October 2025 Provider News
Date: 11/03/25
In this issue:
- General Updates - Youth friendly care, Youth and young adult substance use treatment, Hepatitis C, Prior auth forms for residential substance use disorder treatment, After-Pregnancy Coverage (APC), Childhood Lead Poisoning Prevention, Navigating the Perinatal Journey
- Quality - BCS, CCS, Fluoride, HPV, URI, LBP, BH measures what closes care gaps, CHL, KED, AMR, AIS-E, GSD, Breast Cancer screening
- Tribal - Tribal Encounter
- Clinical & Payment Policies and Prior Authorization Updates - Policy updates, Prior Authorization updates
- Wellcare - CMS Prior Authorization Change Summary
- Apple Health Core Connections - NEW: Mandated Reporter Training
- Training/Education - Culturally Appropriate Care Annual Training Reminder, Coordinated Care 2026 AEP product highlights Webinar 11/05
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General Updates
YOUTH FRIENDLY CARE NETWORK
Young people in Washington want high-quality, age-appropriate, and culturally relevant care.
They value care that centers their needs and experiences—and that feels:
- Trustworthy, safe, and inclusive
- Non-judgmental and compassionate
- Responsive to their needs
- Clear about health and confidentiality
- Integrates their perspectives
That’s why the Washington State Department of Health is partnering with youth and health care organizations to create the Youth Friendly Care Network. Strengthening Care That Works for Teens and Young Adults.
What Is the Youth Friendly Care Network?
The YFCN is a group of youth-serving medical and behavioral health professionals and providers who want to learn more about and get support to establish or enhance youth friendly care in their clinical practice.
Our goals are:
- Promote youth-friendly principles among medical and behavioral health providers
- Build a connected network of youth-friendly providers across Washington
- Support the delivery of high-quality, age-appropriate medical and behavioral health care for young people
Visit Youth Friendly Care Collective to learn more.
Have questions or want to get involved? Email: adolescenthealthunit@doh.wa.gov
Youth and young adult substance use treatment
Getting help for substance use can be hard, but you don’t have to do it alone. Whether you’re a young person looking for support, a caregiver trying to find the right treatment, or a provider wanting useful tools, the HCA resource page can help. Within the resource page providers and patients can find information about treatment options, crisis help, recovery support, caregiver resources, and how to stay involved in continuing to develop and expand youth and young adult substance use disorder (SUD) and co-occurring services across Washington State.
Our provider partners are a key stakeholder in the fight to eliminate Hepatitis C in our state!
Hepatitis C
Coordinated Care would like to remind you that:
- Anti-viral MAVYRET can cure Hepatitis C.
- These daily pills are allowed for up to a 12-week supply at one time.
- Effective for claims on or after March 1, 2024, the Health Care Authority, Apple Health Fee-For-Service (FFS) has increased the maximum allowable days’ supply for Mavyret (glecaprevir/pibrentasvir).
- Pharmacies may dispense and submit claims for up to a 12-week (84 days) supply of Mavyret in a single fill.
- Mavyret is preferred and does not require prior authorization
- To ensure patients receive the full course of treatment, Mavyret prescriptions should be written in a manner to allow the pharmacy to dispense the entire 8-week or 12-week course of treatment.
- Other anti-viral medications will require review and be approved only if Mavyret is not clinically appropriate.
- CDC recommends that all adults 18 years and older be screened for Hep C at least once, as well as pregnant women during each pregnancy.
- Injection drug use is the primary risk for Hepatitis C. Any person requesting HCV screening should receive it.
- Direct-acting antiviral (DAA) medications can be prescribed for children aged 3 and up.
- Patients who have certain liver problems or are taking medicines (atazanavir or rifampin) are not eligible to take MAVYRET.
- Anyone licensed to prescribe direct acting anti-viral medications is allowed to screen and treat Apple Health members, including primary care doctors and pharmacists.
Learn more at:
- Eliminating Hepatitis C | Washington State Health Care Authority
- Eliminating Hepatitis C | Washington State Department of Health
- Antivirals - Hepatitis C Treatment (PDF)
- Mail order pharmacy resource for Mayvret (PDF)
- For questions, email: applehealthpharmacypolicy@hca.wa.gov
- And prescribing info for doctor (PDF)
Prior auth forms for residential substance use disorder treatment
Now live on the Coordinated Care resources site: Prior Authorization-Residential Substance Use Disorder treatment form.
After-Pregnancy Coverage (APC)
Apple Health (Medicaid) After-Pregnancy Coverage (APC) offers services to help with recovery mentally, physically, and emotionally after a pregnancy in the last 12 months.
Benefits and Services
APC offers postpartum follow-up care and provides additional services including dental, contraception, preventive care, behavioral health, and other services covered by Apple Health up to 12 months after pregnancy ends. Visit HCA's website to learn what services are covered under Apple Health and how to apply.
Lead Poisoning Screening - EPSDT
All children 12 – 24 months of age should be tested for the risk of lead poisoning. This testing is a Federally mandated preventative health benefit.
For more information, please visit the Department of Health’s website.
Federal law mandates that all children enrolled in Medicaid are required to get blood lead tests at ages 12 and 24 months.
For more information, click here.
Navigating the Perinatal Journey: Mental Wellness Tools for Every Step
We are pleased to share that Health Care Authority (HCA), in collaboration with state and university partners, has released a new resource: Navigating the Perinatal Journey: Mental Wellness Tools for Every Step (PDF). This comprehensive toolkit is designed to help MCOs, providers, and care teams identify, screen, and support individuals experiencing perinatal behavioral health conditions with compassion and confidence. It offers practical tools, screening guidance, and clinical insights across key areas including:
Perinatal anxiety and depression (PDF)
ADHD during the perinatal period (PDF)
Maternal suicide and risk assessment (PDF)
Maternal sleep and well-being (PDF)
Behavioral health integration in primary care (PDF)
A unique feature of this resource is its flexibility, it can be used as a full toolkit or as individual topic-specific guides, making it easy to adapt for your network’s needs, training, or outreach efforts.
