2019 OUTPATIENT PREAUT - BCBSTX

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2019BLUE CROSS AND BLUE SHIELD OF TEXAS (BCBSTX)OUTPATIENT PREAUTHORIZATION REQUIREMENTSBY PROCEDURE CODEGeneral Information: Procedures on the following pages may require preauthorization. These listsare not exhaustive. The presence of codes on this list does not necessarilyindicate coverage under the member benefits contract. Member contractsdiffer in their benefits. Consult the member benefit booklet or contact acustomer service representative to determine coverage for a specific medicalservice or supply. Providers may also check eligibility and benefits throughAvaility or their preferred vendor to determine if a preauthorization isrequired.Not all requirements apply to each BCBSTX network (Blue Choice PPOSM, BlueEssentialsSM, Blue PremierSM or Blue Advantage HMOSM). Updates to this list are announced routinely in the News and Updates sectionof the bcbstx.com/provider website. Selected procedures codes, within the outpatient service categories listed onthe PreauthorizationNotifications/Referral Requirements page on theBCBSTX provider website, may not be included in this procedure code list. Itis imperative that providers check eligibility and benefits and verifypreauthorization requirements through Availity or their preferred vendor forthese categories.PRESS "CTRL" AND "F" KEYS AT THE SAME TIME ONTHE PROCEDURE LIST TO BRING UP THE SEARCH BOXBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryNeurologyNeurologySelect Outpatient ProceduresSelect Outpatient ProceduresJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgerySelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 1 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryPain ManagementPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 2 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryArthroscopyArthroscopyArthroscopyPage 3 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryArthroscopyEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatCardiologySelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient ProceduresEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and logySelect Outpatient eroscopyLaparoscopy/HysteroscopyAbdominalSelect Outpatient ProceduresSelect Outpatient ProceduresSelect Outpatient copySelect Outpatient ProceduresUrologicalPage 4 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure yNeurologyNeurologyPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPage 5 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementNeurologyNeurologyPain ManagementPain ManagementPain ManagementPain ologyNeurologyEyePage 6 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryEyeEyeNeurologyEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 7 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 8 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced anced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 9 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingCardiologyCardiologyAdvanced anced ImagingPage 10 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryAdvanced diologyCardiologyCardiologyCardiologyAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingPage 11 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabPage 12 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabPage 13 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabEar, Nose and ThroatSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineOrthopedic (Musculoskeletal)Wound CareMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabAdvanced ImagingJoint, Spine SurgeryJoint, Spine SurgeryAdvanced ImagingJoint, Spine SurgeryJoint, Spine SurgeryJoint, Spine SurgeryPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementPain ManagementNeurologyPage 14 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure ologyRadiation OncologyRadiation OncologyCardiologyEar, Nose and ThroatEar, Nose and ThroatRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyNon-Emergent Fixed Wing Air AmbulanceNon-Emergent Fixed Wing Air AmbulancePage 15 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategoryNeurologyWound CareSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineSleep MedicineRadiation OncologyAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingSleep MedicineSleep MedicinePage 16 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategorySleep MedicineSleep MedicineSleep MedicineNeurologyJoint, Spine SurgeryJoint, Spine SurgeryOrthopedic (Musculoskeletal)GastroenterologyOrthopedic (Musculoskeletal)Advanced ImagingAdvanced ImagingAdvanced ImagingPain ManagementWound CareAdvanced ImagingRadiation OncologyRadiation OncologySleep MedicineSleep MedicineSleep MedicineRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyRadiation OncologyMolecular and Genetic LabSelect Outpatient ProceduresEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatPage 17 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure 8092902839028490378C9014, J3590C9016, J3590C9024, J3590C9028, J3590C9257C9273C9466, J3590C9483C9484C9485C9489C9491C9492, J359012/26/2018Service/CategoryEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatEar, Nose and ThroatCardiologyJoint, Spine SurgeryJoint, Spine SurgeryMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabMolecular and Genetic LabAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingAdvanced ImagingSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 18 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure CodeC9493, tegorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 19 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure e/CategorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugPage 20 of 21

2019 BCBSTX OUTPATIENT PREAUTHORIZATION REQUIREMENT BY PROCEDURE CODEProcedure 9354Q2040, J3590Q2041, J3590Q2043Q4081Q5102Q9986Q9989Q9991, J3590Q9992, J3590S0157S0189Service/CategorySpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugSpecialty DrugCPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical AssociationAvaility is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchangeservices to medical professionals. Availity provides administrative services to BCBSTX. Aerial, iExchange and Medecision are trademarks of Medecision, Inc.,a separate company that offers collaborative health care management solutions for payers and providers. BCBSTX makes no endorsement, representationsor warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services theyoffer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized or predetermined for benefits, isnot a guarantee of payment. Benefits will be determined once a claim is received and will be based on among other things, the member’s eligibility andthe terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on themember’s ID card.Update History:Update DateDescription12/26/2018Clarification on General Information pageClarification on General Information page12/10/2018Page 21 of 2112/26/2018

Procedure Code Service/Category 15824 Neurology 15826 Neurology 19316 Select Outpatient Procedures 19318 Select Outpatient Procedures 20930 Joint, Spine Surgery 20931 Joint, Spine Surgery 20936 Joint, Spine Surgery 20937 Joint, Spine Surgery 20938 Joint, Spine Surgery 20974 Joint, Spine Surgery 20975 Joint, Spine Surgery

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Procedure Code Service/Category 15824 Neurology 15826 Neurology 19316 Select Outpatient Procedures 19318 Select Outpatient Procedures 20930 Joint, Spine Surgery 20931 Joint, Spine Surgery 20936 Joint, Spine Surgery 20937 Joint, Spine Surgery 20938 Joint, Spine Surgery 20974 Joint, Spine Surgery 20975 Joint, Spine Surgery

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