Claims submitted with the procedure codes listed in this document must be accompanied by clinical information that supports the services rendered. Some services may require medical review because of one or more of the following reasons:
- The procedure is considered new technology
- There is limited effectiveness when the procedure is used for certain medical conditions
- The procedure was performed for an indication that is not FDA-approved
- The procedure is not performed very often
- There is a potential for the procedure to be used inappropriately or for other reasons related to medical necessity
In some cases, practitioners may request that HMSA review the planned procedure(s) prior to the services being rendered for benefit predetermination. Please refer to Benefit Information for more details on this process.
I. Codes That Require Clinical Information
Claims for the following codes should be submitted with the required documentation indicated in this table.
| CPT Code | Description | Documentation Required |
|---|---|---|
| 64525 | Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) | Clinical notes |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | Clinical notes |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions | Clinical notes |
| 77520 | Proton treatment delivery; simple, without compensation | Clinical notes |
| 77523 | intermediate | Clinical notes |
| 79403 | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion | Clinical notes |
| Category III Codes | Description | Documentation Required |
|---|---|---|
| 0174T | Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation | Clinical notes |
| 0175T | performed remote from primary interpretation | Clinical notes |
| 0347T | Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) | Clinical Notes, Consult Report, Diagnostic/Imaging Report |
| 0348T | Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) | Clinical Notes, Consult Report, Diagnostic/Imaging Report |
| 0349T | Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) | Clinical Notes, Consult Report, Diagnostic/Imaging Report |
| 0350T | Radiologic examination, radiostereometric analysis (RSA); lower extremety(ies), (includes hip, proximal femur, knee and ankle, when performed) | Clinical Notes, Consult Report, Diagnostic/Imaging Report |
| 0419T | Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas | Clinical notes |
| 0420T | Destruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas | Clinical notes |
| HCPCS Code | Description | Documentation Required |
|---|---|---|
| S2118 | Metal-on-metal total hip resurfacing, including acetabular and femoral components as an alternative to hip replacement in patients who are candidates for total hip replacement and who are likely to outlive a traditional prosthesis, and who do not have contraindications for total hip resurfacing. | Operative report
History and physical |
| S2270 | Insertion of vaginal cylinder for application of radiation source or clinical brachytherapy (report separately in addition to radiation source delivery) | Radiation oncology report
Consultation report |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |