Read All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs) text version

All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs)

Inclusion on this list indicates that service should not be billed using APGs; it does not guarantee alternative payment. See codes removed from the Carve out list below.

*The following optional carved-out procedures may be billed as ordered ambulatory services when an APG visit is not billed for the clinic patient on the same date of service.

*J1055 *86580 *81025 Medrxyprogester acetate inj TB intradermal test Urine pregnancy test 435 394 410 Class I Pharmacotherapy Level I Immunology Tests Urinalysis Procedure carve out Procedure carve out Procedure carve out

Effective Date

Alternative Payment Source/Notes

9/1/2008 Ordered Ambulatory Fee Schedule 4/1/2010 Laboratory Fee Schedule 9/1/2008 Laboratory Fee Schedule

Select rate codes carved out of the APG reimbursement methodology: 1604, 1695, 1802, 1850, 2961, 2983, 3107, 3109, 3111, 3139. See list of subsumed rate codes for a complete list of rate codes carved out of the APG reimbursement methodology.

HCPCS

58565 83655 83890 83891 83892 83893 83894 83896 83897 83898 83900 83901 83902 83903 83904 83905 83906 83907

Description

Hysteroscopy, sterilization Lead screen Molecule isolate Molecule isolate nucleic Molecular diagnostics Molecule dot/slot/blot Molecule gel electrophor Molecular diagnostics Molecule nucleic transfer Molecule nucleic ampli, each Molecule nucleic ampli 2 seq Molecule nucleic ampli addon Molecular diagnostics Molecule mutation scan Molecule mutation identify Molecule mutation identify Molecule mutation identify Lyse cells for nucleic ext

APG

200 404 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395

APG Description

HYSTEROSCOPY Toxicology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests

v3.5 APG

200 404 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395

v3.5 APG Description

HYSTEROSCOPY Toxicology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests

Carve out Type

Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out

Effective Date

1/1/2011 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010

page 1 of 14

HCPCS

83908 83909 83912

Description

Nucleic acid, signal ampli Nucleic acid, high resolute Genetic examination

APG

395 395 400

APG Description

Level II Immunology Tests Level II Immunology Tests Level I Chemistry Tests

v3.5 APG

395 395 400

v3.5 APG Description

Level II Immunology Tests Level II Immunology Tests Level I Chemistry Tests

Carve out Type

Procedure carve out Procedure carve out Procedure carve out

Effective Date

1/1/2010 1/1/2010 1/1/2010

83913 83914 85004 85610 87536 87900 87901 87902 87903 87904 87999 88230 88233 88235 88237 88239 88240 88241 88245 88248 88249 88261 88262 88263 88264 88267 88269 88271 88272 88273 88274 88275 88280 88283 88285 88289 88291 90470 90473 90655

Molecular, rna stabilization Mutation ident ola/sbce/aspe Automated diff wbc count Prothrombin time HIV viral load testing Virtual phenotype HIV genotype, drug resistance test Hepatitis C virus, genotype test HIV drug resistance Phenotype, dna hiv w/clt add Microbiology procedure Tissue culture, lymphocyte Tissue culture, skin/biopsy Tissue culture, placenta Tissue culture, bone marrow Tissue culture, tumor Cell cryopreserve/storage Frozen cell preparation F ll ti Chromosome analysis, 20-25 Chromosome analysis, 50-100 Chromosome analysis, 100 Chromosome analysis, 5 Chromosome analysis, 15-20 Chromosome analysis, 45 Chromosome analysis, 20-25 Chromosome analys, placenta Chromosome analys, amniotic Cytogenetics, dna probe Cytogenetics, 3-5 Cytogenetics, 10-30 Cytogenetics, 25-99 Cytogenetics, 100-300 Chromosome karyotype study Chromosome banding study Chromosome count, additional Chromosome study, additional Cyto/molecular report Immune admin H1N1 im/nasal Immune admin oral/nasal Flu vaccine no preserv 6-35m

395 395 408 406 397 397 393 397 393 393 396 391 391 391 391 391 390 390 391 391 395 391 391 391 395 391 391 395 395 395 395 395 391 391 390 390 395 414 490 414

Level II Immunology Tests Level II Immunology Tests Level I Hematology Tests Level I Clotting Tests Level II Microbiology Tests Level II Microbiology Tests Blood And Tissue Typing Level II Microbiology Tests Blood And Tissue Typing Blood And Tissue Typing Level I Microbiology Tests Level II Pathology Level II Pathology Level II Pathology Level II Pathology Level II Pathology Level I Pathology Level I Pathology L l P th l Level II Pathology Level II Pathology Level II Immunology Tests Level II Pathology Level II Pathology Level II Pathology Level II Immunology Tests Level II Pathology Level II Pathology Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Pathology Level II Pathology Level I Pathology Level I Pathology Level II Immunology Tests Level I Immunization And Allergy Incidental To Medical, Significant Level I Immunization And Allergy

