Effective December 1, 2017, the following Current Procedural Terminology (CPT) codes will require prior approval for benefit plans in the following Networks:*
- Enhanced Care Prime Network
- HIP Premium Network**
- HIP Prime Network
- NY Metro Network**
- Select Care Network
- Medicare Essential Network
- VIP Prime Network
*Excludes Monte CMO
**Members are being transitioned to the HIP Prime Network upon renewal. Transition will be completed by December 31, 2017.
These CPT codes are limited to the specialties as indicated in the table below.
| Procedure Code | Description | Specialty |
|---|---|---|
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed | Orthopedics |
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | Orthopedics |
| 36247 | Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family | Vascular Surgery |
| 37221 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | Vascular Surgery |
| 37224 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty | Vascular Surgery |
| 37226 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed | Vascular Surgery |
| 37227 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed | Vascular Surgery |
| 38525 | Biopsy or excision of lymph node(s); open, deep axillary node(s) | Surgery |
| 47562 | Laparoscopy, surgical; cholecystectomy | Surgery |
| 49585 | Repair umbilical hernia, age 5 years or older; reducible | Surgery |
| 50590 | Lithotripsy, extracorporeal shock wave | Urology |
| 52000 | Cystourethroscopy (separate procedure) | Urology |
| 55700 | Biopsy, prostate; needle or punch, single or multiple, any approach | Urology |
| 67255 | Scleral reinforcement (separate procedure); with graft | Ophthalmology |
| 93459 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography | Cardiology, Cardiothoracic Surgery |
| 93460 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed | Cardiology, Cardiothoracic Surgery |
| 93650 | Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement | Cardiology, Cardiothoracic Surgery |
| 93886 | Transcranial Doppler study of the intracranial arteries; complete study | Cardiology, Neurology |
| 96365 | Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour | Hematology/Oncology, Rheumatology, Neurology |
| 96415 | Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) | Hematology/Oncology, Rheumatology, Neurology |
