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Elizabeth M. Whitehorn, Director

Expensive Drugs and Devices for Hospitals and ASTCs

Codes Effective 01/01/13

Auditory Osseointegrated Devices

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
L8690 Auditory osseointegrated device, including all internal and external components No 69714 Implantation, osseointegrated implant, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
    No 69715 Implantation, osseointegrated implant, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
    No 69717 Replacement (including removal or existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
    No 69718 Replacement (including removal or existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy

Cardioverter/Defibrillators

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1721 Cardioverter-defibrillator, dual chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads
    No 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
    No 33262 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system
    No 33263 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system
    No 33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system
C1722 Cardioverter-defibrillator, single chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads
    No 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
    No 33262 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system
    No 33263 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system
    No 33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system
C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 
    No 33230 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing dual leads
    No 33231 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing multiple leads
    No 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator
    No 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator
    No 33262 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; single lead system
    No 33263 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; dual lead system
    No 33264 Removal of pacing cardioverter-defibrillator pulse generator with replacement of pacing cardioverter-defibrillator pulse generator; multiple lead system

Cochlear Devices

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
L8614 Cochlear device, includes all internal and external components No 69930 Cochlear device implantation, with or without mastoidectomy
L8619 Cochlear implant external speech processor, replacement  No 69930 Cochlear device implantation, with or without mastoidectomy
L8627 Cochlear implant external speech processor, component, replacement  No 69930 Cochlear device implantation, with or without mastoidectomy
L8628 Cochlear implant external controller component, replacement No 69930 Cochlear device implantation, with or without mastoidectomy

Drugs

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
J0129 Injection, Abatacept, 10 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
J0490 Injection, Belimumab, 10 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
J0585 Injection, Onabotulinumtoxina, 1 unit Yes - HFS 3082 Drug Prior Authorization Request Form 64612 Chemodenervation of muscle(s); muscle innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64613 Chemodenervation of muscle(s); neck muscles(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64650 Chemodenervation of eccrine glands; both axillae
    Yes - HFS 3082 Drug Prior Authorization Request Form 64653 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day
    Yes - HFS 3082 Drug Prior Authorization Request Form 64999 Unlisted procedure, nervous system
J0586 Injection, Abobotulinumtoxina, 5 units Yes - HFS 3082 Drug Prior Authorization Request Form 64612 Chemodenervation of muscle(s); muscle innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64613 Chemodenervation of muscle(s); neck muscles(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64650 Chemodenervation of eccrine glands; both axillae
    Yes - HFS 3082 Drug Prior Authorization Request Form 64653 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day
    Yes - HFS 3082 Drug Prior Authorization Request Form 64999 Unlisted procedure, nervous system
J0587 Injection, Rimabotulinumtoxinb, 100 units Yes - HFS 3082 Drug Prior Authorization Request Form 64612 Chemodenervation of muscle(s); muscle innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64613 Chemodenervation of muscle(s); neck muscles(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
    Yes - HFS 3082 Drug Prior Authorization Request Form 64650 Chemodenervation of eccrine glands; both axillae
    Yes - HFS 3082 Drug Prior Authorization Request Form 64653 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day
    Yes - HFS 3082 Drug Prior Authorization Request Form 64999 Unlisted procedure, nervous system
J0588 Injection, Incobotulinumtoxin A, 1 unit No 64612 Chemodenervation of muscle(s); muscle innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm)
    No 64613 Chemodenervation of muscle(s); neck muscles(s) (e.g., for spasmodic torticollis, spasmodic dysphonia)
    No 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis)
    No 64650 Chemodenervation of eccrine glands; both axillae
    No 64653 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day
    No 64999 Unlisted procedure, nervous system
J0597 Berinert, 10 units No 96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
      96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure)
      96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (list separately in addition to primary procedure)
J0850 Injection, Cytomegalovirus Immune Globulin intravenous (human), per vial No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
    No 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
    No 96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug; each additional hour). List separately in addition to code for primary procedure.
J1300 Injection, Eculizumab, 10 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
J1459 Injection, Immune Globulin (Privigen), Intravenous, Non-Lyophilized (e.g., liquid), 500 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
J1561 Injection, Immune Globulin (Gamunex), Intravenous, Non-Lyophilized (e.g., liquid), 500 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
    No 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
    No 96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug; each additional hour). List separately in addition to code for primary procedure.
J1562 Injection, Immune Globulin (Vivaglobin), 100 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
    No 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
    No 96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug; each additional hour). List separately in addition to code for primary procedure.
J1566 Injection, Immune Globulin, Intravenous, Lyophilized (e.g., powder), not otherwise specified No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
      96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
      96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
      96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
      96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug; each additional hour). List separately in addition to code for primary procedure.
J1568 Injection, Immune Globulin, (Octagam), Intravenous, Non-Lyophilized (e.g., liquid), 500 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
    No 96370 Subcutaneous infusion for therapy or prophylaxis, (specify substance or drug) each additional hour).  List separately in addition to code for primary procedure. 
J1569 Injection, Immune Globulin, (Gammagard Liquid), Intravenous, Non-Lyophilized (e.g., liquid), 500 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).
    No 96370 Subcutaneous infusion for therapy or prophylaxis, (specify substance or drug) each additional hour).  List separately in addition to code for primary procedure. 
J1745 Injection, Infliximab, 10 mg. - Remicade No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3262 Injection, Tocilizumab, 1 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.
      96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour. List separately in addition to code for primary procedure.
      96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour. List separately in addition to code for primary procedure.
J3364 Injection, Urokinase, 5000 IU Vial - Abbokinase No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour).
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3365 Injection, Urokinase, 250,000 IU Vial - Abbokinase No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J3488 Injection, Zoledronic Acid (Reclast), 1 mg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
J7185 Injection, Factor VIII (Antihemophilic Factor, Recombinant) (Xyntha), Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7186 Injection, Antihemophilic Factor VIII/Von Willebrand Factor Complex (Human), Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7187 Injection, Von Willebrand Factor Complex (Humate-P), Per I.U. VWF:RCO  No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7189 Factor VIIA (Antihemophilic Factor, Recombinant), Per 1 mcg. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7190 Factor VIII (Antihemophilic Factor, Human) Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7191 Factor VIII (Antihemophilic Factor (Porcine), Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7192 Factor VIII (Antihemophilic Factor, Recombinant) Per I.U., Not Otherwise Specified No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7193 Factor IX (Antihemophilic Factor, Purified, Non-Recombinant) per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7194 Factor IX, Complex, Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7195 Factor IX (Antihemophilic Factor, Recombinant), Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7197 Antithrombin III (Human), Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7198 Anti-Inhibitor, Per I.U. No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7199 Hemophilia Clotting Factor, Not Otherwise Classified No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
    No 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour).  List separately in addition to code for primary procedure.
    No 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour).  List separately in addition to code for primary procedure.
    No 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
    No 96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug.  List separately in addition to code for primary procedure. 
    No 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.
J7310 Ganciclovir, 4.5 mg., long-acting implant - Vitrasert No 67027 Implantation of intravitreal drug delivery system (eg., ganciclovir, implant), includes concomitant removal of vitreous
J9226 Histrelin Implant (Supprelin LA), 50 mg. No 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
    No 11981 Insertion, non-biodegradable drug delivery implant
    No 11983 Removal with reinsertion, non-biodegradable drug delivery implant
Q2041 Injection, Von Willebrand Factor, complex (human) Wilate 1 IU No 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, up to 1 hour)
      96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; initial, each additional hour). List separately in addition to code for primary procedure.
      96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug; additional sequential infusion, up to 1 hour). List separately in addition to code for primary procedure.
      96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
      96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug. List separately in addition to code for primary procedure.
      96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility. List separately in addition to primary procedure.

Infusion Pumps

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
EO782 Infusion pump system, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)  No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
    No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
    No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
    No 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming
E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) No 36260 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver)
    No 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump
 

 

 No 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter
    No 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump
    No 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

Neurostimulators

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1767 Generator, neurostimulator (implantable), non-rechargeable No 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 
    No 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays 
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension No 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension  No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension No 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays
    No 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling
    No 64568 Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator
    No 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling

Osteogenesis Stimulator

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
E0749 Osteogenesis stimulator, electrical, surgically implanted No 20975 Electrical stimulation to aid bone healing; invasive (operative)

Pacemakers

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
C1785 Pacemaker, dual chamber, rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular 
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33221 Insertion of pacemaker pulse generator only; with existing multiple leads
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system
    No 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
    No 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system
C1786 Pacemaker, single chamber, rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33221 Insertion of pacemaker pulse generator only; with existing multiple leads
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system
    No 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
    No 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system
C2619 Pacemaker, dual chamber, non rate-responsive (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33221 Insertion of pacemaker pulse generator only; with existing multiple leads
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 
    No 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system
    No 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
    No 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system
C2620 Pacemaker, single chamber, non rate-responsive (implantable)   No 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33221 Insertion of pacemaker pulse generator only; with existing multiple leads
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator)
    No 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system
    No 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
    No 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system
C2621 Pacemaker, other than single or dual chamber (implantable) No 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
    No 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular
    No 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
    No 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular
    No 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular
    No 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)
    No 33221 Insertion of pacemaker pulse generator only; with existing multiple leads
    No 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 
    No 33227 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system
    No 33228 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system
    No 33229 Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system

Skin Replacement

HCPCS Code HCPCS Description Prior Approval APL Code APL CPT Code Description
Q4101 Skin substitute, Apligraf, per square centimeter No 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.
    No 15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
    No 15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.
    No 15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children.