395 395 408 406 397 397 393 397 393 393 396 391 391 391 391 391 390 390 391 391 395 391 391 391 395 391 391 395 395 395 395 395 391 391 390 390 395 414 490 414

Level II Immunology Tests Level II Immunology Tests Level I Hematology Tests Level I Clotting Tests Level II Microbiology Tests Level II Microbiology Tests Blood And Tissue Typing Level II Microbiology Tests Blood And Tissue Typing Blood And Tissue Typing Level I Microbiology Tests Level II Pathology Level II Pathology Level II Pathology Level II Pathology Level II Pathology Level I Pathology Level I Pathology L l P th l Level II Pathology Level II Pathology Level II Immunology Tests Level II Pathology Level II Pathology Level II Pathology Level II Immunology Tests Level II Pathology Level II Pathology Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Pathology Level II Pathology Level I Pathology Level I Pathology Level II Immunology Tests Level I Immunization And Allergy Incidental To Medical, Significant Level I Immunization And Allergy

Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out P d t Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out

1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 9/1/2009 9/1/2009 9/1/2009

page 2 of 14

HCPCS

90656 90657 90658 90660 90663 90669 90732 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9000 B9002 B9004 B9006 B9998 B9999 C9259 D7650 D8050 D8060 D8070 D8080 D8090 D8210

Description

Flu vaccine no preserv 3 & > Flu vaccine, 3 yrs, im Flu vaccine, 3 yrs & >, im Flu vaccine, nasal Flu vacc pandemic Pneumococcal vacc, ped <5 Pneumococcal vaccine Parenteral 50% dextrose solu Parenteral sol amino acid 3. Parenteral sol amino acid 5. Parenteral sol amino acid 7Parenteral sol amino acid > Parenteral sol carb > 50% Parenteral sol 10 gm lipids Parenteral sol amino acid & Parenteral sol 52-73 gm prot Parenteral sol 74-100 gm pro Parenteral sol > 100gm prote Parenteral nutrition additiv Parenteral supply kit premix Parenteral supply kit homemi Parenteral administration ki Parenteral sol renal-amirosy Parenteral sol hepatic-fream Parenteral sol stres-brnch c Enter infusion pump w/o alrm Enteral infusion pump w/ ala Parenteral infus pump portab Parenteral infus pump statio Enteral supp not otherwise c Parenteral supp not othrws c Injection, pralatrexate, 1 mg Open red simp malar/zygom fx Intercep dental tx primary Intercep dental tx transitn Compre dental tx transition Compre dental tx adolescent Compre dental tx adult Orthodontic rem appliance tx

APG

414 414 414 414 414 415 414 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 432 371 371 371 371 371 371 371

APG Description

Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level II Immunization Level I Immunization And Allergy Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Class III Chemotherapy Drugs Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics

v3.5 APG

414 414 414 414 414 415 414 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 454 463 371 371 371 371 371 371 371

v3.5 APG Description

Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level I Immunization And Allergy Level II Immunization Level I Immunization And Allergy Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae Tpn Formulae CLASS XI COMBINED Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics

Carve out Type

Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out Procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Effective Date

9/1/2009 9/1/2009 9/1/2009 9/1/2009 9/1/2009 9/1/2009 9/1/2009 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2011 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

page 3 of 14

HCPCS

D8660 D8670 D8680 D8690 D8692 D8999 E1220 E2227 E2228 E2300 E2301 E2310 E2311 E2312 E2313 E2321 E2322 E2323 E2324 E2325 E2326 E2327 E2328 E2329 E2330 E2331 E2340 E2341 E2342 E2343 E2351 E2360 E2361 E2362 E2363 E2364 E2365 E2366 E2367 E2368 E2369 E2370 E2371

Description

Preorthodontic tx visit Periodic orthodontc tx visit Orthodontic retention Orthodontic treatment Replacement retainer Orthodontic procedure Whlchr special size/constrc Gear reduction drive wheel Mwc acc, wheelchair brake Pwr seat elevation sys Pwr standing Electro connect btw control Electro connect btw 2 sys Mini-prop remote joystick PWC harness, expand control Hand interface joystick Mult mech switches Special joystick handle Chin cup interface Sip and puff interface Breath tube kit Head control interface mech Head/extremity control inter Head control nonproportional Head control proximity switc Attendant control W/c wdth 20-23 in seat frame W/c wdth 24-27 in seat frame W/c dpth 20-21 in seat frame W/c dpth 22-25 in seat frame Electronic SGD interface 22nf nonsealed leadacid 22nf sealed leadacid battery Gr24 nonsealed leadacid Gr24 sealed leadacid battery U1nonsealed leadacid battery U1 sealed leadacid battery Battery charger, single mode Battery charger, dual mode Power wc motor replacement Pwr wc gear box replacement Pwr wc motor/gear box combo Gr27 sealed leadacid battery

APG

371 371 371 371 371 371 453 453 453 456 456 456 456 453 453 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456