Access the toolkit: Navigating the Perinatal Journey (PDF)
If you would like to print hard copies for your organization or provider network, please contact Jennifer Peterson jennifer.peterson@hca.wa.gov for print specifications and instructions. Stay tuned: HCA will be hosting a webinar soon to walk through the toolkit and demonstrate practical ways to apply it in care coordination and provider support. Thank you for your partnership and continued commitment to improving perinatal mental health across Washington.
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Quality
Medicaid Quality
Mammograms (HEDIS Measure)
The HEDIS measure assesses women ages 50-74 who had at least one mammogram to screen for breast cancer in the past 2 years.
Does your patient have any of these risk factors? They may need to be assessed for early onset Breast Cancer:
Reproductive history- menstrual history of starting periods before age 12 and menopause after 55
* Having dense breasts
* Breast/ ovarian cancer personal/family history or personal/family history of genetic mutations
Breast Cancer Screening (BCS) - NCQA
Appropriate Treatment for Upper Respiratory Infection (URI)
The common cold (or URI) is a frequent reason for patients visiting the doctor’s office. Though existing clinical guidelines do not support the use of antibiotics for the common cold, physicians often prescribe them for this ailment1.
Appropriate Treatment for Upper Respiratory Infection (URI) - NCQA
Upper Respiratory Infection (URI)
Preventing transmission of viral respiratory pathogens in healthcare settings.
To prevent the transmission (spread) of all viral respiratory infections in healthcare settings, including influenza virus and SARS-CoV-2 infection, the following infection control measures should be implemented into standard procedures.
Cervical Cancer Screening
The goal for CCS is to assess the following for your patients:
* Women 21 - 64 years of age who have had cervical cytology performed within last 3 yrs.
* Women 30 - 64 years of age who had cervical high risk human papillomavirus testing performed within the last 5 yrs.
* Women 30 - 64 years of age who had cervical/high risk human papillomavirus cotesting within the last 5 yrs.
Cervical Cancer Screening (CCS-E) - NCQA
Fluoride - Health Professionals Fluoride and Healthful Diets Fluoride fact sheet:
Oral Health Training for Healthcare Professionals Smiles for Life is a comprehensive oral health curriculum for healthcare professionals and health educators.
The American Dental Association endorsed curriculum is designed to enhance the role of primary care clinicians in the promotion of oral health for all age groups. This curriculum includes oral health training for all ages and offers free CME to healthcare providers.
Use of Imaging Studies for Low Back Pain (LBP)
Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation in collaboration with more than 70 specialty society partners, promotes a “national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures” by publishing recommendations from the specialty societies to, “facilitate wise decisions about the most appropriate care based on a patient’s individual situation.” Nine specialty societies have published recommendations regarding the use of imaging for patients with low back pain4, indicating the topic’s importance to health care providers.
Use of Imaging Studies for Low Back Pain (LBP) - NCQA
Common BH HEDIS Measures:
Common BH HEDIS® Measures: What is needed to close the care gap? | ||||||
| ADD-E Follow-Up Care for Children Prescribed ADHD Medication | ASF-E | DSF-E Depression Screening and Follow-Up for Adolescents and Adults | DRR-E Depression Remission or Response for Adolescents and Adults | PND-E | APP Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics | SAA Adherence to Antipsychotic Medications for Individuals with Schizophrenia |
Age 6 – 12 years At least 3 follow-up visits • 1 st visit within 30 days of newly dispensed medication (lookback period of 120 days). • Two additional visits within 270 days after initiation phase ends. Remain on medication for at least 210 days | Age 18 and older Screening for unhealthy alcohol use between January 1 and November 1 of the measurement year. Follow-up care within 60 days of the first positive screen. (*brief alcohol counseling, development of personal plan to reduce alcohol intake, motivational interviewing, etc.) *LOINC® code submission via flat file or electronic health | Age 12 and older Screening for clinical depression between January 1 and December 1 of the measurement year. Follow-up care within 30 days of a positive screen. *LOINC® code submission via flat file or electronic health record (EHR) is required. | Age 12 and older Follow-Up PHQ-9 Score: Any PHQ-9 score documented within 4-8 months after the initial score. Remission: PHQ-9 score 50% lower than the initial elevated score. *LOINC® code submission via flat file or electronic heal | No age restriction Screened for clinical depression during pregnancy. Follow-up care within 30 days of a positive screen. *LOINC® code submission via flat file or electronic health record (EHR) is required | Age 1 – 17 years Evidence of psychosocial care before or concurrent with antipsychotic prescription. Lookback period for psychosocial care is 120 days prior to the first antipsychotic prescription | Age 18 and older Remain on medication for at least 80% of treatment period during the measurement year |
FUA Follow-Up after ER Visit for Alcohol or Other Drug Abuse or Dependence | FUH Follow-Up After Hospitalization for Mental Illness | FUI Follow-Up After High-Intensity Care for Substance Use Disorder | FUM Follow-Up within 7 Days after ER Visit for Mental Illness | IET Initiation and Engagement of Substance Use Disorder Treatment | SMD Diabetes Monitoring for People with Diabetes and Schizophrenia
| SSD Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotic Medications |
Age 13 and older Follow-up within 7 days of the ED visit. Follow-Up within 30 days of the ED visit. *Follow-up visit can occur on the same day as the ED visit. | Age 6 and older Follow-up within 7 days of discharge from hospitalization. Follow-up within 30 days of discharge from hospitalization. *Follow-up visit cannot occur on same date as discharge. | Age 13 and older Follow-up within 7 days of discharge from acute inpatient hospitalization, residential treatment, or withdrawal management (detox). Follow-up within 30 days of discharge. *Follow-up visit cannot occur on same date as discharge. | Age 6 and older Follow-up within 7 days of the ED visit. Follow-Up within 30 days of the ED visit. *Follow-up visit can occur on the same day as the ED visit. | Age 13 and older Initiation of treatment for SUD within 14 days of diagnosis. Engagement in at least two additional visits within 34 days of initiation of treatment. *Same day initiation must be with different providers unless it’s a medication dispensing or administration event | Age 18 – 64 years HbA1c test performed during measurement year. LDL-C test performed during measurement year. *These tests can be done on the same or different dates of service | Age 18 – 64 years Diabetes screening test (either HbA1c or Glucose Test) during the same year as antipsychotic medication is dispensed. |
HPV- Why Age 9? Fact Sheet
Starting HPV Vaccination at Age 9.
