The Health Plan · PayerPolicy · EVICORE-HPLAN-THE_HEALTH_PLAN-7DE7C61F62E6
Summary of the payer’s published policy. Not a coverage determination — confirm with The Health Plan before submitting.
Free account. Policy pages stay open to everyone.
Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.
| Code | Code system | Status in this policy |
|---|---|---|
| 33206 | CPT | Prior auth required |
| 33207 | CPT | Prior auth required |
| 33208 | CPT | Prior auth required |
| 33212 | CPT | Prior auth required |
| 33213 | CPT | Prior auth required |
| 33214 | CPT | Prior auth required |
| 33221 | CPT | Prior auth required |
| 33224 | CPT | Prior auth required |
| 33225 | CPT | Prior auth required |
| 33227 | CPT | Prior auth required |
| 33228 | CPT | Prior auth required |
| 33229 | CPT | Prior auth required |
| 33230 | CPT | Prior auth required |
| 33231 | CPT | Prior auth required |
| 33240 | CPT | Prior auth required |
| 33249 | CPT | Prior auth required |
|---|
| 33262 | CPT | Prior auth required |
|---|
| 33263 | CPT | Prior auth required |
|---|
| 33264 | CPT | Prior auth required |
|---|
| 33270 | CPT | Prior auth required |
|---|
| 33274 | CPT | Prior auth required |
|---|
| 33275 | CPT | Prior auth required |
|---|
| 33289 | CPT | Prior auth required |
|---|
| 70336 | CPT | Prior auth required |
|---|
| 70450 | CPT | Prior auth required |
|---|
| 70460 | CPT | Prior auth required |
|---|
| 70470 | CPT | Prior auth required |
|---|
| 70471 | CPT | Prior auth required |
|---|
| 70472 | CPT | Prior auth required |
|---|
| 70473 | CPT | Prior auth required |
|---|
| 70480 | CPT | Prior auth required |
|---|
| 70481 | CPT | Prior auth required |
|---|
| 70482 | CPT | Prior auth required |
|---|
| 70486 | CPT | Prior auth required |
|---|
| 70487 | CPT | Prior auth required |
|---|
| 70488 | CPT | Prior auth required |
|---|
| 70490 | CPT | Prior auth required |
|---|
| 70491 | CPT | Prior auth required |
|---|
| 70492 | CPT | Prior auth required |
|---|
| 70496 | CPT | Prior auth required |
|---|
| 70498 | CPT | Prior auth required |
|---|
| 70540 | CPT | Prior auth required |
|---|
| 70542 | CPT | Prior auth required |
|---|
| 70543 | CPT | Prior auth required |
|---|
| 70544 | CPT | Prior auth required |
|---|
| 70545 | CPT | Prior auth required |
|---|
| 70546 | CPT | Prior auth required |
|---|
| 70547 | CPT | Prior auth required |
|---|
| 70548 | CPT | Prior auth required |
|---|
| 70549 | CPT | Prior auth required |
|---|
| 70551 | CPT | Prior auth required |
|---|
| 70552 | CPT | Prior auth required |
|---|
| 70553 | CPT | Prior auth required |
|---|
| 70554 | CPT | Prior auth required |
|---|
| 70555 | CPT | Prior auth required |
|---|
| 71250 | CPT | Prior auth required |
|---|
| 71260 | CPT | Prior auth required |
|---|
| 71270 | CPT | Prior auth required |
|---|
| 71271 | CPT | Prior auth required |
|---|
| 71275 | CPT | Prior auth required |
|---|
| 71550 | CPT | Prior auth required |
|---|
| 71551 | CPT | Prior auth required |
|---|
| 71552 | CPT | Prior auth required |
|---|
| 71555 | CPT | Prior auth required |
|---|
| 72125 | CPT | Prior auth required |
|---|
| 72126 | CPT | Prior auth required |
|---|
| 72127 | CPT | Prior auth required |
|---|
| 72128 | CPT | Prior auth required |
|---|
| 72129 | CPT | Prior auth required |
|---|
| 72130 | CPT | Prior auth required |
|---|
| 72131 | CPT | Prior auth required |
|---|
| 72132 | CPT | Prior auth required |
|---|
| 72133 | CPT | Prior auth required |
|---|
| 72141 | CPT | Prior auth required |
|---|
| 72142 | CPT | Prior auth required |
|---|
| 72146 | CPT | Prior auth required |
|---|
| 72147 | CPT | Prior auth required |
|---|
| 72148 | CPT | Prior auth required |
|---|
| 72149 | CPT | Prior auth required |
|---|
| 72156 | CPT | Prior auth required |
|---|
| 72157 | CPT | Prior auth required |
|---|
| 72158 | CPT | Prior auth required |
|---|
| 72159 | CPT | Prior auth required |
|---|
| 72191 | CPT | Prior auth required |
|---|
| 72192 | CPT | Prior auth required |
|---|
| 72193 | CPT | Prior auth required |
|---|
| 72194 | CPT | Prior auth required |
|---|
| 72195 | CPT | Prior auth required |
|---|
| 72196 | CPT | Prior auth required |
|---|
| 72197 | CPT | Prior auth required |
|---|
| 72198 | CPT | Prior auth required |
|---|
| 73200 | CPT | Prior auth required |
|---|
| 73201 | CPT | Prior auth required |
|---|
| 73202 | CPT | Prior auth required |
|---|
| 73206 | CPT | Prior auth required |
|---|
| 73218 | CPT | Prior auth required |
|---|
| 73219 | CPT | Prior auth required |
|---|
| 73220 | CPT | Prior auth required |
|---|
| 73221 | CPT | Prior auth required |
|---|
| 73222 | CPT | Prior auth required |
|---|
| 73223 | CPT | Prior auth required |
|---|
| 73225 | CPT | Prior auth required |
|---|
| 73700 | CPT | Prior auth required |
|---|
| 73701 | CPT | Prior auth required |
|---|
| 73702 | CPT | Prior auth required |
|---|
| 73706 | CPT | Prior auth required |
|---|
| 73718 | CPT | Prior auth required |
|---|
| 73719 | CPT | Prior auth required |
|---|
| 73720 | CPT | Prior auth required |
|---|
| 73721 | CPT | Prior auth required |
|---|
| 73722 | CPT | Prior auth required |
|---|
| 73723 | CPT | Prior auth required |
|---|
| 73725 | CPT | Prior auth required |
|---|
| 74150 | CPT | Prior auth required |
|---|
| 74160 | CPT | Prior auth required |
|---|
| 74170 | CPT | Prior auth required |
|---|
| 74174 | CPT | Prior auth required |
|---|
| 74175 | CPT | Prior auth required |
|---|
| 74176 | CPT | Prior auth required |
|---|
| 74177 | CPT | Prior auth required |
|---|
| 74178 | CPT | Prior auth required |
|---|
| 74181 | CPT | Prior auth required |
|---|
| 74182 | CPT | Prior auth required |
|---|
| 74183 | CPT | Prior auth required |
|---|
| 74185 | CPT | Prior auth required |
|---|
| 74261 | CPT | Prior auth required |
|---|
| 74262 | CPT | Prior auth required |
|---|
| 74263 | CPT | Prior auth required |
|---|
| 74712 | CPT | Prior auth required |
|---|
| 74713 | CPT | Prior auth required |
|---|
| 75557 | CPT | Prior auth required |
|---|
| 75559 | CPT | Prior auth required |
|---|
| 75561 | CPT | Prior auth required |
|---|
| 75563 | CPT | Prior auth required |
|---|
| 75565 | CPT | Prior auth required |
|---|
| 75571 | CPT | Prior auth required |
|---|
| 75572 | CPT | Prior auth required |
|---|
| 75573 | CPT | Prior auth required |
|---|
| 75574 | CPT | Prior auth required |
|---|
| 75577 | CPT | Prior auth required |
|---|
| 75580 | CPT | Prior auth required |
|---|
| 75635 | CPT | Prior auth required |
|---|
| 76376 | CPT | Prior auth required |
|---|
| 76377 | CPT | Prior auth required |
|---|
| 76380 | CPT | Prior auth required |
|---|
| 76390 | CPT | Prior auth required |
|---|
| 76391 | CPT | Prior auth required |
|---|
| 76497 | CPT | Prior auth required |
|---|
| 76498 | CPT | Prior auth required |
|---|
| 77021 | CPT | Prior auth required |
|---|
| 77022 | CPT | Prior auth required |
|---|
| 77046 | CPT | Prior auth required |
|---|
| 77047 | CPT | Prior auth required |
|---|
| 77048 | CPT | Prior auth required |
|---|
| 77049 | CPT | Prior auth required |
|---|
| 77078 | CPT | Prior auth required |
|---|
| 77084 | CPT | Prior auth required |
|---|
| 78414 | CPT | Prior auth required |
|---|
| 78428 | CPT | Prior auth required |
|---|
| 78429 | CPT | Prior auth required |
|---|
| 78430 | CPT | Prior auth required |
|---|
| 78431 | CPT | Prior auth required |
|---|
| 78432 | CPT | Prior auth required |
|---|
| 78433 | CPT | Prior auth required |
|---|
| 78434 | CPT | Prior auth required |
|---|
| 78451 | CPT | Prior auth required |
|---|
| 78452 | CPT | Prior auth required |
|---|
| 78453 | CPT | Prior auth required |
|---|
| 78454 | CPT | Prior auth required |
|---|
| 78459 | CPT | Prior auth required |
|---|
| 78466 | CPT | Prior auth required |
|---|
| 78468 | CPT | Prior auth required |
|---|
| 78469 | CPT | Prior auth required |
|---|
| 78472 | CPT | Prior auth required |
|---|
| 78473 | CPT | Prior auth required |
|---|
| 78481 | CPT | Prior auth required |
|---|
| 78483 | CPT | Prior auth required |
|---|
| 78491 | CPT | Prior auth required |
|---|
| 78492 | CPT | Prior auth required |
|---|
| 78494 | CPT | Prior auth required |
|---|
| 78496 | CPT | Prior auth required |
|---|
| 78499 | CPT | Prior auth required |
|---|
| 78608 | CPT | Prior auth required |
|---|
| 78609 | CPT | Prior auth required |
|---|
| 78803 | CPT | Prior auth required |
|---|
| 78811 | CPT | Prior auth required |
|---|
| 78812 | CPT | Prior auth required |
|---|
| 78813 | CPT | Prior auth required |
|---|
| 78814 | CPT | Prior auth required |
|---|
| 78815 | CPT | Prior auth required |
|---|
| 78816 | CPT | Prior auth required |
|---|
| 93350 | CPT | Prior auth required |
|---|
| 93351 | CPT | Prior auth required |
|---|
| 93451 | CPT | Prior auth required |
|---|
| 93452 | CPT | Prior auth required |
|---|
| 93453 | CPT | Prior auth required |
|---|
| 93454 | CPT | Prior auth required |
|---|
| 93455 | CPT | Prior auth required |
|---|
| 93456 | CPT | Prior auth required |
|---|
| 93457 | CPT | Prior auth required |
|---|
| 93458 | CPT | Prior auth required |
|---|
| 93459 | CPT | Prior auth required |
|---|
| 93460 | CPT | Prior auth required |
|---|
| 93461 | CPT | Prior auth required |
|---|
| 93593 | CPT | Prior auth required |
|---|
| 93594 | CPT | Prior auth required |
|---|
| 93595 | CPT | Prior auth required |
|---|
| 93596 | CPT | Prior auth required |
|---|
| 93597 | CPT | Prior auth required |
|---|
| C8900 | HCPCS | Prior auth required |
|---|
| C8901 | HCPCS | Prior auth required |
|---|
| C8902 | HCPCS | Prior auth required |
|---|
| C8903 | HCPCS | Prior auth required |
|---|
| C8905 | HCPCS | Prior auth required |
|---|
| C8906 | HCPCS | Prior auth required |
|---|
| C8908 | HCPCS | Prior auth required |
|---|
| C8909 | HCPCS | Prior auth required |
|---|
| C8910 | HCPCS | Prior auth required |
|---|
| C8911 | HCPCS | Prior auth required |
|---|
| C8912 | HCPCS | Prior auth required |
|---|
| C8913 | HCPCS | Prior auth required |
|---|
| C8914 | HCPCS | Prior auth required |
|---|
| C8918 | HCPCS | Prior auth required |
|---|
| C8919 | HCPCS | Prior auth required |
|---|
| C8920 | HCPCS | Prior auth required |
|---|
| C8931 | HCPCS | Prior auth required |
|---|
| C8932 | HCPCS | Prior auth required |
|---|
| C8933 | HCPCS | Prior auth required |
|---|
| C8934 | HCPCS | Prior auth required |
|---|
| C8935 | HCPCS | Prior auth required |
|---|
| C8936 | HCPCS | Prior auth required |
|---|
| C9791 | HCPCS | Prior auth required |
|---|
| G0219 | HCPCS | Prior auth required |
|---|
| G0235 | HCPCS | Prior auth required |
|---|
| G0252 | HCPCS | Prior auth required |
|---|
| S8037 | HCPCS | Prior auth required |
|---|
| S8042 | HCPCS | Prior auth required |
|---|
| S8085 | HCPCS | Prior auth required |
|---|
| S8092 | HCPCS | Prior auth required |
|---|