXT BELW KNEEE FLXIBLE INNR Approval Required DME Full Clinical Review SOCKT EXT FRME L5646 ADD LOW EXT BELOW KONE PAD SOCKT ADD LOW EXT BELOW KNEE AIR Review FL= Clinical Approval Required SKTEL

178

L5647 ADD LOWER EXTRM BELOW THE KNEE SUCTION ADD LOWER EXTRM BELOW THE KNEE Authorization Required DME Full Clinical Review SOCKT SUCTION SUPPORT L5648 ADD LOWER EXTRM ABOVE THE KNEE ADD LOWER EXTRM ABOVE THE KNEE Author Full Clinical Review FL GEL 5 Review Clin GEL 5 49 ADD LW EXT ISCHIAL MAINTENANCE SCKT ADD EYE LW EXT ISCHIAL Approval Required DME Full Clinical Examination CONTAIN/NARROW M-L SOCKET L5650 ADD LW EXTRM TOT CONTACT ADD LOW EXTERNAL TOTAL CONTACT OVER No Approval Required AK/DISARTC KNEE/KNEE NO. FRME ADD LW EXT ABVE KNEE FLXIBLE INNR Approval Required DME Full Clinical Examination SOCKT EXT FRME L5652 ADD LOW EXTRM SUCTN SUSP ADD LOW EXTERM SUCTN SUSP ABV No Approval Required AK/DISARTC KONE/KNEE DISARTICED L5652 ADD LOW EXTRM SUCTN SUSP OW EXTREME KNEE DISARTIC Authorization DME required Full clinical examination XPNDABLE WALL SOCKT L5654 ADD LOW EXTREM SOCKT INSERT SYMES LOWER EXTREMITY ADD No approval required SOCKET INSERT SYMES L5655 ADD LOW EXTRM SOCKT SETTING KVI SETTING ADTRET SET A. BELOW KNEE L5656 ADD LW EXT SOCKT INSRT KONE DISARTC ADDITION LOWER EXTREMITY SOCKET No approval required INSERT KNEEE DISARTIC L5658 ADD LOW EXTRM SOCKET INSRT ABOVE KONE ADDITION LOWER EXTREM SOCKET CONTROL No approval required. ERT authorization required DME Full clinical examination SYMES MULTIDUROMETER SYMES L5665 ADD LW EXT INSRT MXDROMTR BELW ADD LOW EXTRM SOCKT INSRT No approval required KNEE MXIDUROMETER BELW EXT INSRT MXDROMTR BELW ADD LOW EXTRM SOCKT INSRT MXIDUROMETER KNEE BEL W KONE L5666 ADD LOW EXTREM BELOW THE KNEE CUFF ADD BOTTOM EXTREME 6 LW EXTRM BK MOLD DISTAL CUSHION ADD LOW EXTREM BELOW KNEE No approval required MOLDED DIST CUSHN L5670 ADD LW EXTRM BK MOLD SUPRACOND ADD LOW EXTREM BEOWN KNEE MOLD No approval required SUSP SUPRACONDYLR SUSP L5671 ADD LOW EXTRM B K/AK SURM LOCK MEXTME By Full Prone LOCK/AK SURM LOCK BRAND. ical Review KNEEE SUSP LOCK MECH L5672 ADD LOW EXTRM BK STRAP WITH BRIMP ADD LOW EXTRM BELOW KNEEE No Approval Required SUSP STRMP WITH BRIMP SUSP L5673 ADD LOW EXT BK/AK CSTM FAB XST FURNITURE ADD LOW EXT CSTM FURNITURE/REQUIRED Review Full CSTM FORM / Guides notice / locking mech l5676 Add low bk knee Jnt 1 Axle pair add lower extreme knees knee knee no approval required jnt 1 a axle pair l5677 add lw ext bk knee jnt polycntrc pr add knee knee required p5 78 ads lw knee lnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt jnt COVRS PAIR ADDITIONAL LOW EXTREM BELOW KNEE No Authorization Required LED RUBBER PAIR L5679 ADD LOW EXT BK/AK CSTM FAB XST MOLD ADD LW EXT BK/AK CSTM MOLD/PRFAB Authorization Required ME DEM Full Clinical L560 Review ADD LOW EXTREM BK THI LACER NOT MOLD ADD LOW EXTREME BELOW THE KNEE Approval not required LACER NOT MOLDED L5681 ADD LW EXT BK/AK CONGN/AMPUTÉ INIT ADD LW EXT BK/AK CST INS CNG/ATYP authorization CAMPIT REQUIRED IN DTRA authorization C25 ADD LOW EXTERM BK Thigh LACER FORM ADD LW EXTRM BELW KNEE THI LACER Authorization Required DME Full Clinical Exam GLUTL/ISCH FORM L5683 ADD LOW EXT BK/AK NO KONGN/AMP INIT ADD LW EXTRA BK/AK CST FAB NO Authorization Required Examination CNGN/ TRAUMA AMP INIT L5684 ADD LOW EXTREME LOW EXTREME KNEE FIT ADD LOW EXTREME BELOW No approval required KNEE TAPE TAPE L5685 ADD LOW EXT PROFES BELOW KNEE SLEEVES ADD LOW EXTREME BELOW KNEE BELT/6 6 ADD LOW EXTREME KNEE BACK ADD LOW EXTREME BELOW KNEE No Auth Required CHECK KNEE BK BACK CHECK L5688 ADD L OW EXTRM BK WAIST BAG LTE ADD LOWER EXTREME BELOW KNEE No Auth Required WEBNG WAIST BELT WEBBNG L56 EXTM WEBBNG L56 EXTREME EXTREME BELOW KNEE WAIST No Auth Required BELT PAD & LINER L5692 ADD LW EXTRM AK PELVIC CONTROL BELT ADD LOW EXTRE I ABOVE KNEE NO Clearance Required CONTROL BELT LIGHT L5694 ADD LW EXTRM AK PELV CNTRL Belt Pad ADD LOW EXTREME C&RL AUT. KNEE Required L6 EXT AK PELV CNTRL SLV NEOPRN ADD LOW EXTREME ABOVE KNEE No Approval Required CNTRL SLV NEOPREN L5696 ADD LOW EXTRM AK/DISARTIC PELV JNT ADD LOW EXTREM ABOVE KNEE/KNEE No Approval Required DISARTIC PELV ADD L56 ADD L56 M ABOVE KNEE/KNEE No Authorization Required DISARTIC BANDAGE L5698 ADD LW EXTRM AK/KD SILESIAN BANDAGE ADD LOW EXTRMITY AK/KNEE DISRTC No Authorization Required SILESIAN BANDAGE L5699 ALL LOW EXTREME EXTREME PROSTH Authn. RNESS SHOULDER BELT L5700 REPL PLUG BELOW THE KNEE SHAPE PT MDL REPLACEMENT SOCKS BELOW THE KNEE BK Approval required DME Full Clinical Exam MOLDED PT MODEL L5701 REPL SCKT AK/DISARTIC W/ ATTCH PLAT REPL SOCKT ABOVE KNEE/KNEE Required DME Approval Full Clinical Exam 5701 REPL SCKT AK/DISARTIC W/ ATTCH PLAT REPL SOCKT ABOVE/KNEE Approval Required DME Full Clinical Exam 5701 REPL SCKT AK/DISARTIC DISRTC W/HIP JNT FORM REPLCMT SOCKT HIP DISARTIC W/HIP Approval Required DME Full Clinical Exam JNT MOLD PT MDL L5703 ANK SYMES MLD PT MDL SACH FT REPL ANKLE SYMES MODEL PT MODEL SACH Authorization Required DME Full CPLUSTON CPLUSTON CPLUSTON C4 PROTECTIVE COVER UNDER CUSTOM FORM PROTECTION LEAK DME Approval Required Full Clinical Examination KNEE UNDER KNEE BK L5705 CUSTOM PROTECTION OVER CUSTOM PROTECTION LEAK Authorization Required DME Full Clinical review KNEE BELOW KNEE KNEE ABOVE KNEE 5 KNEE 06 MOLDED PROTECTIVE SLEEVE DME Approval Required Full Clinical Review KNEE DISARTIC L5707 CUSTOM MOLDED PROTECTIVE SLEEVE HIP DISARTIC CUSTOM MOLDED PROTECTIVE SLEEVE Required DME Approval Full Clinical Review HIP DISARTIC L5710 ADD EXOSKL KNEE-TIBIAL 1 SECTION IRA MNL LOCK ADD EXOSKEL Required ADD EXOSKIS L5711 ADD EXO KNEE -Shin Mnl Lock Ultra-Lt Add Exoskel Knee-Shin 1 Axis Mnl No Author VARBL FRICT SWING ADD EXOSKEL KNEE-SHIN VARIBL FRICT No Approval Required SWING CNTRL

179

L5716 ADD EXO KONE-SHIN MECH STANCE LOCK ADD EXOSKL KNEEE-SHIN POLYCNTRC Approval Required DME Full Clinical Review MECH STANCE LOCK L5718 ADD EXO KNEEE-SHIN FRICT SWING CNTRL ADD EXOSKL KONE-SHIN Review Full EXOSKL KONE-SHIN Review Clin. RL L5722 ADD EXO KONE-SHIN PNUMAT SWNG ADD EXOSKEL KNEEE-SHIN PNEUMAT Authorization Required DME Full Clinical Examination FRICT SWING FRICT CNTRL L5724 ADD KONE-SHIN 1 OS FL SWING PHASE ADD EXOSKEL KONE-SHIN FLUKE L5724 Requid. 26 ADD EXO KONE-SHIN EXT JNT FL SWING ADD EXOSKEL KNEEE-SHIN EXT JOINT FL Authorization required DME Full Clinical Exam SWING CNTRL L5728 ADD EXO KONE-SHIN FL SWING&STANCE ADD EXOSKEL KONE-SHIN FLUID DME Full ClinST0 ClinST000 Authorization SHIN PNEUMAT/ HYDRA ADD EXOSKL KNEEE-SHIN Authorization Required DME Full Clinical Examination PNEUMAT/HYDRA PNEUMAT CNTRL L5781 ADD LW LEMB PROS LEMB MGMT SYS ADD LW LEMB PROS RESIDUL LEMB VOLME Complete LIMB DOLME L7MB ADD Authorization C25 S LIMB MGMT HVY ADD LW LIMB PROS RESIDUL LEMB Required authorization DME Full Clinical Examination DUTY MGMT SYS HEVY DUTY L5785 ADD EXOSKEL BELW KNEEE ULTRA-LT MATL ADD EXOSKEL SYSTEM BELW KNEE Authorization Required DMEIAL Full Clinical AB-7 KNEEE MATL. E ULTRA-LT MATL ADD EXOSKEL SYSTEM ABOVE KNEE Approval Required DME Full Clinical Review ULTRA-LGHT MATERIAL L5795 ADD EXOSKEL HIP DISARTIC ULTRA-LGHT ADD EXOSKEL SYSTEM HIP DISARTIC Approval Required DME Full Clinical Review ULTRA-LGOSKEL MATLNECK ULTRA-LGOSKEL MATLIN DISARTIC ULTRA-LGHT LGHT LGHT ENDOSKEL KNEE-SHIN SYSTEM 1 No authorization required AXIS MANUAL LOCK L5811 ADD ENDO KNEEE-SHIN MNL LCK ULTRA-LT ADD ENDOSKEL KNEEE-SHIN MNL LOCK Authorization required DME Full clinical examination ULTRA-LGHT MATL L5812 KONE-SHNDOSKEL FRANCE - SHIN FRICT Authorization required DME Full clinical examination SWING&STANCE CNTRL L5814 ADD ENDO KNEE-SHN HYDRAUL MECH ADD ENDOSKEL KNEE-SHIN HYDRAULIK Authorization required DME Full clinical examination LOCK SWING MECH LOCK ADDINHOCHNE KNEE KNEE KNEE KNEE KNEE KNEE KNEE KNEE KNEE KNEE KNEE KNEE Knee hydraulics -mech approval required DME full clinical review lock Stance phase lock l5818 Add endo knee-shin frict add endoscle knee-shin frict authorization required dme full clinical review swng and Stanc swinc & stance cntrl l5822 add endonTnTnNin. EUMAT Authorization Required DME Full Clinical Review SWING FRICT CNTRL L5824 ADD ENDO KNEE-SHIN FL SWING CNTRL ADD ENDOSCEL KNEE-SHIN FLUID Authorization Required DME Full Clinical Review SWING PHASE CNTRL L5826 ADD ENDO KNEE-SHIN MIN HI ACTIV- SWIN FREMNE Full Author's clinical examination MIN HI ACTV FRME L5828 ADD ENDO KONE-SHIN FL SWING&STANCE ADD ENDO KNEEE-SHIN FL Approval required DME Full clinical examination SWING&STANCE PHASE CNTRL L5830 ADD ENDO KONE-SHIN PNEUMAT-/SWING ADD CNEUSKEL BASE REQUIRED/ SWING PHASE CNTRL L5840 ADD ENDO KONE-SHIN LINK SWING 4-BAR ADD ENDO KNEE-SHIN 4-BAR LINK/MX- Authorization Required DME Full Clinical Review AXIAL PNEUMATIC L5845 ADD ENDOSKL KONE-SHIN STANCEL STACK-KNEE-SHIN STACK. Authorization Required DME full clinical review feature adj l5848 Add endoscel knee with fluid fluid add endoscel knee sys sys fluid DME required full clinical review stand extensn l5850 add endo ak/hip excosst knee add add knee/hip-extusst kn. uth Required KNEEE EXT ASST L5855 ADD ENDO HIP DISARTIC MECH EXT ASST ADD ENDOSKEL SYS HIP DISARTIC MECH No approval required HIP EXT ASST L5856 ADD LOW EXT PROS KN-SHN ADD LOW EXT PROS KNEE-SHIN DYS NEEDED SPHME authorized C SWN review SEE L58 57 ADD LOW EXT PROS KN-SHN SWING ADD LOW EXT PROS KONE-SHIN SYS Authorization Required DME Full Clinical Review SWING PHASE ONLY L5858 ADD LW EXT PROS KONE SHN SYS STAV ADD LW EXT PROS KONE SHIN SYS Full Review C SHIN SYS Full Review ONLY L5859 ADD LW EXT PROS KN-SHN PROG FLX/EXT ADD LOW EXT PROS KN-SHIN PROG Authorization Required DME Full Clinical Exam FLX/EXT ANY ENGINE L5910 ADD ENDOSCEL UNDER KNEEE ALIGNBL SYS ADD SYSTEM ENDOSCEL2 Obtained L5859 0 ADD ENDOSCEL AK/HIP DISRTC ALIGN BL ADD ENDOSKEL SYS AK/HIP DISARTIC Authorization Required DME Full Clinical Review ALIGNABLE SYSTM L5925 ADD ENDO AK/HIP DISARTIC MNL LOCK ADD ENDOSKEL AK-DISARTICNLH REQUIRED L5925 ADD ENDO AK/HIP DISARTIC O HI ACTV KONE CNTRL FRAME ADD ENDOSKEL SYSTEM HIGH ACTV REQUIRED authorization DME Full clinical examination KNEEE CONTROL FRAME L5940 ADD UNDER KNEEE ENDOSKEL ULTRA-LGHT ADD UNDER KNEEE ENDOSKEL SYSTEM No approval required ULTRA-LGHT MATLOVE KENDOSKHT0 ADD L5NE5HT EL SYSTEM ABOVE THE KNEE AK Approval required DME Full clinical examination ULTRA-LGHT MATL L5960 ADD ENDOSKL HIP DISARTC ULTRA -LGHT LGHT ADD ENDOSKEL SYSTEM HIP DISARTIC Authorization Required DME Full Clinical Review ULTRA-LGHT MATL L5961 ADD ENDOSKL HIP DISARTC ULTRA-LGHT ADD ENDO SYS POLYCNTRC HIP REQUIRED DME Full Clinical Review ROTATION CNTRL L5962 ADD ENDO BK FLEX AGAINST OUTER COVER ADD ENDOSKEL BK FLXIBLE PROTVE authorization required DME Full clinical review OUTR SURF COVERING L5964 ADD ENDO AK FLXBL PROTVE OUTENDR FLEX COVER ADDE Author Full clinical review OUTR SURF COVER L5966 ADD Endo HIP CRISTC FLX Protve COVR Add Endo HIP CRESTC FLXIBL Protve Authorization required DME Full clinical review Outr Surf COVR L5968 Add LW Limb Proth MX-Axial Ankle Add LW Limb Proth MX-Axial ANK Authorization Required DME Full Clinical Review W/Swing Phase L5969 Add ADD ENDOSKELETAL ANKLE-FT/ANK PWR ASSIST ENDOSKELETAL ANKLE-FT/ANK Authorization Required FOOT /ANK PWR ASSIST L5970 ALL LW EXTRM PROSTH FOOT SACH FOOT ALL LOW EXTREM PROSTH FT EXTERNAL None REQUIRED L5 SACHFOOT L5 SACHFOS 1 PRO 1 PL ONLY ALL LOWER EXTREME PROS SACH FOOT No approval required REPLACEMENT ONLY L5972 ALL LOW EXT PROS FOOT FLEXIBLE KEEL FOR ALL LOWER LIMB PROSTHETICS No approval required FOOT FLEX COOLER L5973 ENDO ANKPROCS FOOT CNTPROYS FOOT CNTPROYS FOOT MICROS FOOT SCR. DME Full clinical examination required PWR CONTROL PWR SRC L5974 ALL LW EXTRM PROSTH FT 1 AXIS ANK/FT ALL LOWER EXTRM PROSTH FT SINGLE No approval required AXIS ANK/FOOT L5975 ALL LW EXTRM PROSTH COMB 1 AXIS ANK ALL LW EXTRM PROSTH COMB 1 AXIS AFLX 7 AXIS AUT 7 AUT PROSTH ENERGY STOR FT PROSTHETICS FOR ALL LOWER EXTREMITIES DME approval required Full clinical examination ENERGY BEARING FOOT