Every year in the United States, it is estimated that nearly 36,500 individuals are diagnosed with cancer caused by an HPV infection.
Human papillomavirus (HPV) cannot be treated, but there is a vaccine that can prevent transmission and protect against six cancers if initiated prior to exposure. HPV vaccination is a critical prevention tool, safeguarding children and adolescents against more than 90% of HPV cancers when given at recommended ages.1 Because cancer prevention decreases as the age of vaccination increases, it is important to start early!
Why Age 9?
Starting the HPV vaccination series at age 9 is recommended by the American Cancer Society, the American Academy of Pediatrics, and the National HPV Vaccination Roundtable. Previous guidance from the Centers for Disease Control (CDC) and Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination at age 11 or 12 years but notes that the HPV vaccine can be given starting at age 9.
Start HPV Vaccination at Age 9 - National HPV Vaccination Roundtable
National HPV Vaccination Roundtable
Asthma and 90 Day Medication Refills
Moving members with asthma prescriptions to 90-day medication refills may increase their maintenance medication adherence.
(AIS-E) Adult Immunization Status
Measures percentage of members 19 years of age and older who are up to date on recommended routine vaccines for influenza, tetanus, and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap), zoster, and pneumococcal.
Tips:
- Schedule appointments within immunization timeframes.
- Discuss the importance of vaccinations during member appointments.
- Include immunization history from all sources in the member’s medical record.
- Use EMR (electronic medical record) system to set reminders flags.
Description | Codes* |
Adult Influenza Vaccine Procedure | CPT: 90630, 90653–90654, 90656, 90658, 90661–90662, 90673–90674, 90682, 90686, 90688–90689, 90694, 90756 |
Adult Pneumoccocal Vaccine Procedure | CPT: 90670, 90671, 90677, 90732 HCPCS: G0009 |
Td Vaccine Procedure | CPT: 90714 |
Tdap Vaccine Procedure | CPT: 90715 |
Herpes Zoster Vaccine Procedure | CPT: 90736, 90750 |
(KED) Kidney Health Evaluation for Patients with Diabetes
The percentage of members 18–85 years of age with diabetes (Type 1 and Type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR), during the measurement year.
Tips:
- Conduct a diabetic visit with diabetic patients at least once per year.
- Use CPT II coding when completing screening test to assist in administrative collection and gap closure.
- Educate members on why good kidney function is important as they work to manage their health and diabetes.
- Help members schedule their diabetes follow-up appointments and remind them of the care gaps that should be covered to include kidney function.
- Submit applicable codes.
(GSD) Glycemic Status Assessment for Patients with Diabetes (continued)
Description | Codes* |
Estimated Glomerular Filtration Rate (eGFR) — must be within 4 days or less of the uACR | CPT: 80047, 80048, 80050, 80053, 80069, 82565 |
Urine Albumin-Creatinine Ratio (uACR) — must be within 4 days or less of the eGFR | CPT: 82043, 82570 |
Palliative Care | HCPCS: G9054, M1017 |
(CHL) Chlamydia Screening
Measure evaluates the percentage of members 16 to 24 years of age who were recommended for routine chlamydia screening, were identified as sexually active, and had at least one test for chlamydia during the measurement year.
Tips:
- Providers should order an annual chlamydia screening for patients (who will turn 16 years old by Dec. 31 of the measurement year).
- Perform chlamydia screening every year.
- Inform patient that chlamydia screening can be performed through a urine test. Offer this as an option for patients.
- Add chlamydia screening as a standard lab for patients 16 to 24 years of age. Use well-child exams and well-women exams for this purpose.
- Place chlamydia swab next to Pap test or pregnancy detection materials.
- Meet with teens and young adults separately from their parents to allow open conversation.
- Advise members during wellness visits or when they are seen for birth control to get screened for chlamydia.
- Submit applicable codes.
Wellcare Quality
Breast Cancer Screening tests are recommended for the following ages:
Visit Cancer Screening | Resources and FAQ | American Cancer Society for cancer screening FAQs.
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Tribal
Tribal Encounters
T1015 is not reimbursable for the Tribal encounter rate for Ambetter and Wellcare. Claims will not reject with this code, but you will see a denial code for this line item if listed on the claim. If you have any questions, please reach out to the IHCP team at IndianHealthCareProviderAssistance@coordinatedcarehealth.com
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Clinical & Payment Policies and Prior Authorization Updates
Clinical Policy Updates
With the start of the new Evolent Cardiovascular program, the following policies will be effective on January 1, 2026. You will find the policies on Evolent’s public facing website now, or on the Evolent landing page found at the link on our Prior Authorization page after 1/1/26. Please note, this program does not apply to children under the age of 18.
