| CPT and HCPCS Code List
Asuris Northwest Health Commercial Products
Participating and Preferred
The CPT and HCPCS Code List was developed to help you identify services we require be pre-authorized. In some cases no CPT or HCPCS code specifically identifies a service we preauthorize. For example, new services we consider investigational may not yet have a code. Please refer to the current Medical Pre-Authorization Lists to determine which lines of business the pre-authorization applies to and information concerning benefits and eligibility. Please Note: This list does not pertain to Medicare products.
Effective July 1, 2007
Asuris Commercial Products
All Participating and Preferred members
Mental Health and Chemical Dependency
Phone: 1 (800) 780-7881 Fax: 1 (800) 331-3505 |
- Inpatient/partial/residential admissions require notification. Concurrent review will occur after eight days.
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Durable Medical Equipment
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1(800) 423-6884 (out of state)
Fax: (800) 453-4341 |
Equipment purchase or repair with billed charges over $1,500 for any single line item or component unless listed as an exception below. |
Equipment rental with billed charges over $500/month for any single line item or component unless listed as an exception below. |
Extremity prosthetics with billed charges over $5,000 for any single line item or component. |
Exceptions (the following items do not require pre-authorization, regardless of line item charges)
Apnea monitors, bilirubin lights, cardiac monitors, CPAP/BiPAP, CPM (knee only), dynamic splints, home dialysis equipment, infusion pumps, insulin pumps, ocular prostheses, orthotics, oxygen and oxygen equipment, psoriasis lights, SIDs monitors, suction pumps, ventilators (including maintenance). |
Hospice Services:
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1(800) 423-6884 (out of state)
Fax: (800) 453-4341 |
Hospice (including level of care charges) |
S0255, S9125, S9126
Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, and Q5009 |
Inpatient Admissions:
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1(800) 423-6884 (out of state)
Fax: (800) 453-4341 |
All hospital admissions require notification |
Concurrent review will occur after 7 days. |
Long Term Acute Care Facility (LTAC) |
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Rehabilitation |
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Skilled Nursing Facility (SNF) |
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Transplants, ventricular assist devices and total artificial hearts (pre-authorization not required for corneal transplants) |
Transplants
G0267, G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2061, S2065, S2150, S2152, 32850, 32851, 32852, 32853, 32854, 33930, 33935, 33940, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38230, 38240, 38241, 38242, 44132, 44133, 44135, 44136, 47133, 47135, 47136, 47140, 47141, 47142, 48160, 48550, 48554, 48556, 50300, 50320, 50340, 50360, 50365, 50370, 50380, 0141T, 0142T, 0143T
Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 33980, 0048T, 0049T, 0050T, 0051T, 0052T,0053T |
Other Services:
Phone: (206) 464-3748
Toll free: 1 (800) 367-2766 (in state) or 1(800) 423-6884 (out of state)
Fax: (800) 453-4341 |
Cosmetic or potentially cosmetic procedures |
Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368 or 19369
The following codes should be pre-authorized as potentially cosmetic:
11950, 11951, 11952, 11954, 11960, 11970, 11971, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15830, 17360, 19316, 19318, 19324, 19325, 19355, 19370, 19371, 19380, 19396, 21210, 21230, 21235, 21740, 21742, 21743, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37501, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 69300 |
Obesity surgery |
43644, 43770, 43771, 43772, 43773, 43774, 43843, 43846, 43848, S2083 |
Orthognathic surgery |
21120, 21121, 21123, 21125, 21127, 21137, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151,21154, 21155, 21159, 21160, 21193, 21198, 21199, 21206, 21208, 21209, 21210, 21230, 21235, |
Cochlear implants (according to contract language) |
69930 |
Sleep apnea surgery |
21685, 42120, 42140, 42145, 42160, 42299 |
| Investigational or potentially investigational services |
May not be covered under the member's contract. However, pre-authorization is recommended for any policy that has specific medical necessity criteria in addition to the experimental and investigational language. Please refer to the current List of Investigational Services at http://www.regence.com/trgmedpol/investigationalServices/index.html for the most up-to-date listing of possible investigational codes. The investigational list is updated monthly and is the most reliable source.
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| Pregnancy |
Physicians are required to notify Special Beginnings® of pregnancies within two weeks of the member's first prenatal visit. Phone: 1 (888) 569-2229 Fax: (503) 391-8696. |
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