CurrentMass General Brigham Health PlanPolicy N/A

CPT/HCPCS code coverage categories (Commercial and ASO)

This document lists specific CPT/HCPCS codes and groups them by coverage status (not covered experimental/investigational, not covered benefit, covered with prior authorization, covered without prior authorization, and reportable-only) for Mass General Brigham Health Plan commercial and ASO members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyCPT/HCPCS code coverage categories (Commercial and ASO)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for PMA/510(k)/361 HCT/P skin substitute products before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5coverage categories present

100+individual code entries listed

Reportable onlyreportable-only M-codes

Commercial & ASOpopulation governed

Code Coverage Categories

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Example Code Lists by Coverage Status

Not covered - experimental/investigational (examples)mixedNot Covered

C1607	Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system
C1608	Prosthesis, total, dual mobility, first carpometacarpal joint (implantable)
C7570	Catheter placement in coronary artery(s) for coronary angiography...with intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree (list separately in addition to code for primary procedure)
C7571	Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with percutaneous transluminal coronary lithotripsy
G0571	Intraoperative nerve(s) cryoablation for post-surgical pain relief (list separately in addition to code for primary service)

Not covered - benefit exclusion (non-opioid medical devices examples)mixedNot Covered

C9810	Water circulating motorized cold therapy device (e.g., iceman) including all system components (e.g., pads, console, disposable parts) - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9811	Electronic ambulatory infusion pump (e.g., sapphire pump), including all pump components, including disposable components - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9812	Echogenic nerve block needles (e.g., sonoplex, sonoblock, sonotap) - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9813	Perforated continuous infusion catheter set (e.g., infiltralong), including all components - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9814	Continuous anesthesia echogenic conduction catheter set (e.g., sonolong) - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9815	Linear peristaltic pain management infusion pump (e.g., cadd-solis ambulatory infusion pump), and all disposable system components - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9816	Rotary peristaltic infusion pump (e.g., reusable ambit pump) including all disposable system components - reusable non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)
C9817	Electronic cryo-pneumatic compression pain management system (e.g., game ready grpro 2.1 system), including control unit, anatomically correct wrap(s), and other system component(s) - non-opioid medical device (must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023)

Covered without prior authorization (examples)mixedCovered

A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each
A4296	Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supplies
C7566	Arthrodesis, interphalangeal joints, with or without internal fixation, with autografts (includes obtaining grafts)
C7567	Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed, with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(es), with computer-assisted image-guided navigation
C7568	Catheter placement in coronary artery(ies) for coronary angiography...with intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (initial coronary vessel or graft) during coronary angiography including pharmacologically induced stress
C7569	Percutaneous transluminal coronary angioplasty, single major coronary artery or branch with endoluminal imaging of initial 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
C9176	Tc-99m from domestically produced non-HEU Mo-99, [minimum 50 percent], full cost recovery add-on, per study dose
G0568	Initial psychiatric collaborative care management, in the first calendar month
G0569	Subsequent psychiatric collaborative care management, in a subsequent month

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Reportable only / not reimbursable (sample M-codes)mixed

M1426	Encounters conducted via telehealth
M1427	Documentation of medical reason(s) for performing a bone scan (including documented pain related to prostate cancer, salvage therapy, other medical reasons)
M1431	Encounters conducted via telehealth
M1483	Patients who achieve sustained virological response as identified by an HCV RNA test with a negative/undetectable HCV RNA result 20 weeks to 12 months after the first positive/detectable HCV RNA test result within the denominator identification period

Non-opioid device qualification — Must be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023

RequirementMust be a qualifying Medicare non-opioid medical device per section 4135 of the CAA, 2023

Applies toNon-opioid medical devices listed as 'Not covered - benefit' (e.g., C9810–C9817)

Policy impactDevices that do not meet Medicare qualification under CAA §4135 are excluded from benefit for Commercial and ASO members

Billing and Authorization Requirements

Prior Authorization

Prior authorization required for PMA/510(k)/361 HCT/P skin substitutes

PMA, 510(k), and 361 HCT/P skin substitute products require prior authorization before coverage; bill with the appropriate Q4431, Q4432, or Q4433 code as an add-on to the primary procedure once authorized.

Q4431 = PMA skin substitute product, not otherwise specified (list in addition to primary procedure)
Q4432 = 510(k) skin substitute product, not otherwise specified (list in addition to primary procedure)
Q4433 = 361 HCT/P skin substitute product, not otherwise specified (list in addition to primary procedure)

Key Definitions and Reporting Status

Non-opioid medical device (qualifying per CAA section 4135, 2023)

DefinitionQualifying Medicare non-opioid medical device (per CAA section 4135, 2023)

Examples listedC9810 (water circulating motorized cold therapy device), C9811 (electronic ambulatory infusion pump), C9812 (echogenic nerve block needles)

ScopeApplies to non-opioid devices used for post-surgical pain relief enumerated in the 'Not covered - benefit' section

M-code reportable status — Reportable only (not reimbursable)

StatusReportable only — not reimbursable

Example M-codeM1426 — Encounters conducted via telehealth (reportable only)

ApplicabilityM-codes designated 'reportable only' must be submitted for reporting but will not be reimbursed for Commercial and ASO members