180

L5978 ALL LW EXTRM PRSTH FT MX-AXL ANK/FT ALL LOWER EXTREM PROSTH FT MULTI- No approval required AXIAL ANK/FOOT L5979 ALL LW XTRM PRSTH MX-AXL ANK 1 PECE ALL LW EXTRM DYN Clinical examination RSPN FT 1 PECE L5980 ALL LOW EXTREM PROSTH FLX-FOOT SYS ALL LOWER EXTREME PROSTHETICS Required DME Approval Full Clinical Review FLEX-FOOT SYSTEM L5981 ALL LOW EXTREME PROSTH FLX-GAILING PROSTH FLX-GAILING PROSTHESIS Full DME Full Review Clinical Review WALK SYSTEM/EQUAL L5982 ALL EXOS KEL LW EXT PROS AXIAL ROTAT ALL EXOSKEL LOW EXTREM PROSTH Required DME approval Full clinical examination AXIAL ROTAT UNIT L5984 ALL ENDOSKEL LW EXT PRSTH EXTREM PROSTH REQUIRED Clinical examination ROTAT UNIT ADJ L5985 ALL ENDOSKEL LW XTRM PROSTH DYNAMIC ALL ENDOSKEL LOW EXTREM PROSTH No approval required DYN PROSTH PYLN L5986 ALL LW EXTRM PROSTH MX-AXIAL ROT U ALL LOW EXTERM PROSTH MULTI-AXIAL RWT Full Review Clin-AXIAL D5 EXTRM PROSTH SHANK FOOTSYS ALL LW XTRM PRSTH SHNK FT SYS Approval Required DME Full Clinical Review W/VRTCL LOAD PYLN L5988 ADD LW LMB PRSTH VERTCL SUPPORT RDUC ADD LW LEMS PROSTH VERTCL BUMP Approval Required DME Full Clinical Review LXDD0 PRO 9 USE ADJ HEEL HT ADD LOWER LIMB PROSTHESIS USER Authorization Required DME Full Clinical Review ADJUSTABLE HEEL HT L5999 LOWER LIMB PROSTHESIS NO. PROSTHESIS OF THE LOWER EXTREMITIES NO. No Approval Required L6000 PARTIAL REMAINING THUMB View Full REMAINING THUMB View Length L6010 PARTIAL HAND SMALL &/ RING REM PARTIAL HAND SMALL & OR RING Approval Required DME Full Clinical Exam REMAINING FINGER L6020 PARTIAL HAND NO REMAINING FINGER PARTIAL H AND NO FINGER REMAINING Authorization Required DME Full Clinical Review L6026 TransCarpl/MCART/DEL Hand DME Rest DME Full Clinical Review PRO PESARTICULATIONS PROSETS L6050 WRST DSRTC PALLES SPOTCE FLEX ELB HNG DISARTIC PALSCE FLEST ELB MANDATORY Clinical Review TRICP TRICP TRICP /XDISART Authorization Required SCKT W/ XDISART INTERFCE W/ XPNDABLE INTERFCE L6100 BELW ELB MOLD SOCKT FLXIBLE ELB HNG BELW ELB MOLD SOCKT FLXIBLE ELB Authorization Required DME Full Clinical Review HINGES TRICP PAD L6110 BELOW KNEE CAST SOCKET MOLD BELOW Full Review C2 KNEE L 6 SOCKET REQUIRED W W ELB STEP-UP HALF CUFF HOOKS BELG ELB MOLD DBL WALL SCKT STEP- Authorization Required DME Full Clinical Examination UP HNG 1/2 CUFF L6130 BELW ELB STMP ACTV LCK HNG 1/2 CUFF BELW ELB STUB AKTVATD LOCKING HINGE Authorization Required Full Clinical DME Examination L620 CUFF CLINICAL EXAMINATION L6200 CLINICAL EXAMINATION LCK FOREARM ELB DISARTC FORM SOCKT External Approval Required DME Full Clinical Review HINGE LOCK FOREARM L6205 ELB DSRTC FORM SCKT XPND INTRFC HAND ELB DISARTC FORM SCKT M/XPND Approval Required DME Full Clinical Review INTRFEL INTRFEL L62B5 FOREARM L62B5 FORARM FORARM L62B5 M ABVE ELB FORM DBL WALL SCKT INTRL Required approval DME Full Clinical Review LCK ELB FORARM L6300 SHLDR DISARTC INTRL LOCK ELB FORARM SHLDR DISARTIC MOLD SOCKET INTRL Approval Required DME Full Clinical Review LOCK ELB FORARM L6310 SHLASSART DISULDER By PASSHL ART DISULDER ON Required DME Full Clinical Review COMPLETE PROSTH L6320 SHLDR DISART PASS REST SHLDR CAP SHOULDER DISART PASSIVE REST Approval Required DME Full Clinical Review SHOULD CAP ONLY L6350 INTRSCAP THOR INTRL LOCK ELB FOREARM INTERSCAP THOR HUM REQUIRED Full INTBLOCK SECT INTBEL 6 INTERSCAPULAR THOR CO MPLT PROSTH INTERSCAPULAR THOR PASSIVE REST Authorization Required DME Full Clinical Review CMPL PROSTH L6370 INTERSCAPULAR THOR SHLDR CAP ONLY INTERSCAPULAR THOR PASSIVE REST DME required full clinical review SHLDR CAP ONLY L6380 IMMED POSTSURG RIGDRIG DRGI CRSG RIGDRIG CDRSG POSTSURG RIGDRI qui red DME full clinical review DSRTC CHG WRST DISRTC L6382 IMMED POSTSURG STIFFNESS DRSG ELB DIRTC IMMED POSTSURG RIGD DRSG 1 CAST Authorization Required DME Full Clinical Review CHG ELB DISARTIC L6384 IMMED POSTSRG RIGD DRSG SHLDR DSRSG RIGD Full CAST DRSGRIGD CSKRIGD CRIGD CRIGD CRIGD Review CHG SHLDR DISRTC L6386 IMMED POSTSURG EA ADD CAST SHI FT IMMED POSLTURG/EARLY FIT EA ADD No approval required CAST CHG&REALIGN L6388 IMMED POST SURG RIGID DRSG ONLY IMMED POST SURG/EARLY FITTING APPLICATION No approval required ONLY RIGID DRESS L6400 BE PROLD MODK KTELSSKTOS BE PROLDS KLOSDK EL SYS M/SFT Approval required DME Full clinical examination PROS TH TISS SHAP L6450 ELB DISARTIC MOLD SOCKET ENDOSCEL ELB DIRTC MOLD SCKT ENDOSCEL DME Approval Required Full Clinical Review M/SFT PROSTH TISS L6500 ABOVE ALBOW MOLD MOLD SCKT ENDOSCEL DME Approval Required Full Clinical Review PROSTH TISS L6550 SHLDR DISARTC MOLD SOCKET ENDOSCEL SHLDR DISRTC MOLD SC KT ENDOSCEL Authorization Full Clinical Review Required DME W/SFT PRO TISS L6570 INTRSCAP THOR MOLD ENTRY ENDOSCEL INTRSCAP THOR MOLD Approval REQUIRED W/SFT Full Clinical Exam TISS L6580 PREP WRST DISARTIC PLSTC SOCKT MOLD PREP WRST DISRTC/BELW ELB 1 WALL Approval Required DME Full Clinical Exam PLSTC SCKT MOLD L6582 PREP WRST DISARTC ELB SCKT DIR FORM PREP WRST DISRTC/BELW ELB 1 WALL ELB 1 WALL FORM Authorization C6 Wall PREPSC Authorization C5 ELB DISARTC PLASTIC SOCKT MOLD PREP ELB DISRTC/ABVE ELB 1 WALL Authorization Required DME Full Clinical Examination PLSTC SOCKT MOLD L6586 PREP ELB DISARTC SOCKET MOLD PREP ELB DISRTC/ABVE ELB 1 WALL Authorization Required ABVE ELB 1 WALL Authorization required DME PROCKT CHLRT 8. THOR PLSTC SOCKT PREP SHLDR DISRTC THOR 1 WALL Authorization required DME Full Clinical Examination PLSTC SCKT MOLLD L6590 PREP SHLDR DSRTC THOR SCKT DIR FORM PREP SHLDR DISRTC THOR 1 WALL - Authorization required DME Full Clinical review L6TREM DIRRTC THOR 1 WALL authorization PLSTC SCKT FORM L65TREM 0 FORM OF 6TREM AFORM 0 BY END ADD no. Authority required POLYCENTRIC HINGE PAIR L6605 UPPER EXTREMITY ADD 1 SWITCH PAIR UPPER EXTREMITY ADD ONE SWITCH No authorization required HINGE PAIR L6610 UP EXT ADD FLEX METAL HINGE PAIR UPPER EXTREMITY Obtained Auth Auth Auth OP EXT PROS EXT PWR ADD SWITCH ADD UPPER EXT PROS EXTERNAL PWR No authorization required ADDITIONAL SWITCH L6615 UP EXTREM ADD DISCNCT LOCK WRST IN UPPER EXTREM A DD DISCONNECT Authorization not required LOCK WRST UNIT L6616 UP EXT EXTREM ADD WRST-INDS CN ERT LOCK Authorization not required WRST IN EA

181

L6620 UP EXT ADD FLEX/EXT WRIST UNIT UPPER EXT ADD FLEX/EXT WRIST UNIT No Authorization Required W/WO FRICTION L6621 UP EXTREM PROS ADD FLEX/EXTEN WRIST UP EXTREME PROS ADD Authorization Required DMEFLEX WRST 6 EXTREME 6 ADD ROTATL WRST W/LA TCH RLSE UP EXT ADD SPRNG ASST ROTATL WRST Authorization Required DME Full Clinical Exam U W/LATCH RLSE L6624 UP EXT ADD FLX/EXT ROT HAND CONTROL UNIT UPPER LIMB ADD Full FLX/EXT D5 UP EXT ADD ROTAT WRST W/CABLE LOCK UPPER LIMB ADD ROTATION Authorization Required WRST DME Full Clinical Exam UNIT W/CABLE TERMINAL L6628 UP EXTRM ADD QUICK DISCONNECT EXTRM ADD QUICK DISCONNECT L6 In Auth. L6 HANGING HOOK REQUIRED/2 UIK DSCNCT LAMNAT COLLR UP EXTRM ADD QUICK DISCNCT No approval required LAMINATION COLLR L6630 UP EXTREM ADD STAINLESS STEEL HANDLE UPPER EXTREM ADD STAINLESS No approval required STEEL ALL CONNECTIONS L6632 ADD UPLA EXTREE M DITION LATEX No approval required SUSPENSION KEYS EA L6635 UPPER EXTREM ADD LIFT ASSIST ELB UPER EXTREMITY ADD LIFT No approval required ASSIST FOR ALBUW L6637 UP EXTREM ADD NUDGE CNTRL ELB LOCK UPER EXTREMITY ADDIT NUDGE No approval required CONTROL ELB 8 PRONL LOCK L6B 8 PRONL LOCK L6B 8 PRON L LOCK LWB UP OUT PROFESSIONALS ELEC LOCK ONLY Authorization required DME Full Clinical Exam W/MNL PWR ELB L6640 UPPER EXTREM ADD SHLDR ABDUCT JNT PAIR UPPER EXTREMITY ADD SHOULDER No authorization required ABDUCT PAIR OF JOINTS L6641 UPPER EXTRM ADD EXCURSN ADD EXCULSN EXCULL EXCURS EquiUPDD EXPULL EXTREM ADD EXCUR L6642 UP EXTRM ADD EXCURSN AMPL LEVER UPER EXTREM ADD EXCURSION No Authorization Required AMPLIFIER LEVER TYPE L6645 UP EXT ADD SHLDR FLX-ABDUCT JNT EA UPPER EXTREM ADD SHLDR FLEX- No Authorization Required ABDUCT 6XT AHLYS JOINT STN OP EXT ADD SHLDR JNT MX PSTN Authorization Required DME Full Clinical Review W/BDY/EXT PWR SYS L6647 UP EXT ADD SHLDR LOCK MECH BDY PWR UP EXTREM ADD SHLDR LOCK MECH Authorization Required DME Full Clinical Review BDY PWR ACTUATOR L6648 SHLDR LOCK MECH PWR UP EXTREM ADD SHLDR LOCK MECH EXT Authorization Required DME Full Clinica l Overview PWR ACTUATOR L6650 UP EXTRM ADD SHLDR UNIVERSAL JNT EA UPER EXTREM ADD SHLDR No approval required UNIVERSAL JUNCTION EA L6655 UP EXTREM ACTUATOR L6655 UP EXTREM CADDLE XTREM Auth ADD ADDLE STD EXTRAD Auth CABLE EXTRA L6660 UP EX TREM ADD HEVY DUTY CNTRL CABLE UPPER EXTREM ADD HEAVY DUTY No Auth Required CONTROL CABLE L6665 UP EXTREM ADD TEFLON/= CABLE COVER UPER EXTREM ADD No Auth Required TEFLON/ELIQUAND A BLE UPER EXTREMITY EXTRA HOOK No authorization required ADAPTR HAND CABLE ADAPTER L6672 UP EXT ADD HRNSS CHST/SHLDR SADD LE UPPER EXTREM ADD HARNESS No Authorization Required CHST/SHLUPPER EXTREM AD L6675 UP EXT ADD LIGHTING 1 CABLE DESIGN UPPER EXTREM ADD LIGHTING No Authorization Required CHST/SHLUPPER EXTREM AD L6675 UP EXT ADD LIGHTING 1 CABLE DESIGN UPPER ADD EXTREGN REQUIRED CABLES 676 UP EX ADD CABLE DESIGN HARNESS 2 UPPER EXTREME ADD HARNESS DUAL No Approval Required CABLE DESIGN L6677 UP EXT ADD HRNSS 3 CNTRL UP DVC&ELB UP EXT ADD HARNESS 3 CNTRL No Approval Required SIMULTANEOUS OP DEVC&ELB L6680 ADD DISPLAY AXTTREM ADD UPST TST SOCKT WRST No Approval Required D ISARTIC/ BELW ELB L6682 GORE EXTRM ADD TST SOCKT ELB DISARTIC UPER EXTREM ADD TST SOCKT ELB No authorization required DISARTIC/ABVE ELB L6684 UP EXTRM ADD TST SCKT SHLDR DISARTC UP EXTRM Aquicuth Aquict TDR DISARTC UP EXTRM Aquicuth THOR L6686 UPER EXTREMITY ADD SUGE SOCKT EXTRA SUCTION UPPER EXTREM EXTREMITY Needs DME Approval Full Clinical Examination SOCKET L6687 GORE EXT ADD FRME TYPE SCKT BELW ELB GORE EXTRM ADD FRME TYPE SCKT BELW Needs DME Approval Full Clinical Examination 8PE TYPE SCKT ELB BELW 8 ABVE ELB GORE EXTRM ADD FRME TYPE SOCKT ABVE Needs DME Approval Full Clinical examination ELB/ELB DI SRTC L6689 UP EXT ADD FRAME SCKT SHLDR DISARTC UPPER EXTREM ADD FRAME TYPE Approval required DME Full clinical examination SOCKT SHLDR DISART0P DISARTUP L6SC 9DDTRAME PER EXTREME ADD FRAME TYPE Authorization required DME Full clinical examination SOCKT INTERSCAP-THOR L6691 UPPER EXTREM ADD REMV INSERT EA UPER EXTREMITY ADD No Approval Required REMOTE INSERT EACH L6692 UPPER EXTREM ADD SILKONE GEL ADD INSERT/=EXTREM Author Acquired ical Review INSERT/ EQUAL EA L6693 UPPER EXT ADD LOCK ELB FOREARM CNTRBAL UPER EXTREM ADD LOCK ELB FOREARM Approval Required DME Full Clinical review COUNTERBALANCE L66 94 ADD EXT PROS CSTM W/LOCK MECH ADD EXT EXTREME REQUIREMENT BELWAB Authorization Clin PROS BELWAB/Required LOCK MECH L6695 ADD UP EXT PROS CSTM U/O LOCK MECH ADD UP EXT PRO BELW/ABVE ELB Authorization Required DME Full Clinical Exam CSTM U/O LOCK MECH L6696 ADD UP EXT PROS CNGN /TRAUM AMP ADD UP Required DME Full Clinical Exam CNGN/TRAUM AMP INIT L6697 ADD EXT PROS NOT CNGN/TRAUM ADD EXT PROS ELB CSTM NO Authorization Required DME Full Clinical Exam CNGN/TRAUM AMP INIT TRAUMA AMP INIT L6698 ADD UP EXT PROS LOCK UPINS PROS ADDC ELB LOCK MECH EXCL Authorization Required DME Full Clinical Exam SCKT INSRT L6703 TERMINAL DEVICE PASSIVE HAND/GLOVE TERMINAL DEVICE PASSIVE HND/GLOVE No approval required SOME MATERIALS SZ L6704 TERMINAL DEVC SPORT/RECORDING/ CREW DACHME REVISION Complete FREE TIME/ WORK CONNECTION L6706 TERMINAL DEVC HOOK MECH VOL TERMINAL DEVICE HOOK MECH No Approval Required OPENING VOLUNTRY OPENING L6707 TERMINAL DEVC HOOK MECH VOL TERMINAL DEVICE HOOK MECH Approval Required LCLUNTA Clinical LCLUNTA VOLRY AL DEVC HAND MECH VOL TERMINAL DEV ICE HAND MECH Approval Required DME Full Clinical Exam OPEN VOLUNTARY OPEN L6709 TERMINAL DEVC HAND MECH VOL TERMINAL DEVICE HAND MECH Approval Required DME Full Clinical Exam CLOSE VOLUNTARY CLOSE L6711 TERM DVC HOOK MECH VOL OPN OP PED Author A Full ME OPN PED REQ. Browse MATL ANY SZ PED