APG Description

Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories

v3.5 APG

371 371 371 371 371 371 453 453 453 456 456 456 456 453 453 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456

v3.5 APG Description

Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Orthodontics Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Accessories

Carve out Type

APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

page 4 of 14

HCPCS

E2372 E2373 E2374 E2375 E2376 E2377 E2381 E2382 E2383 E2384 E2385 E2386 E2387 E2388 E2389 E2390 E2391 E2392 E2394 E2395 E2396 E2397 G0008

Description

Gr27 non-sealed leadacid Hand/chin ctrl spec joystick Hand/chin ctrl std joystick Non-expandable controller Expandable controller, repl Expandable controller, initl Pneum drive wheel tire Tube, pneum wheel drive tire Insert, pneum wheel drive Pneumatic caster tire Tube, pneumatic caster tire Foam filled drive wheel tire Foam filled caster tire Foam drive wheel tire Foam caster tire Solid drive wheel tire Solid caster tire Solid caster tire, integrate Drive wheel excludes tire Caster wheel excludes tire Caster fork Pwc acc, lith-based battery Admin influenza virus vac

APG

456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 453 490

APG Description

Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Incidental To Medical, Significant Procedure Or Therapy Visit Incidental To Medical, Significant Class V Chemotherapy Drugs Class IV Chemotherapy Drugs Class VII Combined Class IV Chemotherapy Drugs Class V Chemotherapy Drugs Class IV Chemotherapy Drugs Class IV Pharmacotherapy Class II Pharmacotherapy Class I Chemotherapy Drugs

v3.5 APG

456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 456 453 490

v3.5 APG Description

Carve out Type

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 9/1/2009

Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories APG carve out Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Accessories Motorized Wheelchair Incidental To Medical, Significant Procedure Or Therapy Visit Incidental To Medical, Significant CLASS IX COMBINED CLASS VI CHEMOTHERAPY CLASS XII COMBINED CLASS V CHEMOTHERAPY CLASS IX COMBINED CLASS VIII COMBINED CLASS V PHARMACOTHERAPY CLASS V PHARMACOTHERAPY CLASS I CHEMOTHERAPY APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out Procedure carve out

G0009 J0128 J0135 J0180 J0207 J0365 J0480 J0585 J0587 J0640

Admin pneumococcal vaccine Abarelix injection Adalimumab injection Agalsidase beta injection Amifostine Aprotonin, 10,000 kiu Basiliximab Botulinum toxin a per unit Botulinum toxin type B Leucovorin calcium injection

490 434 433 442 433 434 433 438 436 430

490 461 441 464 434 461 460 439 439 430

Procedure carve out procedure carve out APG carve out APG carve out APG carve out procedure carve out procedure carve out Procedure carve out Procedure carve out APG carve out

9/1/2009 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

page 5 of 14

HCPCS

J0641 J0740 J0795 J0878 J0882 J0886 J1190 J1300

Description

Levoleucovorin injection Cidofovir injection Corticorelin ovine triflutal Daptomycin injection Darbepoetin alfa, esrd use Epoetin alfa 1000 units ESRD Dexrazoxane HCl injection Eculizumab injection

APG

431 432 433 431 432 431 431 442

APG Description

Class II Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class II Chemotherapy Drugs Class III Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class VII Combined Chemotherapy & Pharmacotherapy Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class III Pharmacotherapy Class III Pharmacotherapy Class IV Chemotherapy Drugs Class IV Chemotherapy Drugs Class VII Combined Class IV Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class III Chemotherapy Drugs Class VII Combined Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class VI Chemotherapy Drugs Class V Pharmacotherapy Class IV Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class V Pharmacotherapy Class II Chemotherapy Drugs Class III Pharmacotherapy Class I Chemotherapy Drugs Class II Pharmacotherapy Class I Chemotherapy Drugs Class III Pharmacotherapy Class V Chemotherapy Drugs

v3.5 APG

433 460 434 433 439 439 434 465

v3.5 APG Description

CLASS IV CHEMOTHERAPY DRUGS CLASS VIII COMBINED CHEMOTHERAPY AND CLASS V CHEMOTHERAPY DRUGS CLASS IV CHEMOTHERAPY CLASS V PHARMACOTHERAPY CLASS V PHARMACOTHERAPY CLASS V CHEMOTHERAPY DRUGS CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY CLASS I CHEMOTHERAPY CLASS II CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS IV PHARMACOTHERAPY CLASS VII CHEMOTHERAPY DRUGS CLASS VII CHEMOTHERAPY CLASS XII COMBINED CLASS X COMBINED CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY DRUGS APG CLASS VIII COMBINED CLASS VI CHEMOTHERAPY CLASS XIII COMBINED CLASS III CHEMOTHERAPY CLASS XII COMBINED CLASS III CHEMOTHERAPY CLASS VII CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS IX COMBINED CLASS VI CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS III CHEMOTHERAPY CLASS IV CHEMOTHERAPY CLASS X COMBINED CLASS III CHEMOTHERAPY CLASS XI COMBINED CLASS III CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS II CHEMOTHERAPY CLASS II PHARMACOTHERAPY CLASS IX COMBINED