Policy No. | Policy Name |
ECG_7252 | Evolent - Ambulatory Rhythm Monitoring |
ECG_7254 | Evolent - Coronary Artery Bypass Graft |
ECG_7255 | Evolent - Aortic Valve Replacement |
ECG_7258 | Evolent - Device Interrogation and Programming |
ECG_7261 | Evolent - Device (AICD, CRT and/or Pacemaker) Battery Replacement |
ECG_7262 | Evolent - Diagnostic Electrophysiologic Testing |
ECG_7263 | Evolent - Cardiac Resynchronization Therapy |
ECG_7264 | Evolent - Renal Angiography and Intervention |
ECG_7266 | Evolent - Carotid Artery Stenting |
ECG_7268 | Evolent - Carotid Endarterectomy |
ECG_7269 | Evolent - Catheter Based Carotid & Brachiocephalic Arteriography, Venography & Intervention |
ECG_7282 | Evolent - Atrial Fibrillation Ablation |
ECG_7283 | Evolent - Abdominal Aortography w Bilateral Iliofemoral Lower Extremity Runoff |
ECG_7284 | Evolent - Catheter Ablation of Reentrant or Focal Tachydysrhythmias |
ECG_7286 | Evolent - Endomyocardial Biopsy |
ECG_7287 | Evolent - Endovascular Femoropopliteal Interventions |
ECG_7288 | Evolent - Endovascular Aortoiliac Interventions |
ECG_7289 | Evolent - Endovascular Infrapopliteal (Tibioperoneal) Interventions |
ECG_7290 | Evolent - Treatment of Varicose Veins |
ECG_7292 | Evolent - Infra-inguinal Open Arterial Vascular Surgery |
ECG_7295 | Evolent - Hearth Catheterization |
ECG_7299 | Evolent - Hemodialysis Access Creation |
ECG_7301 | Evolent - Implantable Cardioverter Defibrillator |
ECG_7302 | Evolent - Percutaneous Coronary Interventions |
ECG_7303 | Evolent - Interventions for Adults with Congenital Heart Defects |
ECG_7305 | Evolent - Introduction of Inferior Vena Cava Filter Device |
ECG_7310 | Evolent - Mitral Valve Surgery |
ECG_7315 | Evolent - Pacemaker Insertion |
ECG_7319 | Evolent - Percutaneous Iliocaval Interventions |
ECG_7320 | Evolent - Percutaneous Left Atrial Appendage Closure |
ECG_7327 | Evolent - Standalone Right Heart Catheterization |
ECG_7334 | Evolent - Transcatheter Aortic Valve Replacement (TAVR) |
ECG_7335 | Evolent - Transcatheter Edge to Edge Repair (TEER) of Mitral Valve |
ECG_7338 | Evolent - Tricuspid Valve Surgery |
ECG_7339 | Evolent - Ultrasound-Guided Vascular Access |
ECG_7341 | Evolent - Venogram Invasive Vein Mapping |
ECG_7345 | Evolent - Wireless Pulmonary Artery Pressure Device Placement and Monitoring |
Envolve Vision has announced annual updates to their policies. These changes are effective for Apple Health and Ambetter on January 1, 2026. You will find the policies on their website. You can find a link to Envolve Vision’s website on our Prior Authorization page.
The following policies were updated as part of our regular monthly review in September. The policy changes are effective November 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
CP.MP.108 | Allogenic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia | Apple Health & Ambetter |
CP.MP.31 | Cosmetic Surgery | Apple Health & Ambetter |
CP.MP.36 | Experimental Technologies | Ambetter |
WA.CP.MP.532 | Migraine and Tension-Type Headaches | Apple Health |
CP.MP.109 | Panniculectomy | Apple Health & Ambetter |
CP.MP.138 | Pediatric Heart Transplant | Apple Health & Ambetter |
WA.CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Apple Health & Ambetter |
WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Apple Health |
The following policies were updated as part of our regular monthly review in September. The policy changes are effective February 1, 2026. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
CP.MP.107 | DME | Apple Health & Ambetter |
CP.MP.202 | Orthognathic Surgery | Apple Health & Ambetter |
The following policies are new or reinstated effective November 1, 2025. You will find the policies posted on the policy Web site.
Policy Number | Policy Title | Line of Business |
WA.HIM.CP.MP.532 | Migraine and Tension-Type Headaches | Ambetter |
WA.CP.BH.104 | Applied Behavioral Analysis | Medicaid |
The following policies will be archived effective October 31, 2025.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.532 | Migraine and Tension-Type Headaches | Ambetter |
CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | Apple Health |
The following policies will be archived effective December 31, 2025. These services will be managed by Evolent as of January 1, 2026.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.516 | Carotid Artery Stenting | Apple Health & Ambetter |
WA.CP.MP.525 | Catheter Ablation for SVTA | Apple Health & Ambetter |
WA.CP.MP.522 | Varicose Vein Treatment | Apple Health & Ambetter |
WA.CP.MP.513 | Cardiac Stents | Apple Health & Ambetter |
The following policies were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.MP.132 | Heart-Lung Transplant | 10/1/25 | Apple Health & Ambetter |
CP.MP.58 | Intestinal and Multivisceral Transplant | 10/1/25 | Apple Health & Ambetter |
CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | 10/1/25 | Apple Health & Ambetter |
CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | 10/1/25 | Ambetter |
CP.MP.249 | Allogeneic Hematopoietic Progenitor Cell Therapy | 11/1/25 | Apple Health & Ambetter |
CP.MP.137 | Fecal Incontinence Treatments | 11/1/25 | Apple Health & Ambetter |
CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | 11/1/25 | Apple Health & Ambetter |
CP.MP.127 | Total Artificial Heart | 11/1/25 | Apple Health & Ambetter |
WA.CP.MP.54 | Hospice Services | 12/1/25 | Apple Health |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | 12/1/25 | Apple Health & Ambetter |
WA.CP.MP.185 | Skin and Soft Tissue Substitutes | 12/1/25 | Apple Health |
CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | 12/1/25 | Ambetter |
WA.CP.MP.527 | Vitamin D Testing | 1/1/26 | Apple Health & Ambetter |
CP.MP.93 | Bone-anchored hearing aid | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.01 | Infection Disease: Respiratory Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.02 | Infectious Disease: Multisystems Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.03 | Infectious Dz Dermatologic Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.04 | Infectious Dz Gastroenterologic Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.05 | ID Primary Care Preventive Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.CP.MP.06 | ID Vector-Borne and Tropical Dz Lab Testing | 1/1/26 | Apple Health & Ambetter |
CG.PP.551A | Concert Genetic and Molecular Testing Payment Policy | 1/1/26 | Apple Health & Ambetter |
CG.CC.PP.01 | Concert Lab Payment Policy | 1/1/26 | Apple Health & Ambetter |
The following new policies were previously announced as being effective on the dates noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
WA.CP.MP.522 | Varicose Vein Treatment | 10/1/25 | Ambetter |
The following policies were previously announced as being archived on the dates noted.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.MP.146 | Sclerotherapy for Varicose Veins | 9/30/25 | Ambetter |
V1.2025 | CG Exome Genome Genetic Sequencing for Diagnosis of Genetic Disorders | 9/30/25 | Ambetter |
V1.2025 | CG Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay | 9/30/25 | Ambetter |
V1.2025 | CG Oncology Algorithmic Testing | 9/30/25 | Ambetter |
CP.MP.12 | Vagus Nerve Stimulation | 9/30/25 | Ambetter |
CP.MP.194 | Osteogenic Stimulation | 9/30/25 | Ambetter |
WA.HIM.CP.MP.92 | Acupuncture | 12/31/25 | Ambetter |
CC.PP.018 | Inpatient Only Procedures | 12/31/25 | Medicaid |
MP.PP.018 | Inpatient Only Procedures | 12/31/25 | Ambetter |
Prior Authorization Updates
The following services will require prior authorization effective January 1, 2026:
Line of Business | Code | Description |
Apple Health | 69714 | Implantation, osseo-integrated implant, skull; with percutaneous attachment to external speech processor |
Apple Health | 69729 | Implantation, osseo-integrated implant, skull; with magnetic transcutaneous attachment to external speech processor, outside of the mastoid and resulting in removal of greater than or equal to 100 sq mm surface area of bone deep to the outer cranial cortex |
With the implementation of the Evolent Interventional Cardiology program for both Ambetter and Apple Health on January 1, 2026, the following services will require prior authorization from Evolent as of January 1:
Evolent Interventional Cardiology Program Prior Authorization Requirements | |
Code | Description |
33202 | Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) |
33203 | Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) |
33206 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial |
33207 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular |
33208 | Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular |
33210 | Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) |
33211 | Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) |
33212 | Insertion of pacemaker pulse generator only; with existing single lead |
33213 | Insertion of pacemaker pulse generator only; with existing dual leads |
33214 | Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) |
33215 | Repositioning of previously implanted transvenous pacemaker or implantable defibrillator (right atrial or right ventricular) electrode |
33216 | Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator |
33217 | Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator |
33218 | Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator |
33220 | Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator |
33221 | Insertion of pacemaker pulse generator only; with existing multiple leads |
33222 | Relocation of skin pocket for pacemaker |
33223 | Relocation of skin pocket for implantable defibrillator |
33224 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) |
33225 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure) |
33226 | Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) |
33227 | Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; single Lead System |
33228 | Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System |
33229 | Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Multiple Lead System |
33230 | Insertion of implantable defibrillator pulse generator only; with existing dual leads |
33231 | Insertion of implantable defibrillator pulse generator only; with existing multiple leads |
33233 | Removal of permanent pacemaker pulse generator only |
33234 | Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular |
33235 | Removal of transvenous pacemaker electrode(s); dual lead system |
33236 | Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular |
33237 | Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system |
33240 | Insertion of implantable defibrillator pulse generator only; with existing single lead |
33241 | Removal of implantable defibrillator pulse generator only |
33243 | Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy |
33244 | Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous extraction |
33249 | Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber |
33262 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; single lead system |
33263 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system |
33264 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system |
33270 | Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed |
33271 | Insertion of subcutaneous implantable defibrillator electrode |
33272 | Removal of subcutaneous implantable defibrillator electrode |
33273 | Repositioning of previously implanted subcutaneous implantable defibrillator electrode |
33274 | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed |
33275 | Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography), when performed |
33285 | Insertion, subcutaneous cardiac rhythm monitor, including programming |
33286 | Removal, subcutaneous cardiac rhythm monitor |
33289 | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed |
33340 | Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation |
33361 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach |
33362 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach |
33363 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach |
33364 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach |
33365 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy) |
33366 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) |
33367 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) |
33368 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) |
33369 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) |
33405 | Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other than homograft or stentless valve |
33406 | Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand) |
33410 | Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve |
33411 | Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus |
33412 | Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) |
33413 | Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) |
33418 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis |
33419 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) |
33425 | Valvuloplasty, mitral valve, with cardiopulmonary bypass; |
33426 | Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring |
33427 | Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring |
33430 | Replacement, mitral valve, with cardiopulmonary bypass |
33440 | Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure) |
33465 | Replacement, Tricuspid Valve, with Cardiopulmonary Bypass |
33475 | Replacement, Pulmonary Valve |
33477 | Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed |
33510 | Coronary artery bypass, vein only; single coronary venous graft |
33511 | Coronary artery bypass, vein only; 2 coronary venous grafts |
33512 | Coronary artery bypass, vein only; 3 coronary venous grafts |
33513 | Coronary artery bypass, vein only; 4 coronary venous grafts |
33514 | Coronary artery bypass, vein only; 5 coronary venous grafts |
33516 | Coronary artery bypass, vein only; 6 or more coronary venous grafts |
33517 | Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary procedure) |
33518 | Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary procedure) |
33519 | Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary procedure) |
33521 | Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 venous grafts (List separately in addition to code for primary procedure) |
33522 | Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition to code for primary procedure) |
33523 | Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for primary procedure) |
33530 | Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in addition to code for primary procedure) |
33533 | Coronary artery bypass, using arterial graft(s); single arterial graft |
33534 | Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts |
33535 | Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts |
33536 | Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts |
33572 | Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure) |
33641 | Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch |
33768 | Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) |
33820 | Repair of patent ductus arteriosus; by ligation |
33840 | Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis |
33900 | Percutaneous pulmonary artery revascularization by stent placement, initial; normal native connections, unilateral |
33901 | Percutaneous pulmonary artery revascularization by stent placement, initial; normal native connections, bilateral |
33902 | Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, unilateral |
33903 | Percutaneous pulmonary artery revascularization by stent placement, initial; abnormal connections, bilateral |
33904 | Percutaneous pulmonary artery revascularization by stent placement, each additional vessel or separate lesion, normal or abnormal connections (List separately in addition to code for primary procedure) |
33917 | Repair of pulmonary artery stenosis by reconstruction with patch or graft |
33924 | Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to code for primary procedure) |
35001 | Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision |
35011 | Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision |
35141 | Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral) |
35151 | Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery |
35301 | Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision |
35302 | Thromboendarterectomy, including patch graft, if performed; superficial femoral artery |
35303 | Thromboendarterectomy, including patch graft, if performed; popliteal artery |
35304 | Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery |
35305 | Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel |
35306 | Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure) |
35351 | Thromboendarterectomy, including patch graft, if performed; iliac |
35355 | Thromboendarterectomy, including patch graft, if performed; iliofemoral |
35371 | Thromboendarterectomy, including patch graft, if performed; common femoral |
35372 | Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral |
35390 | Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (List separately in addition to code for primary procedure) |
35400 | Angioscopy (noncoronary vessels or grafts) during therapeutic intervention (List separately in addition to code for primary procedure) |
35500 | Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure (List separately in addition to code for primary procedure) |
35556 | Bypass graft, with vein; femoral-popliteal |
35558 | Bypass graft, with vein; femoral-femoral |
35566 | Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels |
35571 | Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels |
35572 | Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure) |
35583 | In-situ vein bypass; femoral-popliteal |
35585 | In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery |
35587 | In-situ vein bypass; popliteal-tibial, peroneal |
35600 | Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure, open |
35621 | Bypass graft, with other than vein; axillary-femoral |
35646 | Bypass graft, with other than vein; aortobifemoral |
35654 | Bypass graft, with other than vein; axillary-femoral-femoral |
35656 | Bypass graft, with other than vein; femoral-popliteal |
35661 | Bypass graft, with other than vein; femoral-femoral |
35665 | Bypass graft, with other than vein; Iliofemoral |
35666 | Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery |
35671 | Bypass graft, with other than vein; popliteal-tibial or -peroneal artery |
35700 | Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than 1 month after original operation (List separately in addition to code for primary procedure) |
35881 | Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition |
35883 | Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium) |
35884 | Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft |
36005 | Injection procedure for extremity venography (including introduction of needle or intracatheter) |
36140 | Introduction of needle or intracatheter, upper or lower extremity artery |
36200 | Introduction of catheter, aorta |
36215 | Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family |
36216 | Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family |
36217 | Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family |
36218 | Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) |
36221 | Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed |
36245 | Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family |
36246 | Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family |
36247 | Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family |
36251 | Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral |
36252 | Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral |
36253 | Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral |
36254 | Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral |
36465 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) |
36466 | Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg |
36473 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated |
36474 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
36475 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated |
36476 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
36478 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated |
36479 | Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
36482 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated |
36483 | Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
36836 | Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation |
36837 | Percutaneous arteriovenous fistula creation, upper extremity, separate access sites of the peripheral artery and peripheral vein, including fistula maturation procedures (eg, transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation |
37215 | Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection |
37220 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty |
37221 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
37224 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty |
37225 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed |
37226 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
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 |
37228 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty |
37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed |
37230 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
37231 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed |
37232 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) |
37233 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) |
37234 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) |
37235 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) |
37236 | Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery |
37237 | Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) |
37238 | Transcatheter Placement of An Intravascular Stent(S), Open or Percutaneous, including Radiological Supervision and Interpretation and including Angioplasty within the Same Vessel, when Performed; initial Vein |
37239 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) |
37246 | Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery |
37247 | Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure) |
37248 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein |
37249 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) |
37765 | Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions |
37766 | Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions |
4110F | Internal mammary artery graft performed for primary, isolated coronary artery bypass graft procedure (CABG) |
75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) derived from augmentative software analysis of the data set from a coronary computed tomography angiography, with interpretation and report by a physician or other qualified health care professional |
75625 | Aortography, abdominal, by serialography, radiological supervision and interpretation |
75630 | Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation |
75710 | Angiography, extremity, unilateral, radiological supervision and interpretation |
75716 | Angiography, extremity, bilateral, radiological supervision and interpretation |
75726 | Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation |
75736 | Angiography, pelvic, selective or supraselective, radiological supervision and interpretation |
76937 | Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) |
76984 | Ultrasound, intraoperative thoracic aorta (eg, epiaortic), diagnostic |
76987 | Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; including placement and manipulation of transducer, image acquisition, interpretation and report |
76988 | Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; placement, manipulation of transducer, and image acquisition only |
76989 | Intraoperative epicardial cardiac ultrasound (ie, echocardiography) for congenital heart disease, diagnostic; interpretation and report only |
92920 | Percutaneous transluminal coronary angioplasty; single major coronary artery or branch |
92921 | Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) |
92924 | Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch |
92925 | Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) |
92928 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch |
92929 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) |
92933 | Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch |
92934 | Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) |
92937 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel |
92938 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure) |
92943 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel |
92944 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure) |
92960 | Cardioversion, elective, electrical conversion of arrhythmia; external |
92961 | Cardioversion, elective, electrical conversion of arrhythmia; internal (separate procedure) |
92972 | Percutaneous transluminal coronary lithotripsy (List separately in addition to code for primary procedure) |
92973 | Percutaneous transluminal coronary thrombectomy mechanical (List separately in addition to code for primary procedure) |
92974 | Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in addition to code for primary procedure) |
92978 | Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately in addition to code for primary procedure) |
92979 | Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List separately in addition to code for primary procedure) |
92986 | Percutaneous balloon valvuloplasty; aortic valve |
92987 | Percutaneous balloon valvuloplasty; mitral valve |
92997 | Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel |
92998 | Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for primary procedure) |
93292 | Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; wearable defibrillator system |
93451 | Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed |
93452 | Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed |
93453 | Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed |
93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; |
93455 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography |
93456 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization |
93457 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization |
93458 | 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 |
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 |
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 |
93461 | 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, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography |
93462 | Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to code for primary procedure) |
93463 | Pharmacologic agent administration (eg, inhaled nitric oxide, intravenous infusion of nitroprusside, dobutamine, milrinone, or other agent) including assessing hemodynamic measurements before, during, after and repeat pharmacologic agent administration, when performed (List separately in addition to code for primary procedure) |
93464 | Physiologic exercise study (eg, bicycle or arm ergometry) including assessing hemodynamic measurements before and after (List separately in addition to code for primary procedure) |
93505 | Endomyocardial Biopsy |
93563 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately in addition to code for primary procedure) |
93564 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free mammary artery graft) to one or more coronary arteries and in situ arterial conduits (eg, internal mammary), whether native or used for bypass to one or more coronary arteries during congenital heart catheterization, when performed (List separately in addition to code for primary procedure) |
93565 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for primary procedure) |
93566 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to code for primary procedure) |
93567 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary procedure) |
93568 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography (List separately in addition to code for primary procedure) |
93569 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary arterial angiography, unilateral (List separately in addition to code for primary procedure) |
93571 | Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; initial vessel (List separately in addition to code for primary procedure) |
93572 | Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; each additional vessel (List separately in addition to code for primary procedure) |
93573 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary arterial angiography, bilateral (List separately in addition to code for primary procedure) |
93574 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary venous angiography of each distinct pulmonary vein during cardiac catheterization (List separately in addition to code for primary procedure) |
93575 | Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective pulmonary angiography of major aortopulmonary collateral arteries (MAPCAs) arising off the aorta or its systemic branches, during cardiac catheterization for congenital heart defects, each distinct vessel (List separately in addition to code for primary procedure) |
93580 | Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant |
93581 | Percutaneous transcatheter closure of a congenital ventricular septal defect with implant |
93582 | Percutaneous transcatheter closure of patent ductus arteriosus |
93583 | Percutaneous Transcatheter Septal Reduction therapy (Eg, Alcohol Septal Ablation) including Temporary Pacemaker Insertion when Performed |
93590 | Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, mitral valve |
93591 | Percutaneous transcatheter closure of paravalvular leak; initial occlusion device, aortic valve |
93592 | Percutaneous transcatheter closure of paravalvular leak; each additional occlusion device (List separately in addition to code for primary procedure) |
93609 | Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure) |
93613 | Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure) |
93619 | Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia |
93620 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording |
93621 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure) |
93622 | Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure) |
93623 | Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure) |
93650 | Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement |
93653 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry |
93654 | Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed |
93655 | Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure) |
93656 | Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed |
93657 | Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure) |
93662 | Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List separately in addition to code for primary procedure) |
93745 | Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events |
C1721 | Cardioverter-defibrillator, dual chamber |
C1722 | Cardioverter-defibrillator, single chamber |
C1730 | Catheter, electrophysiology, diagnostic, other than 3D mapping, 19 or fewer electrodes |
C1731 | Catheter, electrophysiology, diagnostic, other than 3D mapping, 20 or more electrodes |
C1732 | Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping |
C1733 | Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping other than cool-tip |
C1753 | Catheter, intravascular ultrasound |
C1759 | Catheter, intracardiac echocardiography |
C1760 | Closure device, vascular |
C1764 | Event recorder, cardiac |
C1768 | Graft, vascular |
C1777 | Lead, cardioverter-defibrillator, endocardial single coil |
C1779 | Lead, pacemaker, transvenous VDD single pass |
C1785 | Pacemaker, dual chamber, rate-responsive |
C1786 | Pacemaker, single chamber, rate-responsive |
C1876 | Stent, noncoated/noncovered, with delivery system |
C1877 | Stent, noncoated/noncovered, without delivery system |
C1882 | Cardioverter-defibrillator, other than single or dual chamber |
C1895 | Lead, cardioverter-defibrillator, endocardial dual coil |
C1896 | Lead, cardioverter-defibrillator, other than endocardial dual coil |
C1898 | Lead, pacemaker, other than transvenous VDD single pass |
C1899 | Lead, pacemaker/cardioverter-defibrillator combination |
C1900 | Lead, left ventricular coronary venous system |
C2617 | Stent, noncoronary, temporary, without delivery system |
C2619 | Pacemaker, dual chamber, nonrate-responsive |
C2620 | Pacemaker, single chamber, nonrate-responsive |
C2621 | Pacemaker, other than single or dual chamber |
C2623 | Catheter, transluminal angioplasty, drug-coated, nonlaser |
C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components |
C2630 | Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping, cool-tip |
C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch |
C9601 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery |
C9602 | Percutaneous transluminal coronary atherectomy with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch |
C9603 | Percutaneous transluminal coronary atherectomy with drug eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery |
C9604 | Percutaneous transluminal revascularization of or through coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel |
C9605 | Percutaneous transluminal revascularization of or through coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft |
C9606 | Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, single vessel |
C9607 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel |
C9608 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, each additional coronary artery, coronary artery branch, or bypass graft |
E0616 | Implantable cardiac event recorder with memory, activator, and programmer |
G0278 | Iliac and/or femoral artery angiography, nonselective, bilateral or ipsilateral to catheter insertion, performed at the same time as cardiac catheterization and/or coronary angiography |
G0448 | Insertion or replacement of a permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac venous system, for left ventricular pacing |
K0606 | Automatic external defibrillator, with integrated electrocardiogram analysis, garment type |
K0607 | Replacement battery for automated external defibrillator, garment type only, each |
K0608 | Replacement garment for use with automated external defibrillator, each |
K0609 | Replacement electrodes for use with automated external defibrillator, garment type only, each |
S2205 | Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), single coronary arterial graft |
S2206 | Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two coronary arterial grafts |
S2207 | Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft |
S2208 | Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft |
S2209 | Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using two arterial grafts and single venous graft |
Payment Policy Updates
The below policy was updated as part of our regular monthly review in August. The policy change is effective January 1, 2026. You will find the policy, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
CC.PP.145 | Malnutrition | Apple Health & Ambetter |
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Wellcare
CMS Prior Authorization Change Summary: Effective January 1, 2026
On January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) will implement new prior authorization (PA) response time requirements for all providers.