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L6712 TERM DVC HOOK MECH VOL CLOS PED TERM DVC HOOK MECH VOL CLOS ALL Potrebna autorizacija DME Potpuni klinički pregled MATL ANY SZ PED L6713 TERM DVC HAND MECH VOL OPN PED TERM DVC HAND MECH VOL OPN DME Puna autorizacija BILO KOJA REVIZIJA BILO KOJI PED CNY L6714 TERM DEV C HAND MECH VOL CLOS PED TERM DEVC HAND MECH VOL CLOS ALL Potrebna autorizacija DME Potpuni klinički pregled MATL ANY SZ PED L6715 TERM DEVC MX ARTC DIG INIT ISS/REPL TERM DEV MX ARTIC DIGIT C/Potreban pregled IN EDITION/REPL. L6721 TERM DEVC HOOK/HAND HD MECH VOL TERM DEVC HOOK/HND HVY-DUTY Potreban DME puni klinički pregled OPN MECH VOL OPN ANY SZ L6722 TERM DEVC HOOK/HND HD MECH VOL TERM-/DUTY DEHVY HOOK Potreban DME puni klinički pregled CLOS MECH VOL CLOS L6805 ADD TERM DEVICE MODIFIER WRIST UNIT ADDTION TERMINAL DEVICE MODIFIER No Authorization Required WRIST UNIT L6810 ADD TERM DEVC PRECISION PINCH DEVC ADDITION TERMINAL DEVICE NO DEVICE Auth Rquired /MYOELEC CNTRL ARTC DIG ELEC HAND SWTCH/MYO ELEC CNTRL Potrebna autorizacija DME Potpuni klinički pregled INDEP ARTC DIG MTR L6881 AUTOMATIC GRASP ADD UPPER LIMB PROS DEVC AUTOMATIC GRASP ADD UPPER LIMB Potrebna autorizacija DME Potpuni klinički pregled ELEC PROSTH DEVC L6881 ELEC PROSTH DEVC L6 S CNTRL FUNKCIJA ADD Potrebna autorizacija DME Potpuni klinički pregled LIMB PROSTH DEVC L6883 REPL S KOLIČINA BE /WD MODEL PACIJENATA L6884 REPL UKLJUČIVANJE IZNAD ALB ISKLJUČENO PREKO ELB-a DISART KALUŠ PREKO ELB-a Potrebna je ZAMJENSKA PODRŠKA DME Potpuni klinički pregled DME. DME Potpuni klinički pregled DISART MODEL ZA PT L6885 REPL SOCKET SD/INTRSCAP THOR MOLD PT REPL SOCKET SD/INTERSCAPULAR THOR potrebna autorizacija DME Potpuni klinički pregled MODEL PT MODEL L6890 ADD EXT PROSTH GLOV TERM PRFAB PRO ADD Auth. PRFAB W/FIT&ADJ L6895 ADD EXT PROSTH GLOV TERM CSTM ADD EXT PROSTH GLOV TERM DEVC potrebna autorizacija DME Potpuni klinički pregled MATL CSTM FAB L6900 HND REST PART W/GLOV THUMMB/1 FNGR Referenca HAND REST PART Autor HAND REST PART Klinički pregled THUMMB/ 1 FNGR REMAIN L6905 HND REST DIO HND W/GLOV MX FNGR HAND REST DIO RUKA W/RUKAVICA MX Authorization Required DME Full Clinical Review FNGR REMAIN L6910 HND REST DIO HND W/GLOV NO FNGR HAND HAND DIO RUKA W/RUKAVICA NO Authorization Required DME Potpuni klinički pregled FNGR REMAIN L6915 Rukavica - stabilna zamjena za restrikciju Zamjena potrebna autorizacija DME Potpuni klinički pregled Handke Za gore navedeno L6920 WRST DISARTC OTTO BOCK/= SWTCH WRST DISARTIC DISARTI WRST DISARTIC OTTO BOCK/=MYOELEC Potrebno odobrenje DME Potpuni klinički pregled CNTRL CNT RL TERM DEVC L6930 LEW LAKAT OTTO BOCKTO SWITBOCK CNTRL TERM DEVICE CNTRL TERM BOCK/=SWITCH BOCK crveni DME Potpuni klinički pregled CNTRL TERM DEVICE L6935 BELW ELBOW OTTO BOCK/=MYOELEC ISPOD LAKTA OTTO BOCK/=MYOELEC Potrebna autorizacija DME Potpuni klinički pregled CNTRL CNTRL POJAM UREĐAJ L6940 ELB DISRTC OTTO TERM BOCKTO BOCK/= Potrebna autorizacija DME Potpuni klinički pregled CNTRL TERM DEVC L6945 ELB DIRTC OTTO BOCK/=MYOELC CNTRL ELB DISARTIC OTTO BOCK/= MYOELEC Potrebna autorizacija DME Potpuni klinički pregled CNTRL TERM DEVC L6950 IZNAD ELB OTTO BOCKTO BOCKTO BOCKTO BOCKTO BOCKTO BOCKTO BOCKTO BOCKTO BOCKTO BOCK/=PREBACI GORE Klin. ical Review CONTROL CNTRL TERM DEVC L6955 ABVE ELBOW OTTO BOCK/=MYOELEC OVER ELBOW OTTO BOCK/=MYOELEC Authorization Required DME Full Clinical Review CNTRL CNTRL TERM DEVC L6960 SHLDR DSRTC OTTO BOCK/=SWTHLTO BOCK/=SWTHLSW DISCH DISART Author DME Full Clinica l Pregled CNTRL TERM DEVC L6965 SHLDR DSRTC OTTO BOCK/=MYOELC SHOULDR DISARTIC OTTO Potrebna autorizacija DME Potpuni klinički pregled CNTRL BOCK/=MYOELEC CNTRL TERM L6970 INTERSCAPULR-THOR OTTO INTERSCAP-BOTHOR/klinički pregled Autorizacija/klinički pregled =SHIFT CNTRL TERM DEVC L 6975 INTERSCAP- THOR THORAC OTTO INTERSCAP-THOR OTTO Potrebno odobrenje DME Potpuni klinički pregled BOCK/=MYOELEC BOCK/=MYOELEC CNTRL TERM DVC L7007 ELEC HND SWTCH/MYOELECTRIC CNTRL HANDYOELIC POTREBAN ical Review CONTROL ADULT L7008 ELEC HAND SWTCH/MYOELEC CNT RL PED ELEKTRIČNI PREKIDAČ KUKA/MYOELECTRIC Potrebna autorizacija DME Potpuni klinički pregled CNTRL PEDIATRIC L7009 ELECTRIC HOOK SWITCH/MYOELC CNTRL ELECTRIC HOOK SWITCH/MYOELECTRIC autorizacija CNTRL PEDIATRIC L7009 PENDANT ACTUATOR KONTAKT Potrebna autorizacija DME Potpuni klinički pregled KONTROLIRANI L7045 ELECTRIC HOOK SWITCH MYOELEC CO NTRL ELEC HOOK SWITCH/MYOELECTRIC Potrebna autorizacija DME Full Clinical Pregled PE D CONTROL PEDIATRIC L7170 ELEC ELB HOSMER/EQUANTICRL SWITCH HOSMER/EQUANTICEL SWITCH HQ Puni klinički pregled SWITCH CONTROLLED L7180 ELEC ELB SEQUENTL CNL ELEC ELB ADOLES VRITY VILL/=SHIFT ELEC ELB ADOLES VRITY VILLAGE/EQUAL Potrebno odobrenje DME Potpuni klinički pregled SWITCH CNTRL L7186 ELEC ELB CHLD VRITY VILL/=SWITCH ELEC ELB CHILD VRITY VILLAGE/EQUAL Potrebna autorizacija DME Potpuni klinički pregled SWITCH CNTRL L71ELCBILL AELEVELC AELEVELC AELEV AELEV AELEV. DOLES VRITY VILLAGE /= Potrebna autorizacija DME Potpuni klinički pregled MYOELEC CNTRL L7191 ELEC ELB CHLD VRITY VILL/=MYOELEC ELEC ELB CHLD VRITY VILL/= Potrebna autorizacija DME Potpuni klinički pregled MYOELECTRNICALY CNTRL L7259 ELECTRONYEL WRISTRON WRISTROTY izacija Potrebna DME Potpuna klinička Pregled L7360 SIX VOLT BATERIJA SVAKA ŠEST VOLTI BATERIJA SVAKA Nije potrebna autorizacija L7362 PUNJAČ BATERIJA ŠEST VOLT SVAKA PUNJAČ BATERIJA ŠEST VOLT SVAKA Ne potrebna autorizacija L7364 DVANAEST VOLTNA BATERIJA SVAKA DVANAEST VOACH BATERIJA L7364 12 VOLTI SVAKA PUNJAČ 12 VOLT EACH Potrebno odobrenje DME Potpuni klinički pregled L7367 LITIJ-IONSKA BATERIJA PUNJIVA ZAMJENSKA LITIJ-IONSKA BATERIJA PUNJIVA Nije potrebno odobrenje ZAMJENA L7368 PUNJAČ LITIJ-IONSKIH BATERIJA SAMO ZAMJENSKI PUNJAČ LITIJ-IONSKIH BATERIJA A L7368 PUNJAČ LITIJ-IONSKIH BATERIJA SAMO ZAMJENSKI PUNJAČ LITIJ-IONSKIH BATERIJA AUT 0 0 ULT RALT MATL DODAJTE EKSTREMNE PROFESIONALCE POD ELB/WD Nije potrebno odobrenje ULTRALAGANI MATL

183

L7401 ADD EXT PROS ABV ED ULTRALT MATL ADD EXTREM PROS AE DISART No approval required ULTRALIGHT MATL L7402 ADD EXT PROS SD/INTRSCAP THOR ADD EXT PROS SD/INTRSCAPULR No approval required 4 ACRYLIC MATL ADD EXTERNAL PROS BE/WRIST No approval required DISART ACRYLIC MATL L7404 ADD EXT PROS ABVE ED ACRYLC MATL ADD EXTRA PROS ABOVE ELB DME Approval Required Full Clinical Review DISART ACRYLIC MATL UP SDOR L740 AXT 5. EXTREM PROS SD/INTERSCAP DME Approval Required Full Clinical Review THOR ACRYLC MATL L7499 UPPER LIMB PROSTHESIS NO. UPPER LIMB PROSTHESIS NO NO Authorization Required 7520 REPR PROSTH DEVC LABR CMPNT-15 MIN REPAIR PROSTHETIC WORK No Authorization Required CMPNT PER 15 MIN L7700 GKT/SEAL USE PROS SOC IN ALL TYPES EA PACKING/SEAL USE PROS SOCKET INSERT No Authorization Required General Medicine - ANY TYPE and L8000 behavior assessment. BREAST PROS MAST BH NO INTEG FORM BREAST PROS MASTECTOMY BHU WITHOUT Authorization required INTEG PROS FORM L8001 BREAST PROS MAST BRA INTEG FORM UNI BREAST PROS MASTECT BRA W/INTEG No Auth required BREAST FORM UNI L8002 DRUDI BREAST MAST PROS MASTECT BH W/INTEG No authorization required BREAST SHAPE BIL L8010 BREAST PROSTHESIS MASTECTOMY BREAST PROSTHESIS MASTECTOMY No authorization required SLEEV STRAP L8015 EXT BREAST PROS GARMNT POST-EXT BRST PROSTHESIS MASTECTOMY No authorization required SLEEV STRAP L8015 EXT BREAST PROS GARMNT POST-EXT BRST PROS MASTECTOMY THESIS No authorization required SLEAVE STRAP L8015 EXT BREAST PROS GARMNT POST-EXT BRST PROSTHESIS MASTECTOMY No Auth Required ARM STRAP L8015 EXT BREAST PROS GARMNT POST-EXT BRST PROSTHESIS MASTECTOMY No. 0 FORM FOR MASTECTOMY BREAST PROSTHESIS MASTECTOMY BREAST PROSTHESIS No approval required FORM L8030 BREAST PROS SILCON/=NO INTGRL ADHES BREAST PROSTH SILICONE/EQUAL U/O No approval required INTEGRAL ADHES L8031 BREAST PROS SILCON/= W/NTGRL PROSTHES BREAST PROSTHESIS BREAST PROSTHESIS / NTEGRAL ADHESIVE L8032 NIPPLE PROFAB PREFAB REUSABLE ANY T EA NIPPLE PROSTH PREFAB REUSABLE No Approval Required ANY TYPE EACH L8033 NIP PRS CSTM FB USE ANY MTL T EA NIPLE PROSTH CSTM REQUIRED Full FAB T A5 CSTM BRST PROSTH POST MASTECT MOLD CSTM BREAST PROSTHESIS POST MASTECT Authorization Required DME Full Clinical Exam CAST PT MODEL L8039 BREAST PROSTHESIS NO. BREAST PROSTH NOT OTHER No Authorization Required SPECIFIED L8040 NASL PROSTH SUPPLIED NOT COMPLETE By SUB-PHYSICIANS Full Review NON-PHYSICIAN L8041 MIDFCE PROSTH PROV NON-PHYSICIAN INTERMEDIATE MEDICAL PROSTH SUPPLIED WITH AUTHORIZATION REQUIRED DME Full Clinical Review NON-PHY SICIAN L8042 ORB PROSTH NOT SUPPLIED - PHYSICIAN'S ORBITAL PROSTH PROVIDING REQUIRED DME Full CPH4CE DEVELOPMENT NON-PHYDICIAN UPPER FACIAL PROSTHESIS RULE REQUIRED DME AUTHORIZATION Full Clinical Review NON-PHYSICIAN L8044 HEMI-FCE PROSTH PROV NON-PHYSICIAN HEMI-FACIAL PROSTH PROVIDING REQUIRED DME Full Clinical Review NON-PHYSICIAN PHYSICIAN L8045 PERFORMED BY AUTHORITY Required DME Full Clinical Exam PHYSICIAN NO PHYSICIAN L8046 PART FCE PROSTH PROV NON-PHYSICS PARTIAL FACIAL PROSTHESIS SUPPLIED Approval Required DME Full Clinical Exam NO PHYSICIAN L8047 NASL SEPTAL PROS TH PROV. linear review NON-PHYSICIAN L8048 UNS MAXLOFCE PROSTH BR PROV NON-UNS MAXILLOFCE PROSTH BR SUPPLIED No authorization required MD NON-PHYSICIAN L8049 REP MAXLOFCE PROS EA 15 MIN NON-MD REP/MOD MAXLOFCE PROSTH LABREA N8MD TRMIN0 LABR 3. LE SA STANDARD BASE. SINGLE BRACKET WITH STANDARD PAD No approval required L8310 DOUBLE BRACKET WITH STANDARD PAD DOUBLE BRACKET WITH STANDARD PAD No approval required L8320 STANDARD ADDITION STANDARD PAD H2O STANDARD PAD ADDITION TO STANDARD A STAND 3 STAND 3 ARD PAD SCROTAL PAD CARRIER ADDITION TO STANDARD PAD No application roval required SCROTAL PAD L8400 BELOW KNEE PROSTHETIC EACH BELOW KNEE PROSTHETIC No approval required. ACH PROSTHETIC UPPER LIMB EACH No approval required L8417 PROSTHETIC LEG/SOCK-GEL CUSHION BK/AK EA PROSTH SEAT/SOCK W/GEL CUSHION No approval required LAY BK/AK EACH L8420 PROSTHETIC SOCK MX LAYER BELOW THE KNEE EA PROSTHETIC SOCK MULTI-LAYER B3 PROSTHETIC ST MX PLY ABOVE THE KNEE SOCK EA PROSTHETIC SOCK MULTILAYER ABOVE THE KNEE AK EACH L8435 PROSTHETIC SOCK MX PLY UPPER LIMB KNITTED EA PROSTHETIC SOCK MULTILAYER OVER No approval required LIMB EACH L8440 PIECE BELLE KNEICHR K No approval required EACH L8460 ABOVE KNEE STRAP EACH PROSTHETIC CREAM ABOVE KNEE AK No approval required. EACH L8465 PROSTHETIC CREAM UPPER LIMB EACH PROSTHETIC CREAM UPPER LIMB No approval required. red BELOW THE KNEE EA L8480 PROSTHETIC SOCK SINGLE LAYER FIT ABOVE THE KNEE EA PROSTHETIC SOCK SINGLE JOINT No approval required ABOVE THE KNEE EA L8485 PROSTHETIC SOCK 1-LAYER UPPER LIMB FIT FLOW EA PROSTHETIC SOCK SINGLE JOINT No approval required UPPER LIMB PRONLIST PRO UNLST4C UNLST4 DEVELOPMENT requires DME authorization Full Clinical Review PROSTHETIC SERVICES L8500 ARTIFICIAL LARYNX ANY TYPE ARTIFICIAL LARYNX ANY TYPE DME Approval Required Full Clinical Review L8501 TRACHEOSTOMY SPEECH VALVE TRACHEOSTOMY SPEECH VALVE No Approval Required B850 5X REFICCART L8505X REFICC LARYNX REPLCMT No Approval Required BATTERY/ANY ACCESS TYPE L850 7 TRACHEO -ESOPH VOICE PROSTH PT INSRT TRACHEO-ESOPH VOICE PROSTH PT No approval required INSRT ANY TYPE EA

