ND Committee Review
Internal Medical Policy Committee 9-21-20 Revised policy
Internal Medical Policy Committee 1-19-2021 Coding update:
- Removed Procedure Codes 92585; and 92586; and
- Added Procedure Codes 92650; 92651; 92652; and 92653.
Internal Medical Policy Committee 9-21-2021 Coding update.
- Added Diagnosis Codes H81.41; H81.42; H81.43; H81.49; and H83.19
Internal Medical Policy Committee 9-28-2022 Revision of Policy
- Removed Procedure Code 95941 and 95942.
- Updated language throughout policy
Internal Medical Policy Committee 5-23-2023 - Effective July 03, 2023
- Added criteria.
- Added Procedure Code 95941.
Internal Medical Policy Committee 11-15-2023 - Effective October 01, 2023
- Added Diagnosis Codes G93.42, G93.43 and G93.44
- Removed Diagnosis Codes G20.
- Added Diagnosis Codes C75.0, D345, D35.1, D44.0, D44.2, E04.0, E04.1, E04.2, E04.8, E04.9, E21.0, E21.1, E21.2, E21.3, E21.4, E21.5, and H81.4
- Removed Diagnosis Codes H81.41, H81.42, H81.43, H81.49, H83.19, I63.8, S06.2X7D and S06.2X7S
Internal Medical Policy Committee 3-19-2024 Revision - Effective May 06, 2024
- Removed Diagnosis Codes: C72.20; C72.30; C72.40; D33.9; D42.9; D49.6; G52.9; G95.20; G95.9; H71.00; H71.10; H71.20; H71.30; H71.90; H74.40; H81.09; I63.00; I63.019; I63.039; I63.10; I63.119; I63.139; I63.20; I63.219; I63.319; I63.329; I63.339; I63.349; I63.40; I63.419; I63.429; I63.439; I63.449; I63.50; I63.519; I63.529; I63.539; I63.549; I65.09; I66.09; I66.19; I66.29; I66.9; I71.00; M21.759; M21.769; M40.00; M40.10; M40.209; M40.299; M40.30; M40.40; M40.50; M41.00; M41.119; M41.129; M41.20; M41.30; M41.40; M41.50; M41.80; M41.9; M43.8X9; M47.019; M47.029; M47.10; M48.00; M50.00; M50.10; M50.120; M50.20; M50.220; M50.30; M50.91; M50.920; M50.93; M54.30; P11.2; P11.9; P14.9; Q05.4; Q05.9; Q77.9; Q85.00; S06.9X0A; S06.9X0D; S06.9X0S; S06.9X1A; S06.9X1D; ; S06.9X1S; ; S06.9X2A; S06.9X2D; S06.9X2S; S06.9X3A; S06.9X3D; S06.9X3S; S06.9X4A; S06.9X4D; S06.9X4S; S06.9X5A; S06.9X5D; S06.9X5S; S06.9X6A; S06.9X6D; S06.9X6S; S06.9X7A; S06.9X8A; S06.9X9A; S06.9X9D; S06.9X9S; S12.000A; S12.000B; S12.000S; S12.001A; S12.001B; S12.001S; S12.100A; S12.100B; S12.100S; S12.101A; S12.101B; S12.101S; S12.130A; S12.130B; S12.130S; S12.131A; S12.131B; S12.131S; S12.200A; S12.200B; S12.231A; S12.231B; S12.231S; S12.291S; S12.300A; S12.300B; S12.300S; S12.301A; S12.301B; S12.301S; S12.330A; S12.330B; S12.330S; S12.331A; S12.331B; S12.331S; S12.400A; S12.400B; S12.400S; S12.401A; S12.401B; S12.401S; S12.430A; S12.430B; S12.430S; S12.431A; S12.431B; S12.431S; S12.500A; S12.500B; S12.500S; S12.501A; S12.501B; S12.501S; S12.530A; S12.530B; S12.530S; S12.531A; S12.531B; S12.531S; S12.600A; S12.600B; S12.600S; S12.601A; S12.601B; S12.601S; S12.630A; S12.630B; S12.630S; S12.631A; S12.631B; S12.631S; S12.9XXA; S12.9XXD; S12.9XXS; S14.101A; S14.101D; S14.101S; S14.102A; S14.102D; S14.102S; S14.103A; S14.103D; S14.103S; S14.104A; S14.104D; S14.104S; S14.105A; S14.105D; S14.105S; S14.106A; S14.106D; S14.106S; S14.107A; S14.107D; S14.107S; S14.108D; S14.108S; S14.109A; S14.109D; S14.109S; S22.019A; S22.019B; S22.019S; S22.029A; S22.029B; S22.029S; S22.039A; S22.039B; S22.039S; S22.049A; S22.049B; S22.049S; S22.059A; S22.059B; S22.059S; S22.069A; S22.069B; S22.069S; S22.079A; S22.079B; S22.079S; S22.089A; S22.089B; S22.089S; S24.102A; S24.102S; S24.103A; S24.103S; S24.104A; S24.104S; S24.109A; S24.109S; S32.009A; S32.009B; S32.009S; S32.019A; S32.019B; S32.019S; S32.029A; S32.029B; S32.029S; S32.039A; S32.039B; S32.039S; S32.049A; S32.049B; S32.049S; S32.059A; S32.059B; S32.059S; S32.10XA; S32.10XB; S32.10XS; S34.101