Carve out Type

APG carve out procedure carve out APG carve out APG carve out APG carve Now a APG carve Now a APG carve out APG carve out

Effective Date

1/1/2009 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010

J1325 J1327 J1440 J1441 J1451 J1457 J1458 J1566 J1620 J1626 J1675 J1742 J1785 J1825 J1931 J1945 J1950 J2278 J2323 J2425 J2430 J2469 J2504 J2505 J2513 J2562 J2770 J2794 J2805 J2997 J3110

Epoprostenol injection Eptifibatide injection Filgrastim 300 mcg injection Filgrastim 480 mcg injection Fomepizole, 15 mg Gallium nitrate injection Galsulfase injection Immune globulin, powder Gonadorelin hydroch/ 100 mcg Granisetron hcl injection Histrelin acetate Ibutilide fumarate injection Injection imiglucerase /unit Interferon beta-1a Laronidase injection Lepirudin Leuprolide acetate /3.75 MG Ziconotide injection Natalizumab injection Palifermin injection Pamidronate disodium /30 MG Palonosetron hcl Pegademase bovine, 25 iu Injection, pegfilgrastim 6mg Pentastarch 10% solution Injection, plerixafor, 1 mg Quinupristin/dalfopristin Risperidone, long acting Sincalide injection Alteplase recombinant Teriparatide injection

430 432 437 437 433 433 442 433 430 431 434 432 442 431 434 431 434 441 439 433 431 431 431 439 431 437 430 436 430 437 434

430 431 438 438 443 443 464 462 430 430 460 441 465 432 464 432 443 430 461 441 438 432 433 462 432 463 432 438 431 436 461

APG carve out APG carve out Procedure carve out Procedure carve out APG carve out APG carve out carve out procedure carve out APG carve out APG carve out carv procedure carve out APG carve out APG carve out APG carve out procedure carve out APG carve out APG carve out APG carve out Procedure carve out APG carve out APG carve out APG carve out APG carve out Procedure carve out APG carve out Procedure carve out APG carve out Procedure carve out APG carve out Procedure carve out procedure carve out

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2011 12/1/2008 4/1/2009 12/1/2008 1/1/2010 12/1/2008

page 6 of 14

HCPCS

J3246 J3285 J3315 J3396 J3487 J3490 J3590 J7187

Description

Tirofiban HCl Treprostinil injection Triptorelin pamoate Verteporfin injection Zoledronic acid Drugs unclassified injection Unclassified biologics Humate-P, inj

APG

432 432 433 433 432 435 435 438

APG Description

Class III Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class I Pharmacotherapy Class I Pharmacotherapy Class IV Pharmacotherapy

v3.5 APG

434 461 434 443 434 435 435 460

v3.5 APG Description

CLASS V CHEMOTHERAPY CLASS IX COMBINED CLASS V CHEMOTHERAPY CLASS VII CHEMOTHERAPY CLASS V CHEMOTHERAPY CLASS I PHARMACOTHERAPY CLASS I PHARMACOTHERAPY CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY CLASS XIII COMBINED CLASS XIII COMBINED CHEMOTHERAPY AND CLASS XIII COMBINED CLASS XIII COMBINED CLASS XIII COMBINED CLASS XIII COMBINED CLASS XIII COMBINED CLASS IV PHARMACOTHERAPY CLASS VIII COMBINED CLASS III PHARMACOTHERAPY Incidental To Medical, Significant CLASS V PHARMACOTHERAPY CLASS V PHARMACOTHERAPY CLASS II CHEMOTHERAPY CLASS V CHEMOTHERAPY CLASS VII CHEMOTHERAPY CLASS III CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS III CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY DRUGS CLASS IX COMBINED CLASS VII CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS IV CHEMOTHERAPY CLASS V CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS IV CHEMOTHERAPY CLASS VII CHEMOTHERAPY

Carve out Type

APG carve out procedure carve out APG carve out APG carve out APG carve out Procedure carve out Procedure carve out Procedure carve out

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 4/1/2010 4/1/2010 12/1/2008

J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7197 J7198 J7199 J7300 J7302 J7307 J7501 J7504 J7505 J7520 J8498 J8501 J8510 J8515

Factor viia Factor viii Factor VIII (porcine) Factor viii recombinant Factor IX non-recombinant Factor ix complex Factor IX recombinant Antithrombin iii injection Anti-inhibitor Hemophilia clot factor noc Intraut copper contraceptive Levonorgestrel iu contracept Etonogestrel implant system Et t li l t t Azathioprine parenteral Lymphocyte immune globulin Monoclonal antibodies Sirolimus, oral Antiemetic rectal/supp NOS Oral aprepitant Oral busulfan Cabergoline, oral 0.25mg