184

L8509 TRACHEO-ESOPH VOICE PROS INSRT PROV TRACHEO-ESOPH VOICE PROSTH INSRT No approval required LIC HEALTH PROV L8510 VOICE AMPLIFIER VOICE AMPLIFIER No approval required L8511 INSRT INDWLL TRACHERTEOSOPH PROW procured M/WO VALVE REPLCMT L8512 GEL ATIN CAPS/EQUALNT GELATIN CAPS/EQUALNT None approvals required fox M /TRACHEOESOPH VOICE PROS L8513 CLEANING DEVC USED W/TRACHEOESOPH CLEANING DEVC USED No approval required V W/TRACHEOESOPH VOICE PROS PIP L85OENCIL PIP L8514 PIP L8514 TURE DILAT No approval required EA REPLACEMENT ONLY L8515 GELATN C AP APPLC DEV TE VOICE PRSTH GELATINE CAP APPLIC DEVC No approval required TRACHOESOPH VOICE PROSTH L8600 IMPL BREAST PROSTHESIS SILICONE/FLAT BREAST PROSTHESIS REQUIRED DEM L3 LL IMPL URINARY TRACT 2.5ML ACID INJ BULK AGT COLL IMPL URINARY TRACT No approval required 2.5ML SYRINGE L 8604 INJ BULKING AGT URINE 1 ML INJECTABLE BULKING AGENT URINARY No approval required TRACT 1 ML L8605 INJ BLK AGT DX/HA INJALHAIM 1 COPLANALHAIM AGT DX/HA INJ. PL Approval Required DME Full Clinical Examination ANAL CNL 1 ML L8606 INJ SYNTH IMPL URINE TRACT 1 ML ACID INJ BULK AGT SYNTH IMPL URINE TRACT No Approval Required 1 ML SYRINGE L8607 INJ BLK AGT VC MEDIALIZATION IN 01 Cquid. 0.1 ML L8608 MISCELLANEOUS EXT COMP SPL/ACCESS ARGUS II MISCELLANEOUS EXT COMP SPL/ACSS FOR ARGUS II Approval Required Full Clinical Review RET PROS SYS L8609 KUNGSTIG HORNHHANDE Approval Required DME Full Clinical Review L8610 OCULAR IMPLANT OCULAR IMPLANT OQ UE L6 S SHUNT AQUEOUS SHUNT Authorization Required DME Full Clinical Review L8613 OSSICULA IMPLANT OSSICULA IMPLANT No Approval Required L8614 COCHLEAR DEVC INCL INT&EXT COCHLEAR DEVICE INCLUSIVE ALL Authorization Required Hearing Aids Full Clinical Review COMPNADHEET/5 COCHLR IMPL REPL HEADSET/HEADSTIECE COCHLEAR Authorization Required Hearing A ids Full Clinical Review UNIT FOR IMPLANT REPL L8616 MICROPHONE COCHLEAR IMPL DEVC REPL MICROPHONE COCHLEAR IMPLANT Authorization Required Hearing Aids Full Clinical Examination DEVICE REPLACEMENT L8617 TRNSMTTING COIL COCHLEAR IMPLARING COCHLEAR IMPLARING COCHLEAR IMPLARING COCHLEAR IMPLARING COPLIN TRANSFER REPL. ANT DEVICE REPL L8618 TX CBL U CI/ AUD OSSEOINTG DVC REPL TRNSMT CBL USE CI DEVC/AUD Authorization Required Hearing Aids Complete Clinical Examination OSSEOINTG DEVC REPL L8619 COCHLR IMPL SPCH PRCSSR/CNTLR REPL COCHLEÆR IMPL EXT SPEECH Authorization Required Hearing Aids RE PLACE/6 KLINIKA CLINICAL L8619 PROUBCESS/6 AUD SD PRC RPL E ZINC AIR BATT COCHLR IMPL&AUD SD No Approval Required PROC REPL EA L8622 ALKALINE BATT COCHLR IMPL ANY SZ RPL ALKALINE BATTRY COCHLEAR IMPL DEVC No Approval Required ANY SZ REPL EA L8623 LI THIA LEVIONEL LITHIA. LITHIUM LEVIONEL Th than ear no approval required level repl ea l8624 lib ci/ao dvc sp ear level repl ea lib ci/aud osseonteg devc spear no approval required level repl ea l8625 exhrg batt ci/ao devc replication ea sys devc authorization required hearing aids full Clinical Review ONLY REPL EA L8627 COCHLEAR IMPL EXT PROCSSR CMPNT RPL COCHLEAR IMPL EXT SPEECH PROCESSOR Authorization Required DME Full Clinical Review COMPONENT REPL L8628 COCHLR IMPL EXT PROCSSR COCHLR IMPL EXT CONTROL CRPLANT REPLOCH REPLANT KONTROL CPLOCHRET Full Clinical Review COMP ONENT REPL L8629 TRANSMITTER COIL COCHLR DEV RPL TRANSMITTER COIL COCHLR No authorization required IMPL DEV REPL L8630 METACARPOPHALGEAL JOINT IMPLANT METACARPOPHALANGEAL JOINT No authorization required IMPLANT L8631 MPJ MTWO/REPLORE ES METL Authorization required DME Full Clinical Review CER CERAM -SOM MATL L8641 METATARSAL JOINT IMPLANT RSAL ARTICULATION IMPLANT No authorization required L8642 HALLUX IMPLANT HALLUX IMPLANT No approval required L8658 IP JOINT CASTING SILICONE/= EA INTERPHALANGEAL JOUT IPGRANTED DISTANCE/SPACER No S9 PL TO/> PECES METAL IP FNGR JNT REPLACE DVA/MORE PECES authorization required DME Full clinical examination METL CERAM-LIKE L8670 VASC GRAFT MATERIAL SYNTH IMPLANT VASCULAR GRAFT MATERIAL SYNTHETIC Required DME Approval Full Clinical Review IMPLANT L8679 IMPLANT IMPLANT L8679 IMPLANT IMPLANT NEUROSETIMULATOR NEUROSETIMULATOR NEUROSETIZATION Required DME Full Clinical Review PULSE GENERATOR ANY L8681 PT PROG IMPL NEUROSTM PLSE GEN REPL PT PROG W/IMPL PROG NEUROSTM Required DME Full Approval clinical review ONLY PULSE GEN REP L L8682 IMPL NEUROSTIMULATOR RADIOFREQ IMPLANTABLE NEUROSTIMULATOR REQEIV REQEIV REQEIV REQEIV REQEIV C8 3 RF TRNSMT W/IMPL NEUROSTIM RF RECV RF TRNSMT USE W/IMPLANTABLE authorization required DME Full clinical review NEUROSTIM RF RECV L8684 RF TRNSMT BOWEL BLADDER MGMT REPL RF TRNSMT IMPL SCRL NEURO BOWEL Authorization Required DME Full Clinical Review BLADDR MG8MT REPLYS REPLYS L8 YS BATTRY IMPL Authorization Required DME Full Clinical Review ONLY NEUROSTIM REPL L8690 AUDITORY OSSEOINTEGRTD INT/EXT AUDITORY OSSEOINTEGRERED DEVC Authorization Required Hearing Aids Full Clinical Review KOMP INT/EXT COMPONENTS L8691 AO D EXT SP HEARING OSCIL TRNDCREV . Aids Full Clinical Review TRNSDUCR/ACTUATR REPL EA L8693 AUD OSSEOINTEGRATED DEVC ABUT REPL AUD OSSEOINTEGRATED DEVC ABUT Approval Required Full Clinical Review Hearing Aids LENGTH ONLY REPL L8694 AUD OI DVC TRNSDUCR/ACTUATR REPLEADER Full Clinical Review Required DUCER/ ACTR REPL ONLY EA L8695 EXT CHARGE SYS IMPL NEUROSTIM REPL EXT CHARGE SYS BATTERY W/IMPL No Authorization Required NEUROSTIM REPL L8696 ANT FOR IMPL DIA/PN ST DEV REPL EA ANTENNA FOR USE W/IMPL DIA/EA Required ST No Auth. MISCELLANEOUS COMP SPL/ACS USE W/TOT AH SYS MISCELLANEOUS COMP SPL/ACCESS FOR USE WITH REQUIRED AUTHORIZATION Full Clinical Review TOT AH SYSTEM L8699 PROSTHETIC IMPLANT NOSE PROSTHETIC IMPLANT NO OTHER No Approval Required STATED L8701 PWRELBUE WR H ABOVE CUS PWR UE ROM AST DVC ELB WR HAND No Authorization Required 1/DBL UP CUS FAB L8702 PWR UE ROM AD E WR H F 1/DBL UP CUS PWR UE ROM AST DVC ELBO WR H No Authorization Required FINGER 1/DBL UP CUS

185

L9900 ORTHO/PROSTH SUPP ACCESS &/ SERV ORTHO&PROS SPL ACSS&/SRVC CMPNT No Authorization Required OTH HCPCS L CODE M1027 HEAD IMAGE PROTECTION OBTAINED Authorization Required Network Validation HEAD IMAGE PROTECTION PHALIN PHALIN PHAL 8 AND BLOOD FLOCULATION No Authorization Required P2 029 CONGO RED B OLOVA CONGO RED BLOOD Approval not required P2033 TIMOL BLOOD TURNING TIMOL BLOOD TURNING No approval required P2038 MUCOPROTEIN BLOOD MUCOPROTEIN BLOOD No approval required P3000 WUPMD FOR 3WAY PV TECH SCR PAP 3 WAY SMEARS TECH No approval required UND Phys SUP V P3001 SCR PAP SMER to 3 RQR Intepr MD SCR PAP SMER CERV/VAG FOR 3 SMERS NO AUTHION CANVED RQR INTEPR PHYS P9010 Blood for Transfusion per Unit Blood for Transfusion per Unit NO AUTH ANTA Auth Required P9012 CRYOPRECIPITATION EACH UNIT CRYOPREPRIPTATION EACH UNIT No Authorization Required P9016 RBCS LEUKOCYTES REDUCED EACH BY UNIT RED BLOOD CELL LEUCOCYTES No authorization required REDUCED EACH UNIT P9017 HFR S FRAZN PLAS MA FRZN INSIDE 8 No authorization required HRS CLCT EA UNIT P90 19 DRUM PADS EACH UNIT DRUM BLADE EACH UNIT No authorization required P9020 DRUM BLADE PLASMA EACH UNIT DRUM BLADE PLASMA EACH UNIT UNIT No approval required General medicine - Other services and procedures P9021 RED BLOOD CELL EACH UNIT REQUIRED EACH2 UNIT NO. BLOOD CELLS WASHED EACH UNIT RED BLOOD CELLS WASHED EACH UNIT No authorization required P9023 PLASMA POOL MX DONOR FROZEN EA PLSMA MX DONR SOLVNT/DETRGNT No authorization required UNIT TREATD FRZN EA U P9031 PLASMA POOL MX DONOR FROSSEN EA PLSMA MX DONR SOLVNT/D ETRGNT None authorization required UNIT TREATD FRZN EA U P9031 PLATLEATS RED PLEUTECYCY ACH No authorization required UNIT P9032 DRUM BLAD RADIATED EACH UNIT DRUM BLAD RADIATED ACH UNIT No authorization required P9033 PLATLTS LEUKOCYTES RDUC IRRADATD EA DRUM BLADE LEUCOCYTE REDUCED No authorization required Irradiated EA UNIT P9034 PLATLTS FEREZIS EACH UNIT PHERES EACH UNIT P35 LATLTS PHERES LEUKOCYTES RDUC EA IN ROME FEREZIS LEUKOCYTES No approval required REDUCED EACH UNIT P9036 PLATE DRUM PHERES IRRADATD EA UNITS PLATE DRUM PHERES IRRADIATED EACH No approval required UNIT P9037 PLATLT FAIRY LEUKOCITE RDUC IRRADTD PLATLTS FAIRY LEUKOCITE RDUC RDUC UNITS REQUIRED UNITS PTDEA 98 ERBDIACH 08 T RED BLOOD CELLS IRRADIATED EACH No approval required UNIT P9039 RBCS DEGLYCEROLYZED EACH UNIT RED BLOOD CELLS DEGLYCEROLYZED No approval required EACH UNIT P9040 RBCS LEUCOCYTES RDUC IRRADATD EA IN RBCS LEUKOCYTES REDUCE ED No approval required EACH UNIT P9041 INFUSION ALBUMIN 5 ML 5 ML 5 ML 0 ML 0 ML Approval required P9043 INFUS PLSMA PROT FRAC HUMN 5% 50 ML INFUSION PLASMA PROTEIN FRACTION HUMAN 5% 50 ML P9044 PLSMA CRYOPRECIPITATES RDUC EA UNIT PLASMA CRYOPRECIPITATES REDUCED No approval required. 250 ML No approval required P9046 INFUSION ALBUMIN HUMAN 25% 20 ML INFUSION ALBUMIN HUMAN 25% 20 ML No approval required P9047 INFUSION ALBUMIN HUMAN 25% 50 ML INFUSION ALBUMIN HUMAN 25% 50 ML No approval required P9048 INFUS PLASMA 0 TE IN FRACTION Not required approval HUMAN 5% 250 ML P9050 GRANULOCYTE FERESA EACH UNIT GRANULOCYTE FERESA EACH UNIT No approval required P9051 WHOLE BLD/RBCS LEUKOCYTES RDUC CMV- WHOLE BLD/RBCS LEUKOCYTES REQUIRED RDEA CMV-2T-no. D LEUKOCYTE RDUC PLT HLA- MATCHD LEUKOCYTE RDUC No approval required EACH APHERES/PHERE EA P9053 PLT PHERES LEUKOCYTE RDUC CMV-NEG EA PLT PHERES LEUKOCYTE RDUC CMV- No approval required NEG IRRADATD EA P9054 PHERES WHOLE BLDEUBCRS/ FRZN No approval required FRZN DEGLYCEROL WASHD EA P9055 PLT LEUKOCYTE RDUC CMV-NEG PLT LEUKOCYTE RDUC CMV-NEG No approval required APH/PHERS APHERES/PHERES EA P9056 WHOLE BLD LEUKOCYTE RDUC IRRADATD WHOLE BLD LEUKOCYTE Required 5 RBCS FRZN/DEGLYCEROLIZED/WASHED RBCS FRZN /DEGLYCEROLIZED/WASHED No approval required LEU LEUKOCYTES RDUC P9058 RBCS LEUKOCYTES RDUC CMV-NEG RBCS LEUKOCYTES LOWER CMV-NEG No authorization required IRRADA BEFRADATD EA DEVICE P9059 FRESH FR-2 ZN PLASMA BETWEEN 8-24 HR No authorization required CLCT EA DEVICE P90 60 FRESH FRZN PLSMA DONR GENE SITE EA IN FRESH FROZEN DONOR PLASMA No approval required RE-TESTED EACH UNIT P9070 PL POOLD MX DNR WEIGHTS RDUC FRZN EA IN PLASMA POOLED Auth POOLED Auth 9071 PLASMA PATHOGEN REDUCED FROZEN EA PLASMA PATHOGEN REDUCED FROZEN No approval required IN EACH UNIT P90 73 PATHOGEN PHERSIS THROMBJEHURA-REDUCED PATHOGEN PSIS TROMLJEHURA - No approval required REDUCED EACH UNIT P9099 BLOOD COMPONENT OR PRODUCT NOCOR BLOOD PHOGEN PHOGEN NO. EST FOR BROMIDE PLATES PATHOGEN TEST FOR BROMIDE PLATES No. Approval Required P9603 TRAVL 1 WAY NEC LAB SPEC; ACTL MILE TRAVEL 1 WAY WITH NEC LAB SPEC; Approval not required PRORAT ACTL MILE P9604 BUSY 1 ROAD NEC LAB SPEC; TRIP CHRG TRAVEL 1 WAY WITH NEC LAB SPEC; No approval required PRORATD TRIP CHRG P9612 CATH CLCT SPEC 1 PT ALL SITES SRVC CATH CLCT SAMPLE ONE PT ALL No approval required PLACER SERVICE P9615 CATHETERIZATION SPECIMEN COLLECTION CATHETERIZATION NO COLLECTION Q0MO CARDIOCYMOGRAM REQUEST NO COLLECTION Y No approval required Q0081 INFUS TX EXCEPT CHEMO RX VISIT INFUS TX USE OTHER THAN NO APPROVAL REQUIRED CHEMOTHERAPEUTC RX VISIT Q0083 KEMO ADMIN NOT INFUS TECH ONLY VST KEMO ADMIN EXCEPT INFUS TECH No Approval Required PR ONLY. VISIT