- Standard prior authorization requests will be completed within 7 calendar days, with a possible extension up to 14 calendar days under certain circumstances.
- Expedited/Urgent prior authorization requests will be completed within the lesser of 72 hours -OR- the current BD turnaround time.
With shorter response times for supporting clinical information requests, all necessary clinical information should be submitted at the time of the authorization request.
Additional Information
- Complete clinicals include Diagnosis, History and Current Condition, Treatment Plan and Interventions, and Relevant Diagnostic Tests.
- Response times can be lessened if all information is submitted with the authorization request.
- Missing clinical information may lead to a denial due to inadequate supporting records.
- Submitting prior authorization requests via the secure Availity portal allows for faster review.
Centene clinical policies and criteria can be found at Availity.
If you have any questions, please contact your provider relations representative.
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Apple Health Core Connections
The Washington State Department of Children, Youth, and Families (DCYF) has updated its Mandatory Reporter training to help distinguish between families needing support vs. child abuse and neglect. This training was updated with input from a wide variety of community stakeholders, including the medical community.
Mandated Reporters are people who are legally required to report child abuse or neglect. This includes medical practitioners, nurses, dentists, psychologists, medical examiners, pharmacists, social service counselors/therapists, and more. Visit the DCYF Mandated Reporter webpage for more info and resources materials.
Complete the updated training here.
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Training/Education
Annual Cultural Humility and Language Access Training is available to all providers and staff. These trainings support compliance with Title VI, ADA, and ACA Section 1557, and help ensure providers are equipped to deliver culturally and linguistically appropriate care.
Have you completed any form of training in the past 12 months related to Cultural Humility, Cultural Competence, or Culturally Appropriate Care?
Click here to submit your response to Coordinated Care. This quick check-in takes less than 1 minute. Participation is voluntary, and your responses are confidential and anonymous.
Free Provider Training
- Network Providers have free access to a variety of training resources, to include a full catalog of accredited training opportunities through Centene Institute.
- Browse the full catalogue
- Visit the Log-In Page to create a free account.
- Visit the Coordinated Care Provider Events page for the most current schedule of live trainings.
- To request one-on-one training or a refresher reach out to CoordinatedCareProvider@centene.com.
Supporting LGBTQIA+ Youth in Foster Care This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. Monday Nov 3rd 12p – 2p Register.
Secondary Trauma and Self-Care Caring for children who have experienced trauma can be difficult, draining, exhausting, and frustrating. This training will help caregivers and service providers to understand the differences between Secondary Traumatic Stress, Compassion fatigue and Vicarious trauma. Participants will also be able to recognize warning signs and personal triggers, as well as understand why self-care is important and develop a personal self-care plan. Monday Nov 3rd 3p – 4:30p Register.
Coping with Holiday Stress All of us can feel stressed around the holidays. This stress can be amplified by feelings of grief and loss for children and youth in foster care. This training will help participants identify holiday stress that children in foster care feel, create a healthy environment for the holidays, and how to help children and youth cope. Tuesday Nov 4th 10a – 11:30a Register.
Suicide Prevention Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Wednesday Nov 12th 1p – 3p Register.
Trauma Informed Care: Being an Advocate for Youth: Children with a background of trauma in the child welfare system may need to have several advocates to help them. Becoming an advocate for the youth you serve or live with can be invaluable to a young person's life. It can also be confusing or challenging to everyone involved. This webinar provides guidance on: Working with team members, helping others understand the child, utilize trauma informed care, considering treatment modality basics, when to question treatment and caring for your own needs. Content developed by National Child Traumatic Stress Network (NCTSN) Nov 12, 2025 12:01 – 1:45pm Register.
Coping with Holiday Stress with Youth: All of us can feel stressed around the holidays. This stress can be amplified by feelings of grief and loss for youth in foster care, kinship and early adoption. This training will help participants identify holiday concerns that children in new homes feel, create a healthy environment for the holidays, and how to help youth, caregivers & professionals cope. Nov 14, 2025 12:00 – 01:45pm Register.
Attachment: Beyond Infancy: Attachment is the foundation of all relationships, and when caring for children with a history of trauma and trust issues, it does not always occur easily. Lack of bonding is often a core reason why caretakers and children have challenges in placement and/or disrupt from the home. This training addresses the need for Attachment-Focused care, including some practical tips on how to strengthen connections to children. The presentation can help professionals and caregivers understand the basics of how attachment issues are extremely common in children who have experienced complex trauma, and what behaviors may come from that history. Nov 20, 2025 06:00 – 08:00pm Register.
Apple Health/Coordinated Care Overview: Coordinated Care's Apple Health Foster Care Overview includes program information, insurance coverage and special benefits for youth in foster care, adoption support, alumni of foster care and reunified families that choose Coordinated Care, including general Medicaid recipients who choose Coordinated Care insurance. Nov 24, 2025 01:00 -02:30pm Register.
Coordinated Care 2026 AEP product highlights Webinar
Please join us November 5th 2-3, for the Coordinated Care 2026 AEP Product Highlights Webinar. This session will provide an overview of Coordinated Care’s plan offerings and key updates for the upcoming enrollment periods. Topics will include Ambetter, Medicaid, and Wellcare plans for 2026, with a focus on helping providers stay informed and prepared.
Registration is now open! Click here to register.
Please reach out to your provider engagement administrator for questions.