438 439 439 439 439 437 439 436 439 436 490 436 436 433 432 433 431 430 431 430 430

Class IV Pharmacotherapy Class V Pharmacotherapy Class V Pharmacotherapy Class V Pharmacotherapy Class V Pharmacotherapy Class III Pharmacotherapy Class V Pharmacotherapy Class II Pharmacotherapy Class V Pharmacotherapy Class II Pharmacotherapy Incidental To Medical, Significant Class II Pharmacotherapy Class II Ph Cl Pharmacotherapy th Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs

465 465 465 465 465 465 465 438 460 437 490 439 439 431 434 443 432 430 432 430 430

Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out P Procedure carve out d t APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

J8520 J8521 J8530 J8540 J8560 J8565 J8597 J8600 J8610 J8650 J8700 J8705

Capecitabine, oral, 150 mg Capecitabine, oral, 500 mg Cyclophosphamide oral 25 MG Oral dexamethasone Etoposide oral 50 MG Gefitinib oral Antiemetic drug oral NOS Melphalan oral 2 MG Methotrexate oral 2.5 MG Nabilone oral Temozolomide Topotecan oral

432 433 430 430 431 432 430 430 430 430 432 433

Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs

461 443 430 430 433 434 430 430 430 430 433 443

procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

page 7 of 14

HCPCS

J9000 J9001 J9010 J9015 J9017 J9020 J9025 J9027 J9031 J9033 J9035 J9040 J9041 J9045 J9050 J9055 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9098 J9100 J9110 J9120 J9130

Description

Doxorubicin hcl injection Doxorubicin hcl liposome inj Alemtuzumab injection Aldesleukin injection Arsenic trioxide injection Asparaginase injection Azacitidine injection Clofarabine injection Bcg live intravesical vac Bendamustine injection Bevacizumab injection Bleomycin sulfate injection Bortezomib injection Carboplatin injection Carmustine injection Cetuximab injection Cisplatin 10 MG injection Cisplatin 50 MG injection Inj cladribine per 1 MG Cyclophosphamide 100 MG inj Cyclophosphamide 200 MG inj Cyclophosphamide 500 MG inj Cyclophosphamide 1.0 grm inj Cyclophosphamide 2.0 grm inj Cyclophosphamide lyophilized Cyclophosphamide lyophilized Cyclophosphamide lyophilized Cyclophosphamide lyophilized Cyclophosphamide lyophilized Cytarabine liposome inj Cytarabine hcl 100 MG inj Cytarabine hcl 500 MG inj Dactinomycin injection Dacarbazine 100 mg inj

APG

431 434 434 432 432 431 433 433 431 441 441 431 433 432 432 441 431 431 432 430 430 431 430 430 430 430 430 430 430 434 430 430 433 430

APG Description

Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class V Chemotherapy Drugs Class III Chemotherapy Drugs Class III Chemotherapy Drugs Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class IV Chemotherapy Drugs Class II Chemotherapy Drugs Class VI Chemotherapy Drugs Class VI Chemotherapy Drugs Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class III Chemotherapy Drugs Class VI Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class V Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class IV Chemotherapy Drugs Class I Chemotherapy Drugs

v3.5 APG

430 462 443 441 434 432 441 465 431 462 461 430 443 431 434 461 430 431 433 430 430 430 430 430 430 430 430 430 430 464 430 430 461 430

v3.5 APG Description

CLASS I CHEMOTHERAPY CLASS X COMBINED CLASS VII CHEMOTHERAPY DRUGS CLASS VI CHEMOTHERAPY CLASS V CHEMOTHERAPY DRUGS CLASS III CHEMOTHERAPY CLASS VI CHEMOTHERAPY CLASS XIII COMBINED CLASS II CHEMOTHERAPY CLASS X COMBINED CLASS IX COMBINED CLASS I CHEMOTHERAPY CLASS VII CHEMOTHERAPY CLASS II CHEMOTHERAPY CLASS V CHEMOTHERAPY CLASS IX COMBINED CLASS I CHEMOTHERAPY CLASS II CHEMOTHERAPY CLASS IV CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY DRUGS CLASS I CHEMOTHERAPY DRUGS CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY DRUGS CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS XII COMBINED CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS IX COMBINED CLASS I CHEMOTHERAPY DRUGS CLASS I CHEMOTHERAPY DRUGS CLASS III CHEMOTHERAPY DRUGS

Carve out Type

APG carve out procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG Carve out APG carve out procedure carve out procedure carve out APG carve out APG carve out APG carve out APG carve out procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out procedure carve out APG carve out APG carve out procedure carve out APG carve out

