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G6016
PR DELIVERY COMP IMRT
HCPCS
Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2...
G6015
Radiation tx delivery imrt
HCPCS
Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: P...
77386
HC IMRT COMPLEX
HCPCS
Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: P...
77385
HC IMRT SIMPLE
HCPCS
Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: P...
G6016
PR DELIVERY COMP IMRT
HCPCS
Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: P...
G6015
Radiation tx delivery imrt
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statem...
77386
HC IMRT COMPLEX
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statem...
77385
HC IMRT SIMPLE
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statem...
G6016
PR DELIVERY COMP IMRT
HCPCS
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statem...
G6015
Radiation tx delivery imrt
HCPCS
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative defi...
G6016
PR DELIVERY COMP IMRT
HCPCS
Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes. 09/16/2015: Policy description updated regarding IMRT systems. Policy statements unchanged. Policy Guidelines section updated to add medically necessary and investigative defi...
1745
Thoracoscopic robotic assisted procedure
ICD
PMID 17141745. - World Health Organisation. (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation.
D7873
Tmj arthroscopy lysis adhesn
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
96000
PR COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70320
Full mouth x-ray of teeth
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
93762
Peripheral Thermogram
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D7877
Tmj arthroscopy debridement
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
96004
PR PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70310
X-ray exam of teeth
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70300
X-ray exam of teeth
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
S8262
MANDIB ORTHO REPOSITION DEVICE EACH
CPT
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
93760
Cephalic Thermogram
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D8999
PR UNS ORTHODONTIC PROCEDURE BY REPORT
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D8010
PR LTD ORTHODONT TX PRIMARY DENTITION
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D0330
PR PANORAMIC RADIOGRAPHIC IMAGE
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70328
XR TMJ UNILATERAL
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D2999
PR UNSPEC RESTORATIVE PROC BY REPORT
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D0230
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
21240
Reconstruction of jaw joint
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70332
X-ray exam of jaw joint
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
21243
Reconstruction of jaw joint
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D1510
Space maintainer fxd unilat
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70250
XR Skull < 4 Views
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D1550
Recement space maintainer
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
95867
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D2940
PR PROTECTIVE RESTORATION
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D5899
Removable prosthodontic proc
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
70260
XR SKULL 4 VIEWS
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
95868
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D0210
PR INTRAORAL-CMPL SER RADIOGRAPH IMAGS
HCPCS
There are lifetime contractual limits depending on the individual contract. This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70...
D7873
Tmj arthroscopy lysis adhesn
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
96000
PR COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70320
Full mouth x-ray of teeth
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
93762
Peripheral Thermogram
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D7877
Tmj arthroscopy debridement
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
96004
PR PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70310
X-ray exam of teeth
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70300
X-ray exam of teeth
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
S8262
MANDIB ORTHO REPOSITION DEVICE EACH
CPT
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
93760
Cephalic Thermogram
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D8999
PR UNS ORTHODONTIC PROCEDURE BY REPORT
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D8010
PR LTD ORTHODONT TX PRIMARY DENTITION
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D0330
PR PANORAMIC RADIOGRAPHIC IMAGE
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70328
XR TMJ UNILATERAL
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D2999
PR UNSPEC RESTORATIVE PROC BY REPORT
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D0230
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
21240
Reconstruction of jaw joint
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70332
X-ray exam of jaw joint
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
21243
Reconstruction of jaw joint
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D1510
Space maintainer fxd unilat
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70250
XR Skull < 4 Views
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D1550
Recement space maintainer
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
95867
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D2940
PR PROTECTIVE RESTORATION
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D5899
Removable prosthodontic proc
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
70260
XR SKULL 4 VIEWS
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
95868
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D0210
PR INTRAORAL-CMPL SER RADIOGRAPH IMAGS
HCPCS
This therapy will fall within those limits. Sources updated 12/16/2002: HCPCS S8262 added 3/2003: Reviewed by MPAC; Passive Rehabilitation Therapy for Mandibular Hypomobility considered not medically necessary. Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-...
D7873
Tmj arthroscopy lysis adhesn
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
96000
PR COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70320
Full mouth x-ray of teeth
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
93762
Peripheral Thermogram
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D7877
Tmj arthroscopy debridement
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
96004
PR PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
21070
Remove coronoid process
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70310
X-ray exam of teeth
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70300
X-ray exam of teeth
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
93760
Cephalic Thermogram
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
76101
Complex body section x-ray
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D8999
PR UNS ORTHODONTIC PROCEDURE BY REPORT
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D8010
PR LTD ORTHODONT TX PRIMARY DENTITION
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D0330
PR PANORAMIC RADIOGRAPHIC IMAGE
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
21110
PR APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70328
XR TMJ UNILATERAL
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D2999
PR UNSPEC RESTORATIVE PROC BY REPORT
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D0230
PR IO-PERIAPICAL EA ADD RADIOGRPH IMAG
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
21240
Reconstruction of jaw joint
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70332
X-ray exam of jaw joint
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
21243
Reconstruction of jaw joint
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
21085
PR IMPRESSION & PREPARATION ORAL SURGICAL SPLINT
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D1510
Space maintainer fxd unilat
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70250
XR Skull < 4 Views
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
76102
Complex body section x-rays
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D1550
Recement space maintainer
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
95867
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D2940
PR PROTECTIVE RESTORATION
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
D5899
Removable prosthodontic proc
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
70260
XR SKULL 4 VIEWS
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
97762
C/o for orthotic/prosth use
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...
95868
PR NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI
HCPCS
Code ranges 21240-21243, 70328-70332, 76.93-76.95, D7873-D7877, 70250-70260, 93760-93762, 95867-95868, 96000-96004, D0210-D0230, D1510-D1550, D2110-D2999, D5000-D5899, D8010-D8999 listed separately 6/30/2004: Code Reference section updated, HCPCS D0330 moved from non-covered to covered, CPT code 70300, 70310, 70320 del...