186

Q0084 KEMO ADMIN INFUS TECH VISIT KEMOTAPI ADMIN INFUS No approval required TECH VISIT ONLY Q0085 KEMO ADMIN INFUS&OTH TECH VISIT KEMOTHAPI ADMN BOTH INFUS No approval required TECH-1VST TECH P009-1VST TECH. GET PREP&CONVY-LAB EXAM PAPA BRIS; GET PREP & C No Approval Required ONVEY TO LAB Q0092 PORTABLE X-RAY EQUIPMENT SETUP PORTABLE X-RAY EQUIPMENT SETUP No Approval Required Q0111 WET MOUNTS W/PREP VAG CERV/SKN WET MOUNTS INCLUDING SP A PREP VAGVIN SKIN SAMPLES Required Q0112 ALL POTASSIUM UM HYDROXIDE PREPARATION ALL POTASSIUM HYDROXIDE No approval required PREPARATION Q0113 FERN EXAM FERN EXAMINATION No approval required Q0114 FERN TEST FERNATE FERN 5 SETTING REQUIRED No Q-COLATIVE EX POST-COITAL DIRECT QUALIFICATION EXAMINATION Approval required Infertility test or full Clinical examination VAGINAL TREATMENT /CERV MUCUS Q0138 INJ FERUMOXYTOL IDA 1 MG NON-ESRD INJ FERUMOXYTOL TX IRON DEF No approval required ANEMIA 1 MG NON-ESRD Q0139 INJ FERUMOXYTOL TX TX TX IUTRONISD INJ MGOLF IUT MG MG EMIA 1 MG FOR ESRD Q0161 CHLORPROMAZINE HCL 5 MG ORAL CHLORPROMAZINE HYDROCHLORIDE 5 No approval required MG ORAL Q0162 ONDAN 1 MG ORL DO NOT EXCEED 48 HR ONDANSETRON 1 MG ORL NO PRESCRIBING No approval required 6DI TO 48 REG 48 MG ORAL DIPENHYDRAMIN HCL 50 MG ORAL No approval required NOT>48 HR DOSE Q0164 PROCHLORPERAZINE MALEATE 5 MG ORAL PROCHLORPERAZINE MALEATE 5 MG No approval required ORAL NOT >48 HR DOSAGE Q0166 GRANISETRON HCL 1 MG ORAL GRANISETRON HCL 1 MG ORAL GRANISETRON HCL Not required 1 8 MG HR ORLUT 1 REG1 MG HR ABINOL 2.5 MG ORAL DRONABINOL 2, 5 MG ORAL NOT >48 HR No approval required DOSAGE FOAM Q0169 PROMETHAZINE HCL 12.5 MG ORAL PROMETHAZINE HCL 12.5 MG ORAL No approval required NOT>48 HR DOSAGE Q0173 TRIMETHONZAM 25 MG ORAL PROMETHAZINE HCL 12.5 MG ORAL. 50 MG ORL No approval required NOT>48 HR DOSE Q0174 THIETHYLPERAZINE MALEATE 10 MG ORAL THIETHYLPERAZINE MALEATE 10 MG No approval required ORL NOT>48 HR DOSE Q0175 PERPHENZAINE 4 MG ORAL PERPHENZAINE 4 MG ORAL NO USE REGIHRYY NO. PAMOATE 25 MG ORAL HYDROXYZINE PAMOATE 25 MG ORAL No approval required NO >48 HR DOSAGE Q0180 DOLASETRON MESILATE 100 MG ORAL DOLASETRON MESILATE 100 MG ORL No approval required NO >48 HR DOSAGE Q0181 UNS ORAL ANTIEMETIC NO >48 HR DOSAGE IN NS SE Reg Q0477 PWR Module PT CABL ELEC/PN VAD Repl PWR Module PT Cable Basing Required Cardiovascular Surgery Full Clinical Examination Elec/Pneumatic VAD Repl System Only Q0478 PWR AdAPTR Elec/Pneumatic VAD VEAC POWER Adapter Electric/Pneumatic no. Q0479 POWER MODULE ELEC/PNEUMATIC VAD POWER MODULE ELECTRICAL/PNEUMATIC Authorization Required DME Full Clinical Examination REPLACEMENT VAD ONLY REPLACEMENT Q0480 PNEUMATIC VAD DRIVER ONLY REPLACEMENT DRIVER FOR USE WITH PNEUMATIC VAD REPLICATION Full Authorization DME REPLICATION C1 ELEC VAD REPL Microprocessor CNTRL Device for authorization required DME Full Clinica l Examination Elec VAD Repl only Q0482 MicrProcSS Cu Elec/Pneumat VAD Microprocessor CU For approval Required DME Full Clinical Examination Repl Elec/Pneumat VAD Repl ONL Q0483 MON/DISPLAY MODULE W/ELEC VAD Response Monitor/Display/Display MODULE FOR ELEC Requires DME Approval Full Clinical Exam ONLY VAD REPL Q0484 MON ELEC OR ELEC/PNEUMATIC VAD REPL MONITOR FOR ELEC OR ELEC/PNEUMATIC Requires DME Approval Full Clinical Exam ONLY VAD REPL Q0485 MON CNTRL ENGINE CABLE TO ELEC. No approval required ONLY VAD REPL Q0486 MON CABLE FOR ELEC/TYPE VAD RE MON CNTRL CABLE FOR ELEC/TYPE No approval required ONLY VAD REPL Q0487 CABLE FOR ANY ELEC/PNEUMATIC VAD REPL CABLE FOR ANY TYPE REPNEUMAT ELECPLON Q0488 POWER BASE FOR ELECTRONIC VAD REPL POWER PACK BASE FOR USE W/ELEC No Approval Required ONLY VAD REPL Q0489 PWR PACK BASE ELEC/PNEUMAT VAD RE POWER PACK BASE FOR ELEC/PNEUMAT Required DME Approval Full Clinical Exam ANY Q0CY PWRONLY VAD REPL SRC FOR ELEC VAD RE SOURCE EMERGENCY POWER SUPPLIES FOR ELEC Authorization Required DME Full Clinical Exam VAD ONLY REPL Q0491 EMERG PWR SRC ELEC/PNEUMAT VAD RE EMERG POWER SRC FOR Authorization Required DME Full Clinical Exam ELEC/PNEUMAT VAD REPL ONLY VAD REPL POWER SPL CABLE ON No Approval Required ELEC ONLY VAD REPL Q0493 EMRG PWR KABEL ELEC/PNEUMAT VAD EMERG PWR KABEL DO No Approval Required REPL ELEC/PNEUMAT VAD REPL CEMENT ONLY Q0495 BATT CHRG ELEC/ELEC-PNEUMAT VAD RPL BATT CHRGR ELEC OR ELEC/PNEUMAT Authorization Required DME Full Clinical Examination VAD REPL ON LY Q0496 BATT NOT LITHIUM-ION ELEC VAD REPL BATTERY NOT LITHIUM-ION RATED/ Clinical Required REPL Q0497 BATT CLPS ELEC/ELEC-PNEUMAT VAD RPL BATT CLPS FOR ELEC OR ELEC/PNEUMAT No approval required ONLY VAD REPL Q0498 HOLSTR ELEC/ ELEC-PNEU MAT VAD REPL ELEC OR ELEC/PNEUMAT HOLSTER REQUIRED No Q0 Auth/Pneumatly VEST/BAG ANY TYPE VAD ONLY RPL BELT/VEST/BAG WEAR ANY VAD TYPE No Auth Required REPLACE Q0500 FLTRS ELEC OR ELEC/PNEUMAT ONLY VAD REPL FILTERS FOR ELEC OR ELEC /PNEUMAT No Approval Required Q0500 FLTRS ELEC OR ELEC/PNEUMAT VAD REPL FILTERS FOR ELEC OR ELEC/PNEUMAT No Approval Required -PNEUMT VAD SHOWER COVER ELEC OR No Approval Required RPL ELEC/PNEUMAT VAD REPL ONLY Q0502 MOBILITY CART FOR PNEUMATIC VAD REPL MOB ILITY CART FOR PNEUMATIC VAD Requires DME Approval Full Clinical Exam REPL ONLY Q0503 VAD PNEUMATIC VAD Approval Required DME Full Clinical Exam REPLACE EACH Q0504 PWR ADPTR PNEUMATIC VAD REPL VEH POWER ADAPTER FOR PNEUMATIC VAD Approval Required DME Full clinical examination TY ONLY TYPE PE REPL VEH

187

V8. PL/ ACCSSRY USE W/IMPLANT VAD MISCELLANEOUS ACCESSORIES OR ACCESSORIES With Authorization Full Clinical Examination Required IMPLANT VAD Q0509 MISCELLANEOUS SPL IMPL VAD NO PAYMENT MCR PRT A MISCELLANEOUS SPL/ACSS IMPL VAD NO PAYMENT Authorization Full Clinical Examination Required Q0509 MISCELLANEOUS SPL IMPL VAD NO PAYMENT 1st mo FLW TPLNT PHARM SPL FEE INIT IMS DRUG 1ST MO Approval not required FLW TRANSPLNT Q0511 PHRM FEE O ANTI-CA-EMET/IS RX;30-YES PHRM FEE O ANTI-CA ANTI-EMET/IS RX; No Approval Required 1 PRSC 30-DA Q0512 PHRM FEE O ANTI-CA EMET/IS RX;SBSQT PHRM FEE O ANTI-CA ANTI-EMET/IS RX; No approval required SUBSQT 30-DA Q0513 PHRM DISPENS FEE INHAL RX; -30 DAYS PHRM DISPENSATION FEE INHALATION RX; No PR approval required. 30 DAYS Q0514 PHRM INHALA RX ISSUING FEE; -90 DAYS FEES FOR ISSUING PHRM INHALA RX; No PR approval required. 90 DAYS Q0515 INJ SERMORELIN ACTATE 1 MCG INJECTION SERMORELIN ACETATE 1 No Approval Required MICROGRAM Q1004 NOVA TECH IO LENS CATGY 4 FED REG NOVA TECH IO LENS CATGY 4 REQUIRED 1 5 FED REG NOVA TECH IO LENS CATGY 5 DEFINED None Approx. oval required FEDERAL REG Q2004 IRRIG SOL TX BUBBLE CALCULI 500 ML IRIGATION SOL TX LEAF CALCULI No approval required PR. MG PHENYTOIN No Authorization Required EQUIVALENT Q2017 INJECTION TENIPOSIDE 50 MG INJECTION TENIPOSIDE 50 MG Authorization Required Drug Administration Full Clinical Review Q2026 INJECTION RADIESSE 0.1ML INJECTION RADIESSE 0.1ML No Authorization Required Q2028 INJECTION SCULPTRA 0.5 MG INJEC TION RADIESSE Q2 Auth. SCULPTRA 0.5 MG SCULPTRA 0.5 MG SCULPTRA SCUPLUS No. IT VRS IM AGRIFLU FLU VIRUS VAC SPLIT VIRUS No authorization required intramuscular agriflu Q2035 influenza vacc Split 3 years &> im afluria influenza vacc Split virus 3 years &> no author FLULAVAL Q2037 FLU VACC SPLIT 3 YEARS & > IM FLUVIRIN INFLUENZA VACC SPLIT VIRUS 3 years YEAR & > No approval required IM FLUVIRIN Q2038 FLU VACC SPLIT 3 YEARS & > IM FLUZONE INFLUENZA VACC SPLIT A3 YRS IN V9 INFLUENZA VIRUS VACCINE NOS INFLUENZA VACCINE NO No approval required OTHER SPECIFIED Q2041 KTE-C19 TO 200 M A ANTI-CD19 BIL P KTE-C19 UP TO 200 M A ANTI-CD19 CAR Approval required Drug administration Full clinical review POS T6004 PTD POS T601 9 CAR-+ VI T CE P TD TISAGENLECLEUCEL UP TO 600 M CAR-POS Approval Drug administration required Full clinical review VI T CE PER TD Q2043 SIPULEUCEL-T AUTO CD54+ SIPULEUCEL-T AUTO CD54+ Approval Required Drug Administration Full Clinical Review Q20 H4CI9 INJ L4CI9 Q20 IMPRT LIPODOX 10 MG INJ DOXORUBICIN HCI LIP IMPORTED Approval Required Drug Administration Full Clinical Review LIPODOX 10 MG Q2050 INJ DOXORUBIC U HCL LIPO NOS 10 MG INJECTION D OXORUBICIN HCL Approval Required LI COMMGAL 50MGAL Medication Administration Complete Medication Administration 10 MG SUPP HOME MEDICARE IVIG DEM SERVICES SUPPLIES IN HOME MEDICARE No Approval Required IVIG DEM Q3001 ADDITIONAL PROCEDURE ADDITIONAL PROCEDURE No Approval Required Q3014 TELEHEALTH ORIG S ITE FACILITY FEE TELEHEALTH PLACES OF ORIGIN No Authorization Required FACILITY FEE Q3027 INTERNET WEBSITE Q3027 ON BETA-1A 1 MCG No Authorization Required IM USE Q3031 SKIN COLLAGEN TEST SKIN TEST No Authorization Required Q4001 CAST BDY CAST ADLT W/WO HEAD PLAST CASTING SPL BODY CAST ADULT W/ WO No authorization required Plaster head q4002 Cast Cast Wbdy Cast Adlt spray wbdy cast ill covered adults No authorization required m/wo head fibrgls q4003 casting spl shldr cast baced adult platr cast shoulder for adult o adult no approval Gypsum q4004 cast baced baces eust eurn shoulder q0 shoulder shoulder shoulder Cast Required CAST ADULT No approval required GYPS Q4006 CAST SPL LONG ARM CAST ADLT FIBRGLS CAST ACCESSORIES LONG ARM CAST Adult No approval required FIBERGLASS Q4007 CAST SPL LNG ARM CAST PED GIPS CAST BASE NO A00 CARM ACCESSORIES REQUIRED SPL LNG ARM CAST PED FIBERS CAST SU APPLIED LONG ARM GAST No approval required know PEDIATRIC FIBERGLASS Q4009 CAST SPL SHORT ARM CAST ADLT GASTER CAST SUPPLY SHORT ARM GAST No approval required ADULT GIPS Q4010 CAST SPL AD SHRT CUT SARM CAST CAST CUT Required ADULT FIBERGLASS CAST Q4011 CAST SPL SHORT ARM GASTER GAST CAST SUPP LY SHORT ARM GAST No PEDIATRIC approval required Q4012 CAST SPL SHORT ARM CAST PED FIBRGLS CAST SUPPLIES SHORT ARM CAST No PEDIATRIC approval required FIBRGAST CPLAST CPLAST C13 CPLAST PLIES GAUNTLET CAST ADULT No authorization required GYPS Q4014 CAST SPL GAUNTLET CAST ADLT F-GLASS CAST ACCESSORIES GAUNTLET CAST Adult No approval required FIBERGLASS Q4015 CAST SPL GAUNTLT CAST PED PLASTR CAST SUPPLYS GAUNTLET CAST No approval required PEDIATRIC GAUNT CLASS PEDIATRIC CGLAST WITH ACCESSORIES GLOVE CAST Nr Authority required PEDIATRIC FIBERGLASS Q4017 CAST SPL LNG ARM SPLINT ADLT PLASTR CAST SUPPLIES LONG ARM SPLINT No approval required ADULT PLASTER Q4018 CAST SPL LNG ARM SPLNT ADLT FIBRGLS CAST SUPPLIES LONG ARM SPLINT Q4018 CAST SPL LNG ARM SPLNT ADLT FIBRGLS CAST SUPPLIES LONG ARM SPLINT Q4018 CAST SPL LNG ARM SPLNT ADLT FIBRGLS CAST SUPPLIES LONG ARM SPLINT Q4018 PED PLASTR CAST SUPPLIES LONG LONG ARM No approval required PEDIATRIC PLASTER Q4020 CAST SPL LNG ARM SPLIT PED FIBRGLS CAST SUPPLYS LONG ARM SPLINT No approval required PEDIATRIC FIBRGLS Q4021 CAST SPL SHRT ARM SPLINT ADLT PLAST AD CAST SUPPLYS Q4 PUT SHORT SUPPLIES AST SPL SHRT ARM SPLNT ADLT F-GLSS CAST SUPPLIES SHORT ARM SPLINT No ADULT GLAZING approval required