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

J9140

Dacarbazine 200 MG inj

430

Class I Chemotherapy Drugs

430

APG carve out

12/1/2008

J9150

Daunorubicin injection

431

Class II Chemotherapy Drugs

432

APG carve out

12/1/2008

page 8 of 14

HCPCS

J9151

Description

Daunorubicin citrate inj

APG

431

APG Description

Class II Chemotherapy Drugs

v3.5 APG

432

v3.5 APG Description

CLASS III CHEMOTHERAPY DRUGS

Carve out Type

APG carve out

Effective Date

12/1/2008

J9155

Degarelix injection

434

Class V Chemotherapy Drugs

434

CLASS V CHEMOTHERAPY DRUGAPG carve out

1/1/2010

J9160

Denileukin diftitox inj

434

Class V Chemotherapy Drugs

463

J9171 J9178 J9181 J9185 J9190 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J9211 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9230 J9245 J9250 J9260 J9261 J9263

Docetaxel injection Inj, epirubicin hcl, 2 mg Etoposide injection Fludarabine phosphate inj Fluorouracil injection Floxuridine injection Gemcitabine hcl injection Goserelin acetate implant Irinotecan injection Ixabepilone injection Ifosfomide injection j Mesna injection Idarubicin hcl injection Interferon alfacon-1 inj Interferon alfa-2a inj Interferon alfa-2b inj Interferon alfa-n3 inj Interferon gamma 1-b inj Leuprolide acetate suspnsion Leuprolide acetate injeciton Leuprolide acetate implant Vantas implant Mechlorethamine hcl inj Inj melphalan hydrochl 50 MG Methotrexate sodium inj Methotrexate sodium inj Nelarabine injection Oxaliplatin

432 433 430 432 430 432 433 432 433 432 432 431 431 430 432 432 430 432 434 434 434 434 431 441 430 430 434 441

Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class III Chemotherapy Drugs py g Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class V Chemotherapy Drugs Class V Chemotherapy Drugs Class V Chemotherapy Drugs Class V Chemotherapy Drugs Class II Chemotherapy Drugs Class VI Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class V Chemotherapy Drugs Class VI Chemotherapy Drugs

443 432 430 432 430 431 443 433 433 463 432 432 432 430 434 433 430 434 434 430 463 460 432 460 430 430 441 461

J9264

Paclitaxel protein bound

433

Class IV Chemotherapy Drugs

461

J9265

Paclitaxel injection

432

Class III Chemotherapy Drugs

431

CLASS XI COMBINED procedure carve out CHEMOTHERAPY AND PHARMACOTHERAPY CLASS VII CHEMOTHERAPY DRU APG carve out CLASS III CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out CLASS III CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS II CHEMOTHERAPY APG carve out DRUGS CLASS VII CHEMOTHERAPY APG carve out CLASS IV CHEMOTHERAPY APG carve out DRUGS CLASS IV CHEMOTHERAPY APG carve out CLASS XI COMBINED procedure carve out CLASS III CHEMOTHERAPY APG carve out CLASS III CHEMOTHERAPY APG carve out CLASS III CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS V CHEMOTHERAPY APG carve out CLASS IV CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS V CHEMOTHERAPY APG carve out CLASS V CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS XI COMBINED procedure carve out CLASS VIII COMBINED procedure carve out CLASS III CHEMOTHERAPY APG carve out CLASS VIII COMBINED procedure carve out CLASS I CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS VI CHEMOTHERAPY APG carve out CLASS IX COMBINED procedure carve out CHEMOTHERAPY AND PHARMACOTHERAPY CLASS IX COMBINED procedure carve out CHEMOTHERAPY AND PHARMACOTHERAPY CLASS II CHEMOTHERAPY APG carve out

12/1/2008

1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 1/1/2010

12/1/2008

12/1/2008

page 9 of 14

HCPCS

J9266 J9268 J9270 J9280 J9290 J9291 J9293 J9300 J9303 J9305 J9310 J9320 J9328 J9330 J9340 J9350 J9355 J9357 J9360 J9370 J9375 J9380 J9390 J9395 J9600 J9999 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828

Description

Pegaspargase injection Pentostatin injection Plicamycin (mithramycin) inj Mitomycin 5 MG inj Mitomycin 20 MG inj Mitomycin 40 MG inj Mitoxantrone hydrochl / 5 MG Gemtuzumab ozogamicin inj Injection, panitumumab, 10 mg Pemetrexed injection Injection, rituximab, 100 mg Streptozocin injection Temozolomide injection Temsirolimus injection Thiotepa injection Topotecan injection Trastuzumab injection Valrubicin injection Vinblastine sulfate inj Vincristine sulfate 1 MG inj Vincristine sulfate 2 MG inj Vincristine sulfate 5 MG inj Vinorelbine tartrate inj Injection, Fulvestrant Porfimer sodium injection Chemotherapy drug POV group 1 std up to 300lbs POV group 1 hd 301-450 lbs POV group 1 vhd 451-600 lbs POV group 2 std up to 300lbs POV group 2 hd 301-450 lbs POV group 2 vhd 451-600 lbs Power operated vehicle NOC PWC gp 1 std port seat/back PWC gp 1 std port cap chair PWC gp 1 std seat/back PWC gp 1 std cap chair PWC gp 2 std port seat/back PWC gp 2 std port cap chair PWC gp 2 std seat/back PWC gp 2 std cap chair PWC gp 2 hd seat/back PWC gp 2 hd cap chair PWC gp 2 vhd seat/back PWC gp vhd cap chair PWC gp 2 xtra hd seat/back