A; S34.101S; S34.102A; S34.102S; S34.103A; S34.103S; S34.104A; S34.104S; S34.105A; S34.105S; S34.109A; S34.109S; S34.119A; S34.119S; S34.129A; S34.129S; S34.139A; S34.139S; S44.00XA; S44.00XS; S44.10XA; S44.10XS; S44.20XA; S44.20XS; S44.30XA; S44.30XS; S44.40XA; S44.40XS; S44.50XA; S44.50XS; S44.8X9A; S44.8X9S; S44.90XA; S44.90XS; S54.10XA; S54.10XS; S54.20XA; S54.20XS; S54.30XA; S54.30XS; S54.8X9A; S54.8X9S; S54.90XA; S64.00XA; S64.00XS; S64.10XA; S64.10XS; S64.20XA; S64.20XS; S64.30XA; S64.30XS; S64.40XA; S64.40XS; S64.498A; S64.498S; S64.8X9A; S64.8X9S; S64.90XA; S64.90XS; S74.00XA; S74.00XS; S74.01XA; S74.01XS; S74.20XA; S74.20XS; S84.00XA; S84.00XS; S84.10XA; S84.10XS; S84.20XA; S84.20XS; S84.809A; S84.809S; S84.90XA; S84.90XS; S94.00XA; S94.00XS; S94.10XA; S94.10XS; S94.20XA; S94.20XS; S94.30XA; S94.30XS; S94.8X9A; S94.8X9S; S94.90XA; S94.90XS; and
- Added Diagnosis Codes: G40.A01; G40.A09; G40.A11; G40.A19; G40.B01; G40.B09; G40.B11; G40.B19; G40.C01; G40.C09; G40.C11; G40.C19; G40.001; G40.009; G40.011; G40.019; G40.101; G40.109; G40.201; G40.209; G40.301; G40.309; G40.401; G40.409; G40.501; G40.509; G40.801; G40.802; G10.811; G40.812; G40.813; G40.814; G40.821; G40.822; G40.823; G40.824; G40.833; G40.834; G40.89; G40.901; G40.909; G40.911; G40.919; G40.A01; G40.A09; G40.A11; G40.A19; G40.B01; G40.B09; G40.B11; G40.B19; G40.C01; G40.C09; G40.C11; G40.C19; G80.3; and Z98.890.
Internal Medical Policy Committee 9-17-2024 Coding update - Effective October 01, 2024
- Corrected Procedure Code from 95886 to 95868; and
- Added Diagnosis Codes G40.841; G40.842; G40.843; G40.844; M51.360; M51.361; M51.362; M51.369; M51.370; M51.371; M51.372; and M51.379; and
- Added Policy Application
Internal Medical Policy Committee 5-13-2025 Revision - Effective July 07, 2025
- Moved Procedure Codes 95907; 95908; 95910; 95911; 95912; 95913; and 95937 to not medically necessary ; and
- Moved 0464T from maybe medically necessary section to experimental/investigational section ; and
- Added Procedure Codes 95961; 95863; 95822; 95866; 95870; 95865; and 95930 ; and
- Added Diagnosis Code C41.0; D34.5 ; and
- Removed Diagnosis Codes E05.00; E05.01; E05.10; E05.11; E05.20; E05.21; E05.30; E05.31; E05.40; E05.41; E05.80; E05.81; E05.90; E05.91; E07.9; E21.0; E21.1; E21.2; E21.3; E21.4; E21.5; G24.3; G24.4; G25.1; G25.2; G25.5; G25.71; G25.79; G25.89; G25.9; G26; G40.111; G40.842; G40.843; G40.844; G40.301; G40.309; G40.401; G40.409; G40.501; G40.509; G40.89; G45.1; G45.2; G45.8; G45.9; G46.0; G46.1; G46.2; G46.3; G46.4; G50.0; G50.1; G80.3; G80.4; G80.8; G80.9; G96.44; G93.5; H71.01; H71.02; H71.03; H71.11; H71.12; H71.13; H71.21; H71.22; H71.23; H71.31; H71.32; H71.33; H71.91; H71.92; H71.93; I46.8; I46.9; I63.011; I63.012; I63.013; I63.02; I63.031; I63.032; I63.033; I63.09; I63.111; I63.112; I63.113; I63.12; I63.131; I63.132; I63.133; I63.19; I63.20; I63.211; I63.212; I63.213; I63.22; I63.231; I63.232; I63.233; I63.29; I63.311; I63.312; I63.313; I63.319; I63.321; I63.322; I63.323; I63.331; I63.332; I63.333; I63.341; I63.342; I63.343; I63.39; I63.411; I63.412; I63.413; I63.421; I63.422; I63.423; I63.431; I63.432; I63.433; I63.441; I63.442; I63.443; I63.49; I63.511; I63.512; I63.513; I63.521; I63.522; I63.523; I63.531; I63.532; I63.533; I63.541; I63.542; I63.543; I63.59; I63.6; I63.81; I63.89; I63.9; I67.2; I67.5; M21.751; M21.752; M21.761; M21.762; M21.763; M21.764; M40.202; M40.203; M40.204; M40.205; M40.292; M40.293; M40.294; M40.295; M40.35; M40.36; M40.37; M40.45; M40.46; M40.47; M40.55; M40.56; M40.57; Z98.890
- Replaced invalid Diagnosis Code D34.5 with Diagnosis Code D34