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Q4023 CAST SPL SHORT ARM SPLIT PED PLAST CAST SUPPLY SHORT ARM SPLIT No authorization required PEDIATRIC PLASTER Q4024 CAST SPL SHORT ARM SPLIT PED FIBRGLS CAST SUPPLYS SHORT ARM SPLIT No approval required SP4 F2ASTIC SPLASTIC SPLASTIC 5 SUPPLER HIP SPICA ADULT No authorization required ed. GYPSUM Q4026 CAST SPL HIP SPICA ADULT ADULT FIBER GLASS ADULT HIP SPICA No authorization required FIBERGLASS Q4027 CAST SPL HIP SPICA PEDIATRIC GISPHER HIP SPICA PEDIATRIC GASPER HIP SPICA PEDIATRIC No authorization required PLASTIC Q4027 CAST SPL HIP SPICA PEDIATRIC PLASTER PLASTER HIP SPICA PEDIATRIC No authorization required PLAST IKA Q4 02 7 GAME DIATRIC No approval required FIBERGLASS Q4029 CAST SPL LONG LEG BRACKET FOR ADULTS GASTER CAST ACCESSORIES LONG LEG CAST Adult No approval required PLASTIC Q4030 CAST SPL LONG LEG CAST ADLT FIBRGLS CAST SUPPLIES LONG LEG CAST Adult No approval required FIBERGLASS Q4031 CPLAST LEG PLAST LAY AST no authorization required PE DIATRIC PLASTER Q403 2 CAST SPL LNG LEG CAST PED FIBRGLS CAST SUPPLIES LONG LEG CAST no authorization required PEDIATRIC GLASS PLATE Q4033 CAST LNG LEG CYCLE CAST ADLT PLAST CAST SUPPLIES LONG LEG AD CYCLE Auth CYCLE Cred. CLE CAST ADLT F- GLSS CAST SUPPORT LNG LEG CYCLE CAST No approval required ADLT FIBERGLASS Q4035 CAST LNG LEG CYCLE CAST PED PLAST CAST SHIPMENTS LONG LEG CYCLE CAST No approval required PED PLASTR Q4036 CAST LNG LEG LEG CYCLE CYCLE A LNGSS LEG CYCLE A LNG SS Play Cast Bike Required Pediatric Fibrgls Q4037 Cast Spl Short Leg Cast Adlt Plastr Cast Supplies Short Leg Leg Adult Gypser No Approval Required Q4038 Cast Spl Shrt Leg Cast Adlt Fibrgls Cast Supplies Short Leg Cast Adult Q4038 Cast Spls Spl Shrt Leg Cast Adlt Fibrgls Cast Supplies Short Short Short Short Short CAST ADULT Q4038 CAST SPL SHRT LEG CAST ADLT FIBRGLS CAST DUPLI SHORT LEG CAST ADULT Q4038 CAST SPL SHRT LEG CAST ADLT FIBRGLS CAST DUPLI SHORT LEG CAST ADULT Q4038 CAST SPL SHRT LEG CAST ADLT FIBRGLS CAST DUPLI SHORT LEG CAST AD ULT Q4038 CAST SPL ASTR CAST SUPPLIERS SHORT LEG CAST No approval required PEDIATRIC PLASTER Q4040 CAST SPL SHORT LEG CAST PED FIBRGLS CAST SUPPLINT SHORT LEG CAST No approval required PEDIATRIC FIBRGLS Q4041 CAST SPL LNG LEG LEG SPLINT ADLT PLASTR CAST SUPPLINT ADULT No LEG SPLINT Rquid ADULT No LEG SPLNG E.g. SPLNT ADLT FIBER CAST ADULT LONG SPLIT No approval required FIBERGLASS Q4043 CAST SPL LNG LEG SPINT PED GIPS CAST REQUIRED LONG-LEG SPINT No approval required PEDIATRIC PLASTER Q4044 CAST SPL LNG LEG SPINT PED SPINT A FIBER REQUIRED LS Q40 45 CAST SPL SHORT LEG SPLIN ADLT PLAST CAST SUPPLYS SHORT LEG SPLINT No approval required ADULT PLASTIC Q4046 CAST SPL SHRT LEG SPLNT ADLT F-GLSS CAST SUPPLY SHORT LEG SPLINT ADULT FIBERGLASS Q4047 CAST SPLINT SPLAST SPLINT SPLINT No approval required PEDIATRIC PLASTER Q4048 CAST S PL SHRT LEG SPINT PED FIBER HEALING SHORT LEG SPINT No approval required PEDIATRIC FIBRGLS Q4049 FINGER SPLIT STATIC FINGER SPLIT STATIC No approval required Q4050 CAST BRACKET ON PLASTIC FITTED SPINT TYPES AND MATERIALS REQUIRED CAST BRACKET Q4051 RESULTS VARIOUS SPLITS CONSUMABLES VARIOUS USES Approval required Full clinical review Q4074 ILOPROST INHAL UNIT DOSE FOR 20 MCG ILOPROST INHAL SOL THROUGH DME UNIT No approval required DOSE FOR 20 MCG Q4081 INJ EPOETIN ALFA 100 UNITS ALFA 100 INJ EPOYS NOT REQUIRED FOR 100 UNITS. JE Q4082 DRUG/BIOLOGICAL NOC PART B DRUG OR BIOLOGICAL NOC PART B No authorization required DRUG CAP Q4100 SKIN REPLACEMENT NON OTHER SPEC SKIN REPLACEMENT NON OTHER No authorization required SPECIFIED Q4101 APLIGRAPH PO SQ CM A 4 Q0 SQ CM CM 1 OUND MATRIX PR . SQ CM OASIS SQ CM Approval not required Q4103 OASIS BURN MATRIX PO KV CM OASIS BURN MATRIX PO. CM2 P INTEGRA DRT/INTEGRA OMNIGR DRML No Approval Required SC RGN MTX P SQ CM Q4106 DERMAGRAFT PO SQ CM DERMAGRAFT PO SQ CM No Approval Required Q4107 GRAFT JACKET PER SQ CM GRAFT JACKET PER. PR. SQ CM Approval not required Q4110 PRIMATRIX PR. SQ CM PRIMATRIX PR. CM2 S INJECTABLE 1CC GRAFTJACKET XPRESS INJECTABLE 1 CC Br. Auth Required Q4114 INTEGRA FLOWABLE WND MATRIX INJ 1 CC INTEGRA FLOWABLE WON MATRIX No authorization required INJECTABLE 1 CC Q4115 ALLOSKIN PER SQ CM ALLOSKIN PER SQ CM No authorization required Q4116 Auth SQALLODE No Q4116 Auth Q4116 Auth 17 H YALOMATRIX PR. KV CM HYALOMATRIX PER. SQ CM No approval required Q4118 MATRISTEM MICROMATRIX 1 MG MATRISTEM MICROMATRIX 1 MG No approval required Q4121 THERASKIN PO KV CM THERASKIN PER. MACLL AWM POROUS P SC Q4123 ALLOSKIN RT PR. SQ CM ALLOSKIN RT PR. SQ CM No Authorization Required Q4124 OASIS ULTRA TRI-LAY WND MATRX SQ CM OASIS ULTRA TRI-LAYER WOUND No Authorization Required MATRIX PO SQ CM Q412 CM Q4125 No Authorization Required Q4126 MEMODERM TRANZGRAFT/INTEGUPLY SQ MEMODERM DERMASPAN No Authorization Required CM TRANZ GRAFT/INTEGUPLY PO SQ CM Q4127 TALYMED PO SQ CM TALYMED PO SQ CM No Approval Required Q4128 FLEX HD OR ALLOPATCH CM HD OR ALLOPATCH ALLOPATCH HD OR ALLOPATCH HD uth Required PO SQ CM Q4130 STRATTICE PO SQ CM STRATTICE PO SQ CM No Approval Required Q4 132 GRAFIX CORE & GRAFIXPL CORE-SQ CM GRAFIX CORE AND GRAFIXPL CORE PER No authorization required SQUARE CM Q4133 GRFX P GRFXPL P STRVX & STRAFIXPL P AUTCH VIXPL P SC Q4134 HMATRIX PR. square centimeter HMATRIX PR. square centimeter No approval required Q4135 MEDISKIN PR. CENTIMETER SQUARE MEDICATION PER square centimeter No approval required

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Q4136 E-Z DERM PR. square centimeter E-Z DERM PR. square centimeter No approval required Q4137 AMNIOEXL AMNIOEL PLUS/BIODEXL P SC AMNIOEXCEL AMNIOEXCEL No approval required PLUS/BIODEXCEL PR. PR. SQ CM No Authorization Required Q4139 AMNIOMATRIX OR BIODMATRIX INJ 1 CC AMNIOMATRIX OR BIODMATRIX No Authorization Required INJECTABLE 1 CC Q4140 BIODRANA PER KV CM BIODOBENA PER SQ CM No Authorization Required Q4141 ALLOSKIN AC PER SQ CM CM Auth. UE MATRIX PER KV C XCM BIOLOGICAL TISSUE MATRIX PER KV No approval required CM Q4143 REPAIR PER KV CM REPAIR PER KV CM No approval required Q4145 EPIFIX INJECTABLE 1 MG EPIFIX INJECTABLE 1 MG No approval required Q4146 TENSIX PO KV SQ CM TENSAR Q4146 TENSIX PO KV SQ CM TENSAR TRACELLULAR MATRIX PO. ARCHITECT EXTRACELLULAR MATRIX No approval required PO SQ CM Q4148 NEOX CORD 1K-RT/CLARIX CORD 1K-SC NEOX CORD 1K NEOX CORD RT/CLARIX No approval required CORD 1K-SQ CM Q4149 EXCELLAGEN 0.1 CC EXCELLAGEN 0.1 CC No Q0501 Requip DS/ DRY PER SQ CENTIMETER ALOWRAP DS OR DRY PER SQUARE No Auth Required CENTIMETER Q4151 AMNIOBAND/GUARDIAN PER SQ AMNIOBAND OR GUARDIAN PER No Auth Required CENTIMETER SQUARE CENTIMETER Q4152 DERMAPURETIME PER SQUATER CREDEN 4153 DERMAVEST AND PL URIVEST PR. KV CM DERMAVEST AND PLURIVEST PER SQ CM Approval not required Q4154 BIOVANCE PR. square centimeter BIOVANCE PR. square centimeter No approval required Q4155 NEOXFLO OR CLARIXFLO 1 MG NEOXFLO OR CLARIXFLO 1 MG40OX 1 MG40OX 100X 1 MG400 1 MG400 1 MG40X 5 CM NEOX 100 OR CLARIX 100 PR. SQUARE no. Authorization required CM Q4157 REVITALON PR. square centimeter REVITALON PER. square centimeter No approval required Q4158 KERECIS OMEGA3 PR. CM KERECIS OMEGA3 PR. 160 NUSHIELD PER SQUARE CENTIMETER NUSHIELD PER SQUARE CENTIMETER No Authorization Required Q4161 BIO-CONNEKT WOUND MATRIX PO KV BIO-CONNEKT WOUND MATRIX PO No Auth Required CM SQUARE CENTIMETER Q4162 WOUNDEX FLOW BIOSKIN FLOW 0.5 CC WOUNDEX FLOW BIOSKIN FLOW QEXO 06 FLOW 4 Q416 2 WOUNDEX FLOW BIOSKIN FLOW 0 . 5 of the CC. CM WOUNDEX BIOSKIN PER. SQUARE CM No approval required Q4164 HELICOLL PR. square centimeter HELICOLL PR. square centimeter No approval required Q4165 KERAMATRIX OR KERASORB PR. SQ CM KERAMATRIX OR KERASORB PER. 4167 TRUSKIN PER SQ CM TRUSKIN PR SQ CM No Authorization Required Q4168 AMNIOBAND 1 MG AMNIOBAND 1 MG No Authorization Required Q4169 ARTACENT WOUND PER KV CM ARTACENT WOUND PER KV CM No Authorization Required Q4170 CYGNUS PER KV CM CYGNUS PER SQ CM CYGNUS PER KV CM None authorization asked. 1 MG No authorization required PALINGEN OR PALINGEN XPLUS PR. SQ No approval required Q4173 PALINGEN/PALINGEN XPLUS PR. M BY SQUARE CM No authorization required Authorization required Wound therapy PA for code in group Full clinical review Q4176 Applies to all codes NEOPATCH BY SQUARE CM NEOPLASTS BY SQUARE CM within specific group Authorization required Wound therapy PA for code in group Full clinical review Q4177 Applies to All Codes FLOWERAMNIOFNIOFLO.1OFCC 0.1 CC within Special Group Authorization Wound Therapy Required PA for Code in Group Full Clinical Review Q4178 Applies to All Codes FLOWERAMNIOPTCH BY SQUARE CM FLOWERAMNIOPTCH BY SQUARE CM within Special Group Authorization Wound Therapy Required PA for the Code in the Group Full clinical review CJEVTNJAKA PR. SQUARE CM FLOWER SKIN PER SQUARE CM within specific group approval required Wound Therapy PA for code in group Full Clinical Review Q4180 Applies to all REVITA codes PER SQUARE CM REVITA PR. square centimeter within a specific group Wound therapy PA authorization is required for the code in the group Overview Q4181 Applies to all codes AMNIO WOUND PR. SQUARE CM AMNIO WOUNDS PER SQUARE CM within specific group Approval required Wound therapy PA for code in group Full clinical review Q4182 Applies to all codes TRANSCYTE PER SQUARE CM TRANSCYTE PER SQUARE Q41 CM within specific group SQ CM SURGIGRAFT PR. SQ CM No approval required No approval required Q4184 CELLESTA OR CELLESTA DUO PR. KV CM CELLESTA OR CELLESTA DUO PER. PR. 0.5 No approval required Q4185 CELLESTA FLOWABLE AMNION; PR. 0.5 CC CC Q4186 EPIFIX PR. SQ CM EPIFIX PO. m2 PR. SQ CM No approval required Q4189 ARTACENT AC 1 MG ARTACENT AC 1 MG No approval required Q4190 ARTACENT AC PO SQ CM ARTACENT AC PO SQ CM No approval required Q4191 RESTORIGIN PO SQ CM RESTORIGIN PR. 193 COLLECTION -E-DERM PER SQ CM COLL-E-DERM PR. No approval required Q4194 Novhor per sq cm Novachor per sq cm No approval required Q4195 Puraply per sq sq cm Puraply per sq sq cm no approval required Q4196 PURAPLY PURAPLY PER SQ CM CM NON RESISTANCE APPROVED PARAPLY XS SQ CM PURAPL CM authorization required GENESIS AMNIOT MEMBRANE PER . SQ GENESIS AMNIOT MEMBRANE PER. 4201 MATRION CM MATRION PO KV CM No approval required Q4202 KEROXX (2.5G/CC) 1CC KEROXX (2.5G/CC) 1CC No approval required Q4203 DERMA-GIDE PO KV CM DERMA-GIDE PER. CM X WRAP PO SQ CM No approval required MEMBRANE GFT/MEMBRANE WRAP P SQ MEMBRANE GRAFT OR MEMBRANE No approval required Q4205 CM WRAP PO SQ CM Q4206 LIQUID FLOW OR LIQUID GF 1 CC LIQUID FLOW NO IX PR. KV CM NOVAFIX PER KV CM Approval not required Q4209 UPGRADE PER KV CM UPGRADE PER KV CM No approval required

190

AXOLOTL GRAFT OR AXOLOTL No approval required Q4210 AXOLOTL GFT/AXOLOTL DUALGFT P SQ CM DUALGRAFT PO SQ CM AMNION BIO/AXOBIOMEMBRANE PO SQ AMNION BIO OR AXOBIOMEMBRANE Q4PER2Q1 CMPER ALLOGEN REQUIRED PO CC No approval required Q4213 A MIRIS 0.5 MG ASCENT 0.5 MG Approval not required Q4214 CELLESTA CORD PR. CM2 SKV CM ARTACENT WIRE PO. SQ CM No approval required No approval required Q4217 WNDFIX BIOWND WNDFIX BIOWND WNDFIX + X + /X+ P SC WNDFIX+BIOWND+WNDFIX X+/X+ P SC Q4218 SURGICORD PER SQ CM Q4 SURGICORD Auth URGIGRAFT -DOUBLE PER. SQ CM No approval required BELLACELL HD OR SUREDERM PR. SQ No approval required Q4220 BELLACELL HD OR SUREDERM PR. SQ CM CM Q4221 AMNIO WRAP2 PR. SQ CM AMNIO WRAP2 PR. PR. SQ CM No Approval Required MYOWN SKIN INCL HARVEST & PREP No Approval Required Q4226 MYOWN SK INCL HARV & PREP PROC P SC PROC PR. SQ CM HOSPIC/HOME HEALTH CARE PROV PT No Authorization Required Hospice Q5001 HOSPIC/RESIDENTIAL HOME/HEMME HOME /Home Health Care In No Authorization Required Hospice Q5002 Hospice/HHC Prov Asstd Living FACL Assisted Living FACL Hospice Care Prov Nursing LTC No Authorization Required Hospi ce Q5003 Hospice Care FIRST LTC/Non-Skill NF FACL/Non-Skill NF Hospice Care Qualified No Auth Required Hospice Q5004 HOSPICE CARE PROVIDED IN SNF NURSING FACILITY HOSPICE CARE PROVIDED TO PATIENT No Auth Required Hospice Q5005 HOSPICE CARE PROVIDED IN IP HOSPICE TAL HOSPICE CARE PROV INPATIENT Q500 HOSPIC FACILITIES HOSPIC CARE PROV LONG TERM CARE No authorization required Hospice Q5007 HOSPIC CARE PROV I LTC FACL FACILITY HOSPIC CARE PROV INPATIENT No authorization required Hospice Q5008 HOSPICATION CARE PROV IP PSYCHIATRIC FACILITIES PSYCHIATRIC FACILITIES HOSPIC/HOME Au th HEALTH Q0 No on-site care required SITES NOS HOSPIC HOME CARE PROVIDED IN A No Authorization Required Hospice Q5010 HOSPIC HOME CARE TRIAL HOSPIC FACL HOSPIC FACILITY INJECTION FILGRASTIM BIOSIMILAR 1 Authorization Required Full Clinical Review Q5101 INJ FILGRASTIMC INJ FILGRASTIMIL FILGRASTIM BIOSIMILAR Order Full Drug Administration Review Q5103 INJ INFLIXIMAB-DYYB BIOSIMILR 10 MG BIOSIMILAR 10 MG INJECTION INFLIXIMAB-ABDA Approval Required Drug Administration Full Clinical Review Q5104 INJ INFLIXIMAB-ABDA BIOSIMILR 10 MG BIOSIMILAR 10 MG INJECTION Required DYYB-DYYB-ADV. ALFA-EPBX BIOSIMILAR 100 U BIOSIMILAR 100 UNITS INJECTABLE EPOETIN ALFA-EPBX Needs Authorization Drug Administration Full Clinical Review Q5106 INJ EPO ALFA-EPBX BIOSIMILAR 1000 U BIOSIMILAR 1000 U INJ BEVACIZUMAB-AWWBUMCLR-BEVACBINJEBRUM- Authorization Full BIOSIMILAR Review 10 Q5107 MG BIOSIMILAR 10 MG INJECTION PEGFILGRASTIM-JMDB Approval Required Drug Administration Full Clinical Review Q5108 INJ PEGFLGRSTM-JMDB BIOSIMLR 0.5 MG BIOSIMILAR 0.5 MG INJECTION INFLIXIMAB-QBTX Approval Required Drug Administration Full Clinical Review INBFLIXIMABJ0 INBFLIXIMABJRQ TX5109 INJECTION 0.5 MG MG INJECTION FILGRASTIM-AAFI Approval Required Medicines Administration Full Clinical Review Q5110 INJ FILGRASTIM-AAFI BIOSIMILR 1 MCG BIOSIMILAR 1 MCG INJECTION PEGFILGRASTIM-CBQV Approval Required Drug Administration Full Clinical Review Q5111 INJ PEGFLGRASTM-CBQV BIOSMLR- TRAUMBILATION Author BIOSMLR 0.5 MGABIL 0.5 MG Red Full Clinical Review Q5112 INJ TRASTUZUMAB-DTTB BIOSIM 10 MG BIOSIMILAR 10 MG INJECTION TRASTUZUMAB-PKRB Authorization Required Full Clinical Review Q5113 INJ TRASTUZUMAB-PKRB BIOSIM 10 MG BIOSIMILAR 10 MG INJECTION TRASTUZUMAB-DKST Full Clinical Review DKST 10 MG BIOSIMILAR 10 MG INJECTION TRASTUZUMAB -DKST Full Authorization TRJ1 Authorization Required Q 5 CLUZ1 10 MG BIOSIMILAR 10 MG INJECTION RITUXIMAB-ABBS Approval Required Full Clinical Review Q5115 INJ RITUXIMAB-ABBS BIOSIMILAR 10 MG BIOSIMILAR 10 MG INJECTION TASTUZUMAB-QYYP Approval Required. Approval Required AB-ANNS Full Clinical Review Q5117 INJ TASTUZUMAB-ANNS BIOSIMLR 10 MG BIOSIMILAR 10 MG INJECTION BEVACIZUMAB-BVCR Approval Required Full Clinical Review Q5118 INJ BEVACIZUMAB-BVCR BIOSIMLR 10 MG BIOSIMILAR 10 MG INJ RITUXIMAB-BVCR Approval Required Full Clinical Review RITUXIMAB- PVVR1 BIOSIMILAR Q5118 INJ BEVACIZUMAB-BVCR BIOSIMLR 10 MG XIMAB-PVVR BIOSIMILAR 10 MG RUXIENCE 10 MG INJ PEGFILGRASTIM-BMEZ BIOSIMLR Approval Required Drug Administration Full Clinical Review Q5120 INJ PEGFILGRSTM-BMEZ BIOSMLR 0.5 MG ZIEXTENZO 0.5 MG INJ INFLIXIMAB -AXXQ BIOSIMILAR Approval Required Drug Administration IFX1ARRQIM Full Clinical Review Q5-2ARRQM BIOS AVSOLA 10 MG INJECTION Sulfur Hexafluoride Lipid No Author Required Q9953 INJ MR IRON BASED CONTRAST AGENT ML AGENT PER ML ORAL MAGNETIC RESONANCE AGENT No Approval Required Q9954 ORAL MR CONTRAST AGENT 100 ML CONTRAST AGENT 100 ML INJECTION PERFLEXAN LIPID No Auth Required Q995EX REQUIRED MORAL MR CONTRAST AGENT ROSPHERES PER ML INJ OCTAFLUOROPROPANE MICROSPHRS INJECTION OCTAFLUOROPROPANE No Auth Required Q9956 ML MICROSPHERE PR. ML INJECTION PERFLUTREN LIPID No approval required Q9957 INJ PERFLUTREN LIPID MICROSPHERE ML MICROSPHERE PR. INE CONC ML HI OSM CONTRST MATL 150-199 No Approval Required Q9959 HOCM 150-199 MG/ML IOD CONC ML MG/ML IODINE CONC ML HI OSM CONTRST MATL 200-249 No Approval Required Q9960 HOCM 200-249 HOCM 200-249 CONC ML MG/ML I CONCMG HI OSM CONTRST MATL 250-299 No Approval Required Q9961 HOCM 250-299 MG/ML IODINE CONC ML MG/ML IODINE CONC ML

191

HI OSM CONTRST MATL 300-349 No approval required Q9962 HOCM 300-349 MG/ML IODINE CONC ML MG/ML IODINE CONC ML HI OSM CONTRST MATL 350-399 No approval required Q9963 HOCM 9 CONTR./MLC MG/MLC ML IODINE CONC ML ML HIGH OSM CONTRAST MATL 400/> No Approval Required Q9964 HOCM 400 OR > MG/ML IODINE CONC. ML MG/ML IODINE CONC. ML LOCM 100-199 MG/ML IODINE No approval required Q9 960 ML 9 960 MG I CONC. PR. ML CONCENTRATION BY ML LOCM 200-299 MG/ML IODINE No approval required Q9966 LOCM 200-299 MG/ML IN CONC. PR. ML CONCENTRATION BY /ML AND CONC. PER ML CONCENTRATION PER ML INJ NON-RADIATED NOONTRST VISA No authorization required Q9968 INJ NONRA NONCNTRST VIZ ADJNCT 1 MG ADJUNCT 1 MG TC-99M NON-HEU FULL COST REC ADD- Q9 EU Auth-Nr. -ON STDY DS ON PER STDY DOS FLUTEMETAMOL F18 DX P STUDY ON No approval required Q9982 FLUTEMETAML F18 DX STDY DO ON 5 MCI 5 MILLICURIES FLORBETABEN F18 DX P STDY ON No approval required P8ET9ABEN D8 MCI 8.1 MILLICURIES INJECTION BUP RENORPHINE EXT-RLSE no required approval Q9991 INJECTION BU EXT-RLSE 100 MG TRANS PRTBL X-RAY EQP&PERS No approval required R0070 TRANS PRTBL XRAY EQP&PERS-TRIP 1 PT TRANS-PRES-TRIP 1 PT TRANS-PRES-EQP 1 PT HOM/NRS HOMPRT HOM required R0075 TRANS PRTBL XRAY EQP&PERS-TRIP>1 PT HOM/NRS HOM-TRIP>1 PT TRANS PRTBLE ECG No approval required R0076 TRANS PRTBLE ECG FACL/LOCATION-PT FACL/LOCATION PR. LENSES SRVC MISCELLANEOUS REPORTED SEP REPORTED SEP ARTHROSCOPY SURGICAL KNEE Authorization Required Full Clinical Review S2112 ARTHROSCOPY SURGICAL KNEE HARVEST CARTILAGE HARVEST BREAST RECONSTRUCTION W/GLUTEAL ART Authorization Required Full Clinical Review S206 WLAPER 6 WLAPER UNIVERSITY 206 FLAP UNI BRST RECON 1 BRST DIEP FLAP(S) & / GAP approval required full clinical review S2067 BRST RECN 1 BRST DIEP&/GAP FLP(S) FLAP(S) UNI BREAST RECON DIEP/SIEA FLAP & CLOS approval required full clinical review S2068 BREAST RECON DIEP/SIEA FLAP DONR SITE UNI NEWBORN METABOLIC SCREENING No Approval Required S3620 NEWBORN METABOLIC SCREENING PANEL SPEC-STAT MISCELLANEOUS TX ITEMS AND SPL RETAIL PURCHASE Authorization Required Full Clinical Exam T1999 MISCELLANEOUS TX ITEMS BUY AND BUY 2 FRAMES BUY 2 FRAMES BUY0 BUY No Approval Required SP HERE ONE VISION PLAN +/- 4.00 No approval required V2100 SPHER 1 VISN PLANO +/- 4.00 LENSES PER LENS SPHERE SINGLE VISION +/- 4.12 +/- No approval required V2101 SPHER 1 VISN +/- 4.12 +/0D EA7. LENS SPHERE ONE VISN +/- 7.12 +/- 20.00D No approval required V2102 SPHER 1 VISN +/- 7.12 +/- 20.00D EA PER LENS 1 VISN PLANO TO+/-4.00D SPHER 0.12- Not supplied VI210 Put -+/ -4.00D 0.12-2.00D EA 2.00D CYL EA 1 VISN PLANO-+/- 4.00D SPHER 2.12- No approval required V2104 1 VISN PLANO-+/-4.00D 2.12-EA 4.000D VISN PLANO-+/- 4.00D SPHER 4.25- No approval required V2105 1 VISN PLANO-+/-4.00D 4.25-6.00D EA 6.00D CYL EA 1 VISN PLANO-+/- 4.00D Authentic SPHER no required VISN 1 SPHER PLANO-+/-4.00D OVR 6.00 D EA 6.00D CYL-LENSA 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12- No approval required V2107 1 VISN +/-4.25-+/-7.00 .002D .002D .002D .002D . CYL EA 1 VISN +/-4.25D-+/-7.00D SPHER 2.12- No approval required V2108 1 VSN +/-4.25D-+/-7.00D 2.12-4.00D 4.00D CYL EA 1. VISN+/- 1 / - 7.00D SPHER 4.25- No Authorization Required V2109 1 VISN+/- 4.25-+/- 7.00D 4.25-6.00D 6.00D CYL EA 1 VISN +/- 4.25-7.00D SPHERE Required OVER 12 Auth/Auth 4.25-7.00D OVER 6.00D 6.00D CYL EA 1 VISN +/-7.25-+/-12.00D SPHER 0.25- No approval required V2111 1 VISN +/-7.25-+/-12.00D 2.525D 0.2525 1 VISN +/- 7.25 +/- 12.00 D SPH 2.25D- No approval required V2112 1 VSN +/-7.25-+/-12.00D 2.25D-400D 400D CYL EA 1 VISN +/- D S 7.125. 4.25- No Approval Required V2113 1 VISN +/-7.25-+/-12.00D 4.25-6.00D 6.00D CYL EA SINGLE VISION SPHERE OVER +/- 12.00D No Approval Required V2114 1.000 VISN SPER. PER LENS V2115 LENTICULAR PER LENS SINGLE VISION LENTICULAR PER LENS SINGLE VISION No Authorization Required V2118 ANISEICONIC LENSES SINGLE VISION ANISEICONIC LENS SINGLE VISION No Authorization Required V2121 LENSTICULAR LENS LENS Red NOT OTHERWISE CLASSIFIED SINGLE VISION No Auth Required V2199 NOC SINGLE VISION LENSES VISION LENSES SPHERE B IFOCL PLANO TWO PLUS/MINUS No approval required V2200 SHERE BIFOCL PLANO +/-4.00D LENSES 4.00D PER LENS SHERE BIFOCIAL +/- 4.12 TO +/- 2.12 SHERE 7.00 required. -4.12-+/-7.00D LENSES PER LENS SPHERE BIFOCL +/- 7.12 TO +/- 20.00D Approval not required V2202 LENSES BIFOCL +/-7.12-+/-20.00D EA PER LENS BIFOCL SPHERE +/0- BIFOCL PLANO 0.12- No approval required V2203 BIFOCL PLANO +/-4.00D 0.12-2.00D EA 2.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 2.12- No approval required V22004 BIFO2 4.20D 4.2004 BIFOCL 4. 0.00 D CYL - EA BIFOCL PLANO +/- 4.00D SPHER 4.25- No approval required V2205 BIFOCL PLANO +/-4.00D 4.25-6.00D EA 6.00D CYL-EA BIFOCL PLANO +/- V2205 required BIFOCL PLANO +/-4.00D 4.25-6.00D EA 6.00 D CYL-EA BIFOCL PLANO +/- required V2205 BIFOCL PLANO +/-4.00D OVER 6.00D EA 6.00D CYL-EA BIFOCL +/-4.25 -+/-7.00D SPHER 0.12- No approval required V2207 BIFOCL +/ -4.25 -+/-7.00D 0.000 CYL 2.00D. -EA BIFOCL +/-4.25-+/-7.00D SPHER 2.12- No approval required V2208 BIFOCL +/-4.25-+/-7.00D 2.12-4.00D 4.00D CYL-EA BIFOCL +/-4.70-0 D SPHER 4.25 - No approval required V2209 BIFOCL +/-4.25-+/-7.00D 4.25-6.00D 6.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER OVR No approval required BIFO.2510/4CL +- -+ /-7.00D ABOVE 6.00D 6.00D CYL-LENS BIFOCL +/-7.25-+/-12.00D SPHER 0.25- No Approval Required V2211 BIFOCL +/-7.25-+/-12.00D 0.5D 2.5D 2.5D 2.5D - EA

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BIFOCL +/-7.25-+/-12.00D SPHER 2.25- No approval required V2212 BIFOCL +/-7.25-+/-12.00D 2.25-4.00D 4.00D CYL-EA BIFOCL +/-7.25-0D. 4.25- No approval required V2213 BIFOCL +/-7.25-+/-12.00D 4.25-6.00D 6.00D CYL-EA BIFOCAL SPHERE OVER +/-12.00D PER No approval required V2214 BIFOCL SPHENS 0PER. V2215 LENTICULAR PER LENS BIFOCAL LENTICULAR PER LENS BIFOCAL No approval required V2218 ANISEIKONIC PER LENS BIFOCAL ANISEIKONIC PER LENS BIFOCAL No approval required V2219 BIFOCAL SEG WIDTH OVER 28MM BIFOCAL OVER 28MM BRequired BIFOCAL ADD OVER 3. 25D BIFOCAL ADD OVER 3, 25D No veterinary authorization required V2221 LENTICULAR LENS PR. LENSES BIFOCAL LENTICULAR LENSES PER LENS BIFOCAL No authorization required V2299 SPECIAL BIFOCAL SPECIAL BIFOCAL no authorization required SPHERE TRIFOCAL PLANO OR +/-4.00D V230000PH No aut. D LENS BY LENS GLOBAL TRIFOCL +/- 4.12 TO +/- 7.00D No Approval Required V2301 SHERE TRIFOCL +/- 4.12-+/-7.00 LNS PR. LENS SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 No approval required SPHER TRI.CL TRI.CL V2302 -+/-20.00 LNS PR. LENSES TRIFOCL PLANO +/-4.00D SPHER 0.12- No approval required V2303 TRIFOCL PLANO +/-4.00D 0.12-2.00D 2.00D CYL EA TRIFOCL PLANO +/-2.00D required. V2304 TRIFOCL PLANO +/-4.00D 2.25-4.00D 4.00D CYL EA TRIFOCL PLANO +/-4.00D SPHER 4.25- No approval required V2305 TRIFOCL PLANO +/-4.00D 4.0CYL-0EA 4.00D SPHER OVR No approval required V2306 TRIFOCL PLANO CL PLANO +/-4.00D OVR 6.00D 6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 0.12- No approval required V2307 TRIFCL +/0-4.7.25 +/+-4.7. -2.00D 2.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 2.12- No approval required V2308 TRIFOCL +/-4.25-+/-7.00D 2.12-4.00D 4.00D CYL-/4.00D CYL-/ +/-7.00D SPHER 4.25- No approval required V2309 TRIFOCL +/-4.25-+/-7.00D 4.25-6.00D 6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER required V3.01 OVR No A31 /-4.25-+/-7.00D OVR 6.00D 6.00D CYL EA TRIFOCL +/-7.25-+/-12.00D SPHER 0.25- No approval required V2311 TRIFCL +/-7.25-+/-12.5.00D 2.200D 2.200D D CYL E TRIFOCL +/-7.25-+/-12.00D SPHER 2.25- No approval required V2312 TRIFCL +/-7.25-+/-12.00D 2.25-4.00D 4.00D CYL E TRIFOCL+/-125.0-/+-0D. SPHER 4.25- No authorization required V2313 TRIFCL +/-7.25-+/-12.00D 4.25-6.00D 6.00D CYL EA TRIFOCL SPHER OVER +/-12.00D PER No authorization required V2314 SPHER TRIFOD TRIFOD > +0 CLENS. V2315 LENTICULAR PER LENS TRIFOCAL LENTICULAR PER LENS TRIFOCAL No authorization required V2318 ANISEICON LENS TRIFOCAL ANISEICON LENS TRIFOCAL No authorization required V2319 TRIFOCAL SEG WIDTH OVER 28 MM SEG 2 TRIFOCAL 3 Auth 8 MM TRIFOCAL 3 Auth. OCAL ADD OVER 3.25D TRIFOCAL ADD OVER 3.25 D No Authority required V2321 LENTICULAR LENS PER LENS TRIFOCAL LENS LENS PER LENS TRIFOCAL No approval required V2399 SPECIAL TRIFOCAL SPECIAL TRIFOCAL No approval required VARIBL ASPHRCTY LENS 1 FULL FLD No approval V2399 SPECIAL TRIFOCAL SPECIAL TRIFOCAL no. approval required VARIBL ASPHRCTY LENS 1 FULL FLD No approval V2399 SPECIALTY TRIFOCAL SPECIALTY TRIFOCAL No approval required VARIBL ASPHRCTY LENSES 1 FULL FLD No approval required V2399 ASS/PLASTC LNS VARIBL ASPHRCITY LENS BIFOCL FULL No approval required V2430 VRIBL ASPHRC BIFOCL FULL FIELD LENSES POLISH LENS Not required approval V2499 VARIA BLE SPHERICITY LENSES ANOTHER TYPE OF VARIABLE SPHERICITY LENSES ANOTHER TYPE OF CONTACT LENSES PMMA SPHERICAL LENSES PMMA SPHERICAL LENSES VTC000 LENS REQUEST No. CONTACT LENSES PMMA TORIC/PRISMA Approval not required V2501 CNTC LENSES PMMA/PRISMA BALLST LENSES BALAST PR. CONTACT LENSES PMMA BIFOCAL PR. No approval required V2502 CONTACT LENSES PMMA BIFOCAL PR. CONTACT LENSES PMMA COLOR VISION25 REQUIRED LENSES VICN LENSES 0PM PR. LENSES CONTACT LENSES GAS permeable No approval required V2510 CNTC LENSES GAS PRMEABL SFERICL LENSES SPHERICAL PR. LENSES CNTC LENSES GAS TRANSMISSION TORIC No approval required V2511 CNTC LENSES GAS GAS PRSMEABL PRSM BLLST EA PRISM BALLT TRANSMISSION LENS G5 TC LENS GAS TRANSMISSION BIFOCL LENS BIFOCL PR. LENSES CNTC LENSES GAS PERMEABLE EXTENDED No approval required V2513 CNTC LENSES GAS PRMEABL EXT WEAR LENSES FIT PR. HYDROPHILIC CONTACT LENSES No approval required. No approval required V2521 CNTC LENS HYDROPHL /PRIZMA BLLST LENS BALLST PR. CONTACT LENSES HYDROPHILIC BIFOCAL No approval required V2522 CNTC LENSES HYDROPHILIC BIFOCAL LENSES PR. LENSES CONTACT LENSES HYDROPHILIC EXTENDED No authorization required V2523 WEAROPPHILENS LENSES LINTERE HYDROPHILENS LENSES EXTERNAL GAS No authorization required V2530 CNTC LENSES SCLERAL GAS LEAK PR. NO PERMEABLE PO CONTACT LENSES SCLERAL GAS Approval required NA Full clinical examination V2531 CNTC LENSES SCLERAL GAS PERMEABLE PERMEABLE PR. Required V2600 MANUAL LW VISN&OTH NON SPEC AID GLASS GUIDANCE AID SINGLE LENS GLASSES MOUNTED No authorization required V2610 SNGL GLASS THREAD LW VISION AID LOW VISION AID TELESCOPIC AND OTHER COMPOUND LENSES Approval required Eye surgery and o26 COMPULAR LENS SYSTEM M S15 COMPULAR INFORMATION adnexa V 2623 EYE PROSTHESIS PLASTIC CUSTOM PROSTHESIS EYES PLASTIC CUSTOM Approval required NA Full clinical examination EYE POLISHING/RESURFACE No authorization required V2624 POLISHING/RE SURFACE OCULR PROSTHESIS No authorization required V262 CLAMP V2626 EAR PROSTHESIS REDUCTION EAR REDUCTION PROSTHESIS No approval required V2627 SKLER ALNI SHELL SCLERAL COVER SHELL Authorization required NA Full clinical examination EYECLAP FABRICATION AND FITTING No approval required V2628 OCULAR CONFORMER FABRICATION AND FITTING V2629 PROSTIE EYE PROTOTYPE No authorization required OR INTRAOCULAR CHAMBER No approval required V2630 ANTERIOR CHAMBER INTRAOCULAR LENS V2 631 INTRAOCULAR SUPPORT IRIS SUPPORTED INTRAOCULAR LENSES LENSES No approval required. INTRAOCULAR POSTERIOR Ocular CHAMBER No approval required V2632 INTRAOCULAR POSTERIOR Ocular CHAMBER LENS

193

V2700 LENS BALANCE PER LENS BALANCE LENS PER LENS No Authorization Required PLAST OFF PRISM GLASS OR PLASTIC PO No Authorization Required V2710 SLAB OFF PRISM GLASS/PLSTC PER LENS V2715 PRISM PER LENS REQUIRED PRESS PRISM LENS No Authorization Required V2718 PRESS-ON LENS FRESNELL PRISM P LENSES SPECIAL CURVE LENSES GLASS OR PLASTIC Approval not required V2730 SPCL BASE CURVE GLASS/PLSTC-LENS PO. LENS V2744 TINE PHOTOCHROMATIC BY LENS TINE Authentic PHOTOCHROMATIC BY LENS TONE; LR EXC ADD LENS; COLOR SHADE SOLID EXCLD No approval required V2745 PHOTOCHRMATC PHOTOCHRMATC V2750 ANTI-REFLECTIVE COATING PR. ANTI-REFLECTIVE LENS COATING BY LENS No approval required V2755 U-V LENSES PR. LENSES U-V LENSES 7 GLASS SET No approval required No approval required V2760 SCRATCH RESISTANT COATING PO. SCRATCH RESISTANT LENS COATING PO LENS MIRROR FINISH SOLID GRADENT/= No approval required V2761 MIRROR FINISH SOLID GRADENT/= LE LENS MATL-LENS POLARIZATION ALL LENS MATERIALS PO No approval required V2761 LENS MATERIAL LENS V276CC DER LENS PER LENS LOCK LENS PO LENSES No authorization required V2780 OVERSIZE LENSES PER LENS OVERSIZE LENSES PER LENS No authorization required V2781 PROGRESSIVE LENSES PER LENS PROGRESSIVE LENSES PER LENS. NS I 1.54 -1.65 PLST/1.60-1.79 GLA GLASS LENS INDX >/= 1.66 PLSTC/>/= 1.80 No approval required V2783 LNS INDX >/=1.66 PLSTC/ >/=1.80 GLA GLASS LENSES Acquired LENSES A7 A4 QUAL. LENSES POLYCARBATE/EQUAL ANY INDEX LENS INDEX PO. LENS PROCESSING PRES & TRANSPORT No Approval Required V2785 PRC PRES & TRANSPORTING CORNL TISS CORNEAL TISSUE SPECIALTY TRADE No Approval Required V2786 SPCLTY OCCIFENS MULTNIFENSTILL. E SURG RECNSTR- AMNIOT MEMBRANE SURGICAL Authorization Required Reconstructive Full Clinical Exam V2790 PROC RECONSTRUCTION PER PROC VISN SPL ACSS &/ SRVC CMPNT No Authorization Required V2797 VISN SPL ACSS&/SRVC CMPNT OTHER HCPCS OTHER HCPCS CODE VISION ELEM. OR SERVICE Authorization required Full clinical review of MILANSCELUSION V279. 08 HEARING CHECK HEARING CHECK Approval not required V5010 HEARING AID ASSESSMENT HEARING AID ASSESSMENT No approval required INSTALLATION/ORIENTATION/CHECK No approval required V5011 HEARING AID INSTALLATION/ORIENTATION/CHECK HEARING AID REPAIR/REPLACEMENT/CHANGE NO. HEARING AID V5020 CONFORMITY ASSESSMENT CONFORMITY ASSESSMENT No approval required HEARING AID MONAURL BDY WRN AIR HEARING AID MONAURL BODY WEAR No approval required V5030 CONDCT AIR HEARING AID MONAURL BDY BDY WEAR AID MONAURN0 CONCLUSIVE WEAR AID BN HEARN0 DCT BONE CONDUCTIVE V5050 HEARING AID MONO Aurally in the ear Aurally MONAURAL IN-EAR AID No authorization required Hearing aid MONAURAL CASE HEARING AID MONAURAL CASE No authorization required. uth ISSUING FEE UNSPECIFIED HEARING No approval required V5090 ISSUING FEE UNSPECIFIED HEARING AID SEMI-IMPLANT MIDDLE EAR No approval required V5095 SEMI-IMPLAT HEARING PROSTHESIS MIDDLE EAR HEARING PROSTHESIS No approval required V5100 HEARING ABIODAL HEARING BODY Y BLOOD V5110 DISTRIBUTION GB YR BILATERAL NAKN ADA TO SHARE BILATERAL No authentication required V5120 BINAURAL BODY BINAURAL BODY No authentication required V5130 BINAURAL IN EAR BINAURAL IN EAR No authentication required V5140 BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL BINAURAL INAURAL BINAURAL V50 BURALES No authorization required V50 BURALES 5160 BINAURAL ISSUING FEE BINAURAL ISSUING FEE No Authority Required Veterinarian HEARING AID UNIT No Approval Required V5171 HA CONTRALAT RTE DVC MONAURAL ITE MONAURAL ITE HEARING AID UNIT CONTRAL PATH No Approval Required V5172 HA CONTRALAT RTE DVC MONAURAL AND CONTRALAT RTE DVC MONAURAL A Required V5181 HA CONTROL RTE DVC MONO BTE DVC MONAURAL BTE HEARING AID CONTRALATERAL RTE No approval required V5190 HA CONTRALATERAL RTE MONO GLASSES MONO GLASSES ISSUING FEE CONTRALATERAL ISSUING FEE CONTRALATERAL No approval required V5200 MONAURAL REQUIRED V5211 HA CONTRALATERAL RS BINAURAL ITE /ITE BINAURAL ITE /ITE HEARING AID CONTRALAT ROUT SYS No Authorization Required V5212 HA CONTRALAT RS BINAURAL ITE/IT BINAURAL ITE/ITC HEARING AID CONTRALAT ROUT SYS No Authorization Required V5213 HA CONTRA RTE SYS BINAURAL ITE/ITC BINAURAL ITE/ITC BINAURAL Auth Required v5214 ha contra rout sys binaural it /bte binaural ITC /ITC hearing aid contralat rout sys no author /BTE BINAURAL BTE/BTE HEARING AID CONTRALAT RTE SYS No authorization required V5230 HA CONTRALAT RTE SYS BINAURAL GLASSES BINAURAL GLASSES ISSUANCE FEE CONTRALATERAL RTE No authorization required V5240 DISPNS SYSTEM FEE BINAURAL REE ING No Authorization Required V5241 DISPNS FEE MONAURL TYPE OF HEARING AID AID ANY TYPE No Authorization Required V5242 HEARING AID ANALOG MONAURAL CIC HEARING AID APPLICATION ANALOG MONAURAL CIC No Authorization Required V5243 HEARING AID ANALOG MONAURAL ITC HEARING AID ANALOG MONAURAL ITC PROMONALOG HEARING PO MAGALO Not necessary approval V5 244 CIC MONAURAL CIC HEARING PROGRAM ANALOG MONAURL HEARING AID DIGTLLY PROG ANALOG No approval required V5245 ITC MONAURAL ITC

194

HEARING AID PROG ANALOG MONAURL HEARING AID DIGTLLY PROG ANALOG No approval required V5246 ITE MONAURAL ITE HEARING AID PROG ANALOG MONAURL HEARING AID DIGTLLY PROG ANALOG No approval required V5247 BTE MONAURAL BTE ANALOG A48 HEARINALOG A48 HEARINALOG V52 INAURAL C IC No approval required V5249 HØ CALL AID ANALOG BINAURAL ITC HEARING AID ANALOG BINAURAL ITC No authorization required HEARING AID DIGTLLY PROG ANALOG No authorization required V5250 HEARING AID PROG ANALOG BINAURL CIC BINAURAL CIC HEARING AID DIGTLLY PROG ANALOG ANALOGUE VANA AUT Auth required I5250 Auth AL ITC HEARING AID DIGITAL no. required V5252 HEARING AID PROG BINAURAL ITE PROGRAMMABLE BINAURAL ITE HEARING AID DIGITAL No authorization required V5253 HEARING AID PROG BINAURAL BTE PROGRAMMABLE BINAURAL BTE No authorization required V5254 HEARING AID DIGITAL CITY uth Required V5255 HEARING AID DIGITAL MONO IT HEARING AID DIGITAL MONAURAL ITC No authorization required V5256 HEARING AID DIGITAL MONAURAL ITE HEARING INSTRUMENT DIGITAL MONAURAL ITE No authorization required V52 57 HEARING INSTRUMENT DIGITAL MONAURAL BTE HEARING INSTRUMENT DIGITAL MONAURAL ITE HEARING INSTRUMENT DIGITAL MONAURAL BTE V52 TAL BINAURAL CIC No authorization required V5259 HEARING INSTRUMENT DIGITAL BINAURAL ITC HEAR ING INSTRUMENT DIGITAL BINAURAL ITC No authorization required V5260 HEARING AID DIGITAL BINAURAL ITE HEARING AID DIGITAL BINAURAL ITE No authorization required V5261 HEARING AID DIGITAL BINAURAL BTE HEARING AID BINAURAL ITE TYPE REQUIRED No authorization required V5262 HEARING AID DISPBL TYPE MONAURAL MONAURAL HEARING AID DISPOSABLE PE ANY TYPE No authorization required V5263 HEARING AID DISPBL TYPE BINAURAL BINAURAL BINAURAL EAR MOLD/DISPOSABLE MOLD No authorization required V5264 EAR MOLD/DISPOSABLE MOLD/NON-FLASH MOLD No. red V5265 EAR MOLD / SINGLE USE MOLD ANY TYPE TYPE No approval required V5266 BATTERY FOR HEARING AID USE BATTERY FOR HEARING AID USE HEARING AID/ALD/SUPP/ACCESS NO No approval required V5267 HA/ALD/SUPP/ACCESS NO OTHERS SLEEP. TEL LISTENING UNIT No approval required V5268 ASST TEL LISTENING UNIT AMPLIFIER TYPE AMPLIFIER ANY TYPE ASSISTED LISTEN ALERT No approval required V5269 ASST LISTENING UNIT ALERT TYPE ANY TYPE ASSTIVE TELEVISION REQUIRED A5 VICE TV AMPLIFIER TYPE AMPLIFIER TYPE AS STIV DEVICE FOR LISTEN DEVC TELEVISION No approval required V52 71 ASST LISTEN DEVC TV CAPTION DECODER CAPTION DECODER V5272 ASST LISTEN TDD ASST LISTEN TDD No approval required ASST LISTEN USE No approval required V5273 WPLOCHISTENARC DEVICE WPLAROCHISTENARC V5274 LEARNING ASSISTED NOS TEACHING ASSISTED DEVICE ENJE NO. No Approval Required V5275 EAR PRINT EACH EAR IMPRESS EACH No Approval Required ALD PERS FM/DM SYS MONAURL ANY ASSIST.LISTE DEVC PERS FM/DM SYS No Approval Required V5281 TYPE MONAURL. Required V5282 ALD PERS FM/DM SYS BINAURL ANY TYPE BINAURL ANY TYPE ASSIST LIST DEVC PERS FM/DM NCK No Auth Required V5283 ALD PERS FM/DM NCK LOOP INDUCT RECV LOOP INDUCT RECV ASSIST LIST AFM8 DEV8 Required ALD PERS FM/DM EAR LEVEL RECEIVER LEVEL RECEIVER HELP SHEET DEVC PERS FM/DM DIR No Authorization Required V5285 ALD PERS FM/DM DIR AUDIO INPUT RECV AUDIO INLET RECV ASSIST LISTEN DEVC PO BLUE TOOTH V5 Auth Auth Rquired 28 DM RECEIVER FM/DM RECEIVER ASSIST LISTEN DEVC PERS None authorizations Required V5287 ALD PERS FM/DM RECEIVER NOS FM/DM RECEIVER NOS ASSIST LISTEN DEVC PERS FM/DM No authorization required V5288 ALD PERS ALD/DM TRANSMITTER DM ADPTR/BOOT CPLG ASSIST LIST DEVC PERS FM/DM No authorization required V5289 RECV ADPTR / BOOT CPLG RECV ASSIST LISTEN DEVC TRANSMIT Approval not required V5290 ALD TRANSMIT MICROPHONE ANY TYPE OF MICROPHONE NOT REQUIRED V8 ING AID NOC CLASSIFIED V5299 HEARING SERVICES MISCELLANEOUS HEARING SERVICES MISCELLANEOUS No approval required CDC 2019 NOVI CORONAVIRUS RT RT- U0001 CDC 2019 ROMAN COV RT RT -PCR DX PNL PCR DX PANEL NOT NEEDED 2 SAVIRVIRUS-0RS-Auth. 2 2019-NCOV CORONAVIRUS 2/ 2019-NCOV (COVID-19) No approval required DETECTION OF INFECTIOUS AGENT USING NUCLEIC ACID (DNA OR RNA); SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-CoV-2) DETECTION OF INFECTIOUS AGENT U U0003 (CORONAVIRUS DISEASE [COVID-19]), AMPLIFIED NUCLEIC ACID (DNA OR RNA) PROBE TECHNIQUE PERFORMANCE DEVELOPMENT TECHNIQUES. MS-2020-01-R. No approval required 2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR 2019-NCOV CORONAVIRUS, SARS-COV-U0004 SUBTYPES (INCLUDING 1/20) NCOV (COVID - 19) NON-CDC, USE HIGH-FLOW TECHNOLOGIES AS DESCRIBED IN CMS-2020-01-R. No approval required

195

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Jan 27, 2023

2021_MA-POS_PA-List_20210101 V30_non_EXL_filexlsx [PDF] - Free Document Online (2023)

2021_MA-POS_PA-List_20210101 V3.0_non_EXL_file.xlsx

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