APG

441 434 432 431 431 431 433 442 440 441 440 432 432 434 431 433 434 432 430 430 430 431 431 433 441 430 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453

APG Description

Class VI Chemotherapy Drugs Class V Chemotherapy Drugs Class III Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class VII Combined CLASS VI PHARMACOTHERAPY Class VI Chemotherapy Drugs CLASS VI PHARMACOTHERAPY Class III Chemotherapy Drugs Class III Chemotherapy Drugs Class V Chemotherapy Drugs Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class V Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class VI Chemotherapy Drugs Class I Chemotherapy Drugs Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair

v3.5 APG

462 463 434 432 433 432 433 465 462 463 463 434 434 443 433 460 460 434 430 430 430 430 430 441 463 430 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453

v3.5 APG Description

Carve out Type

Effective Date

1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 1/1/2011 1/1/2010 1/1/2011 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

CLASS X COMBINED procedure carve out CLASS XI COMBINED procedure carve out CLASS V CHEMOTHERAPY APG carve out CLASS III CHEMOTHERAPY APG carve out CLASS IV CHEMOTHERAPY APG carve out CLASS III CHEMOTHERAPY APG carve out CLASS IV CHEMOTHERAPY APG carve out CLASS XIII COMBINED APG carve out CLASS X COMBINED Procedure carve out CLASS XI COMBINED procedure carve out CLASS XI COMBINED Procedure carve out CLASS V CHEMOTHERAPY APG carve out CLASS V CHEMOTHERAPY DRUGAPG carve out CLASS VII CHEMOTHERAPY APG carve out CLASS IV CHEMOTHERAPY APG carve out CLASS VIII COMBINED procedure carve out CLASS VIII COMBINED procedure carve out CLASS V CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS I CHEMOTHERAPY APG carve out CLASS VI CHEMOTHERAPY APG carve out CLASS XI COMBINED procedure carve out CLASS I CHEMOTHERAPY APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out APG carve out Motorized Wheelchair Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out Motorized Wheelchair APG carve out

page 10 of 14

HCPCS

K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880

Description

PWC gp 2 xtra hd cap chair PWC gp2 std seat elevate s/b PWC gp2 std seat elevate cap PWC gp2 std sing pow opt s/b PWC gp2 std sing pow opt cap PWC gp 2 hd sing pow opt s/b PWC gp 2 hd sing pow opt cap PWC gp2 vhd sing pow opt s/b PWC gp2 xhd sing pow opt s/b PWC gp2 std mult pow opt s/b PWC gp2 std mult pow opt cap PWC gp2 hd mult pow opt s/b PWC gp 3 std seat/back PWC gp 3 std cap chair PWC gp 3 hd seat/back PWC gp 3 hd cap chair PWC gp 3 vhd seat/back PWC gp 3 vhd cap chair PWC gp 3 xhd seat/back PWC gp 3 xhd cap chair PWC gp3 std sing pow opt s/b PWC gp3 std sing pow opt cap PWC gp3 hd sing pow opt s/b PWC gp3 hd sing pow opt cap PWC gp3 vhd sing pow opt s/b PWC gp3 std mult pow opt s/b PWC gp3 hd mult pow opt s/b PWC gp3 vhd mult pow opt s/b PWC gp3 xhd mult pow opt s/b PWC gp 4 std seat/back PWC gp 4 std cap chair PWC gp 4 hd seat/back PWC gp 4 vhd seat/back PWC gp4 std sing pow opt s/b PWC gp4 std sing pow opt cap PWC gp4 hd sing pow opt s/b PWC gp4 vhd sing pow opt s/b

APG

453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453

APG Description

Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair

v3.5 APG

453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453 453

v3.5 APG Description

Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair

Carve out Type

APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

page 11 of 14

HCPCS

K0884 K0885 K0886 K0890 K0891 K0898 K0899 Q0166 Q0515 Q4074 Q9955 Q9956 Q9957 S0091 S0108 S0156 S0170 S0172 S0175 S0176 S0178 S0179 S0182 S0187

Description

PWC gp4 std mult pow opt s/b PWC gp4 std mult pow opt cap PWC gp4 hd mult pow s/b PWC gp5 ped sing pow opt s/b PWC gp5 ped mult pow opt s/b Power wheelchair NOC Pow mobil dev no SADMERC Granisetron hcl 1 mg oral Sermorelin acetate injection Iloprost non-comp unit dose Inj perflexane lip micros,ml Inj octafluoropropane mic,ml Inj perflutren lip micros,ml Granisetron 1mg Mercaptopurine 50 mg Exemestane, 25 mg Anastrozole 1 mg Chlorambucil 2 mg Flutamide 125 mg Hydroxyurea 500 mg Lomustine 10 mg Megestrol 20 mg Procarbazine 5 mg Tamoxifen 10 mg

APG

453 453 453 453 453 453 456 431 433 434 430 430 430 431 430 430 430 430 431 430 432 430 430 430

APG Description

Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Accessories Class II Chemotherapy Drugs Class IV Chemotherapy Drugs Class V Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy Drugs Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs Class I Chemotherapy Drugs

v3.5 APG

453 453 453 453 453 453 456 430 443 461 430 430 431 431 430 430 430 430 432 430 434 430 430 430

v3.5 APG Description

Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair Motorized Wheelchair

Carve out Type

APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Effective Date

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 1/1/2010 12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010

Motorized Wheelchair Accessories APG carve out CLASS I CHEMOTHERAPY DRUG APG carve out CLASS VII CHEMOTHERAPY APG carve out DRUGS CLASS IX COMBINED procedure carve out CHEMOTHERAPY AND CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS II CHEMOTHERAPY APG carve out DRUGS CLASS II CHEMOTHERAPY DRUGAPG carve out CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY DRUG APG carve out CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS III CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS V CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY APG carve out DRUGS CLASS I CHEMOTHERAPY DRUG APG carve out

page 12 of 14

HCPCS

S0190 S0191 S3818 S3819 S3820 S3822 S3823 S3828 S3829 S3830 S3831 S3833 S3834 S3835 S3840 S3842 S3843 S3844 S3845 S3846 S3847 S3848 S3849 S3850 S3851 S3852 S3853 S4989 S5550 S5551 S5552 S5553 S5560 S5561 S5565 S5566 S5570 S5571

Description

Mifepristone, oral, 200 mg Misoprostol, oral, 200 mcg BRCA1 gene anal BRCA2 gene anal Comp BRCA1/BRCA2 Sing mutation brst/ovar 3 mutation brst/ovar Comp MLH1 gene Comp MLH2 gene Gene test HNPCC comp Gene test HNPCC single Comp APC sequence Sing mutation APC Gene test cystic fibrosis DNA analysis RET-oncogene Gene test Hippel-Lindau DNA analysis factor v DNA analysis deafness Gene test alpha-thalassemia Gene test beta-thalassemia Gene test Tay-Sachs Gene test Gaucher Gene test Niemann-Pick Gene test sickle cell Gene test canavan DNA analysis APOE alzheimer Gene test myo musclr dyst Contracept IUD Insulin rapid 5 u Insulin most rapid 5 u Insulin intermed 5 u Insulin long acting 5 u Insulin reuse pen 1.5 ml Insulin reuse pen 3 ml Insulin cartridge 150 u Insulin cartridge 300 u Insulin dispos pen 1.5 ml Insulin dispos pen 3 ml

APG

435 435 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 417 452 452 452 452 452 452 452 452 452 452

APG Description

Class I Pharmacotherapy Class I Pharmacotherapy Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests gy Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Minor Reproductive Procedures Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies

v3.5 APG

436 435 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 395 417 452 452 452 452 452 452 452 452 452 452

v3.5 APG Description

CLASS II PHARMACOTHERAPY CLASS I PHARMACOTHERAPY Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests gy Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Level II Immunology Tests Minor Reproductive Procedures Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies Diabetes Supplies

Carve out Type

Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out Procedure carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out APG carve out

Effective Date

12/1/2008 12/1/2008 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 1/1/2010 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

page 13 of 14

HCPCS

Description

APG

APG Description

v3.5 APG

v3.5 APG Description

Carve out Type

Effective Date Date Added to Carve out List

Procedures Removed from the Procedure Carve out List

HCPCS

Q4080

Description

Iloprost non-comp unit dose

APG

434

APG Description

Class V Chemotherapy Drugs

APG - updated w/ v3.5 2011 drug APG Description - updated w/ groupings v3.5 2011 drug groupings

NA NA APG carve out

12/1/2008

J3472 J0885 J9170

Ovine, 1000 USP units Epoetin alfa, non-esrd Docetaxel injection

433 432 433

Class IV Chemotherapy Drugs Class III Chemotherapy Drugs Class IV Chemotherapy Drugs

437 439 NA

CLASS III PHARMACOTHERAPY APG carve out CLASS V PHARMACOTHERAPY APG carve out NA APG carve out

1/1/2011 1/1/2011 12/1/2008

E2393

Valve, pneumatic tire tube

456

Motorized Wheelchair Accessories

NA

NA

APG carve out

12/1/2008

E2399

Noc interface

456

Motorized Wheelchair Accessories

NA

NA

APG carve out

12/1/2008

page 14 of 14

Information

All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs)

14 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1045016

You might also be interested in

BETA
All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs)