ModifiedUnitedHealthcarePolicy CS079OH.D

Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only)

Coverage and medical necessity guidance for minimally invasive procedures to treat upper gastrointestinal diseases (GERD, achalasia, gastroparesis) for UnitedHealthcare members in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only)

Policy CodePolicy CS079OH.D

Change TypeMaterial coverage additions and coding updates (GES & pyloroplasty addedCPT codes added)

Effective DateApr 1, 2026

Next Review Date

Key ActionWhen requesting authorization, document prior failed therapies and objective testing and refer to InterQual CP: Procedures Gastric Stimulation for GES and related prior authorization criteria.

SourceLink

POLICY UPDATE CHANGES

Removed notation limiting the policy to individuals 18 years and older; pediatric cases will be evaluated using Ohio Administrative Code 5160-1-01.

Gastric electrical stimulation (GES) therapy is added as proven and medically necessary for refractory gastroparesis and chronic intractable nausea/vomiting of diabetic or idiopathic etiology; refer to InterQual CP: Procedures Gastric Stimulation and FDA/HDE labeling for specifics.

Surgical pyloroplasty (open or laparoscopic) is added as proven and medically necessary for refractory gastroparesis after failure of other therapies.

Replaced prior InterQual instruction for surgical procedures with referencing InterQual CP: Procedures Gastric Stimulation for minimally invasive GERD procedures and for GES clinical criteria.

Removed language indicating functional lumen imaging probe technology is unproven and not medically necessary for diagnosing achalasia.

Added CPT codes 43647, 43648, 43659, 43881, 43882, 64590, and 64595 to the policy's Applicable Codes and supporting information.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Ohio-onlyjurisdiction

GES & pyloroplastyproven treatments added

83% vs 81.7%POEM 2yr success

Coverage and Medical Necessity Criteria

Covered when ALL general selection criteria are met and device-specific evidence supports use

Covered when ALL general selection criteria are met and device-specific evidence supports use:

ALL of the following

Gastric electrical stimulation (GES) therapy (Enterra™) is considered proven and medically necessary for the treatment of refractory gastroparesis or chronic intractable (drug-refractory) nausea and vomiting secondary to diabetic or idiopathic gastroparesis when InterQual® CP: Procedures Gastric Stimulation medical necessity criteria are met.
Refer to InterQual® for specific clinical entry criteria and required documentation.
Surgical pyloroplasty (open or laparoscopic) is considered proven and medically necessary for refractory gastroparesis or chronic intractable (drug-refractory) nausea and vomiting secondary to diabetic or idiopathic gastroparesis when prior conservative therapies have failed and clinical criteria in InterQual® are met.
Includes pyloroplasty performed alone or in combination with other procedures when clinically indicated and documented.
For members under 18 years of age, GES and surgical pyloroplasty may be evaluated for medical necessity on a case-by-case basis in accordance with applicable state rules (e.g., Ohio Administrative Code 5160-1-01) and InterQual® criteria; the prior policy age restriction has been removed.
Pediatric evaluation should follow applicable OAC or contractual requirements and include specialist consultation documentation.
Medical records documentation (legible and available on request) must support the medical necessity for the requested service, including relevant medical history, prior therapies tried and failed, objective testing, and specialty consultation notes.
Incomplete or illegible documentation may be a basis for denial.
FDA labeling/HDE considerations: Coverage determinations are clinical and may reference FDA indications; FDA approval or HDE status alone does not guarantee coverage. The Enterra™ device has an FDA Humanitarian Device Exemption (HDE) indication for chronic intractable nausea and vomiting secondary to diabetic or idiopathic gastroparesis (see FDA section).
Providers should document how the patient meets device-specific labeling or HDE criteria when applicable.

Applicable and Added Procedure Codes

Applicable CPT codes (reference list)CPT

43210	Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.
43257	Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease.
43284	Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed.
43289	Unlisted laparoscopy procedure, esophagus.
43497	Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM]).
43499	Unlisted procedure, esophagus.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43659	Unlisted laparoscopy procedure, stomach.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.

1–10 of 14

1/2

Regulatory device identifiers referencedmixed

P100049	FDA PMA number for LINX Reflux Management System
K071651	Bard EndoCinch Endoscopic Suturing System PMN/approval reference
K071553	NDO Surgical Endoscopic Plication System PMN/approval reference
K143634	MUSE System 510(k) approval reference
K103017	Stretta System approval reference
K233240	GERDx-System 510(k) number (GERDx-System under 510(k) Number K233240)

Applicable CPT Codes (added)CPT

43647	CPT code added (description in Applicable Codes section)
43648	CPT code added (description in Applicable Codes section)
43659	CPT code added (description in Applicable Codes section)
43881	CPT code added (description in Applicable Codes section)
43882	CPT code added (description in Applicable Codes section)
64590	CPT code added (description in Applicable Codes section)
64595	CPT code added (description in Applicable Codes section)

Added CPT codesCPT

43647	CPT code added (description as listed in Applicable Codes section)
43648	CPT code added (description as listed in Applicable Codes section)
43659	CPT code added (description as listed in Applicable Codes section)
43881	CPT code added (description as listed in Applicable Codes section)
43882	CPT code added (description as listed in Applicable Codes section)
64590	CPT code added (description as listed in Applicable Codes section)
64595	CPT code added (description as listed in Applicable Codes section)

Applicable/Added CPT CodesCPT

43647	CPT code added per policy history
43648	CPT code added per policy history
43659	CPT code added per policy history
43881	CPT code added per policy history
43882	CPT code added per policy history
64590	CPT code added per policy history
64595	CPT code added per policy history

Added CPT CodesCPT

43647	CPT code 43647 (added)
43648	CPT code 43648 (added)
43659	CPT code 43659 (added)
43881	CPT code 43881 (added)
43882	CPT code 43882 (added)
64590	CPT code 64590 (added)
64595	CPT code 64595 (added)

Added CPT Codes (supporting information)CPT

43647	CPT code added (description in policy supporting information)
43648	CPT code added (description in policy supporting information)
43659	CPT code added (description in policy supporting information)
43881	CPT code added (description in policy supporting information)
43882	CPT code added (description in policy supporting information)
64590	CPT code added (description in policy supporting information)
64595	CPT code added (description in policy supporting information)

Added CPT CodesCPT

43647	CPT code added (description not provided in excerpt)
43648	CPT code added (description not provided in excerpt)
43659	CPT code added (description not provided in excerpt)
43881	CPT code added (description not provided in excerpt)
43882	CPT code added (description not provided in excerpt)
64590	CPT code added (description not provided in excerpt)
64595	CPT code added (description not provided in excerpt)

Added CPT Codes (Policy History)CPT

43647	CPT code added (as listed in Policy History)
43648	CPT code added (as listed in Policy History)
43659	CPT code added (as listed in Policy History)
43881	CPT code added (as listed in Policy History)
43882	CPT code added (as listed in Policy History)
64590	CPT code added (as listed in Policy History)
64595	CPT code added (as listed in Policy History)

inv-42: BMI cutoff in Bell RCT inclusion

BMI cutoff (Bell RCT inclusion)< 35 kg/m2

ContextListed as an inclusion criterion in the Bell randomized trial comparing MSA vs PPI

Implication for selectionPatients with BMI >= 35 kg/m2 would not have met the trial eligibility criteria

inv-43: Hiatal hernia size in Bell RCT inclusion

Hiatal hernia size (Bell RCT inclusion)< 3 cm

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization — codes and workflows

Prior authorization may be required for several procedures discussed in this policy. Providers should verify prior authorization (PA) requirements with UnitedHealthcare before scheduling procedures. Inclusion of CPT codes added in the policy (see Policy History) implies these codes must be incorporated into PA workflows where applicable.

Added CPT codes (policy changes): 43647, 43648, 43659, 43881, 43882, 64590, 64595 — these code additions should be included in prior authorization systems and claim workflows.
Some newly added CPT codes were included for reference; presence in the policy does not by itself establish a coverage rule — check payer PA policies for specifics.

Prior Authorization

Prior Authorization Guidance for POEM

Per oral endoscopic myotomy (POEM) may require prior authorization. When requesting PA for POEM, document that the patient meets selection criteria (e.g., achalasia diagnosis, prior treatment history) and include objective testing and symptom assessments used to establish candidacy.

Demonstrate refractory symptoms and failure of other therapies (e.g., pneumatic dilation, botulinum injection, medical therapy) prior to POEM.

Clinical Background and Evidence Context

Background context in the policy explains that Gastroesophageal Reflux Disease (GERD) results from lower esophageal sphincter dysfunction and can lead to esophagitis, strictures, and Barrett’s esophagus, while gastroparesis causes delayed gastric emptying with symptoms such as nausea, vomiting, and early satiety and requires objective testing (gastric emptying studies) for diagnosis. Minimally invasive procedures target LES function or gastric outlet mechanisms to reduce symptoms and dependence on medical therapy; the policy references InterQual as the primary clinical criteria source.

Definitions and Abbreviations

inv-102: Achalasia definition

TermAchalasia

DefinitionA primary esophageal motor disorder characterized by degeneration of the myenteric plexus resulting in impaired relaxation of the esophagogastric junction and loss of organized peristalsis

SourceASGE-based definition in policy Definitions section

inv-103: Diffuse Esophageal Spasm definition

TermDiffuse Esophageal Spasm (DES)

DefinitionRare esophageal motility disorder characterized by simultaneous, uncoordinated, or rapidly propagated contractions of normal amplitude accompanied by dysphagia

Policy Revision Notes

2026-04-01Title change (operational)Latest

Policy title changed from 'Minimally Invasive Procedures for Gastric and Esophageal Diseases (for Ohio Only)' to the current title.

Coverage additions (material)

Gastric electrical stimulation (GES) therapy and surgical pyloroplasty (open or laparoscopic) were added as proven and medically necessary for refractory gastroparesis and chronic intractable nausea/vomiting of diabetic or idiopathic etiology; instruction to refer to FDA labeling/HDE relocated from another policy.

Policy Summary

PayerUnitedHealthcare

PolicyMinimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only)

Policy CodePolicy CS079OH.D

Change TypeMaterial coverage additions and coding updates (GES & pyloroplasty addedCPT codes added)

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

ContextSpecified by endoscopy as an eligibility requirement in the Bell randomized trial of MSA vs PPI

Implication for selectionPatients with hiatal hernia >= 3 cm would not have met trial eligibility

Include objective testing such as high-resolution esophageal manometry, timed barium swallow, and Eckardt score or other validated symptom measures.

If POEM is being considered as alternative to laparoscopic Heller myotomy (LHM), provide documentation of multidisciplinary discussion when available.

Prior Authorization

Prior Authorization — refractory symptoms and objective testing

For gastric peroral endoscopic myotomy (G-POEM) and gastric electrical stimulation (GES), PA requests should demonstrate refractory disease, use of appropriate objective testing, and adherence to selection criteria reported in clinical trials and guidance.

Document symptom severity using validated instruments (e.g., GCSI, PAGI-SYM) and show symptoms persistent > 6 months despite optimized medical therapy.
Provide objective testing results when applicable (e.g., gastric emptying scintigraphy) and link test results to symptom burden and treatment failure.
For GES, reference InterQual CP: Procedures Gastric Stimulation for clinical coverage criteria and include documentation required by InterQual.
If G-POEM or GES is being requested based on RCT eligibility, include the same or analogous selection criteria (age, severity thresholds, prior therapy failure) used in the trials.

Prior Authorization

Prior Authorization Recommended for Device-based GERD Procedures

Device-based GERD procedures (including LINX, MSA, transoral fundoplication/TIF, endoscopic plication/suturing, GERDx, MUSE, EsophyX, Stretta) commonly have PA expectations. Providers should obtain PA and supply objective testing and selection criteria supporting procedure candidacy.

Include objective evidence of GERD (ambulatory pH testing/DeMeester score, endoscopic findings, esophageal manometry) and documentation of PPI use (dose/duration) and response.
Document hiatal hernia size, presence/absence of Barrett’s esophagus, and other anatomic considerations that affect candidacy (trial inclusion criteria often required hiatal hernia <= specified size).
For LINX/MSA, include preoperative diagnostics per trial and institutional protocols (e.g., pH testing, manometry, endoscopy).

Note

InterQual Cross-reference for Prior Authorization

UnitedHealthcare uses InterQual for primary medical/surgical criteria. For gastric electrical stimulation (GES) requests, use InterQual CP: Procedures Gastric Stimulation as the medical necessity criteria reference when submitting PA.

If InterQual lacks applicable criteria for a specific device/procedure, UnitedHealthcare may apply its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines.
PA submissions for GES should explicitly reference InterQual criteria and include the documentation elements InterQual requires.

Documentation Required

Documentation Requirements and Denial Risk

Documentation must fully support medical necessity. Insufficient or incomplete documentation (e.g., missing objective test results, absent symptom-score documentation, or lack of prior therapy records) may lead to PA denial or claim denial. Ensure records are legible and available on request.

Include relevant history, physical examination, and results of pertinent diagnostic tests/procedures.
Document prior conservative management and step-therapy where applicable (duration, agents/trials tried, and objective response).
Maintain legible records and be prepared to provide them at review; documentation insufficiency may result in denial.

Denial Risk

Evidence Limitations and Candidate Evaluation

Clinical evidence for several interventions has limitations (small trials, short follow-up, inconsistent results). When requesting PA for procedures with limited high-quality evidence (for example GES, G-POEM, some endoscopic GERD procedures), include detailed justification linking the patient to trial-like selection criteria and demonstrating prior therapy failure.

Where randomized trial eligibility criteria exist (e.g., G-POEM, POEM, LINX trials), provide documentation showing the patient meets analogous inclusion/exclusion criteria (symptom thresholds, test results, prior treatment failure).
If the evidence base is limited or conflicting, describe rationale for treatment including severity, functional impact, and why alternative treatments are not appropriate.
Be aware that insufficient high-quality evidence may trigger denial if medical necessity per payer criteria cannot be established.

Step Therapy

Step Therapy and Prior Conservative Management

Step therapy expectations apply to certain modalities (notably GES per InterQual guidance). Document prior conservative management and failure of other therapies where required. If no step therapy requirement is described for a specific procedure in the policy, note that PA criteria or contract terms may still impose such requirements.

For GES requests: document failure of other therapies (medical, nutritional, prokinetics) and absence of contraindicating factors (e.g., ongoing opioid use when specified).
If policy or PA guidance does not state explicit step-therapy, verify member-specific benefit plan and state/contract requirements.

Billing Rule

CPT Code Additions — Prior Authorization Implications

Policy history notes multiple CPT code additions. While some chunks add codes without specifying PA policy changes, providers should assume newly listed codes may need to be included in PA and claim-adjudication workflows and verify payer-specific PA rules.

Added CPT codes should be reviewed with payer PA teams to ensure accurate inclusion in PA tools and billing systems.
Presence of codes in the policy does not automatically establish coverage; follow PA criteria and contractual/federal/state requirements.

Note

Denial Triggers and Governing Documents

No explicit, provider-facing denial triggers beyond documentation and criteria non-adherence are listed in this section. However, failure to supply required documentation, match trial/InterQual selection criteria, or demonstrate prior therapy failure may result in denial.

Policy states that benefit coverage is governed by federal, state (OAC), or contractual requirements and may override standard policy language.
If uncertainty exists regarding coverage for a given procedure, contact UnitedHealthcare clinical review prior to service.

National Library of Medicine–style definition in policy Definitions section

inv-104: GERD definition

TermGastroesophageal Reflux Disease (GERD)

DefinitionA condition in which the lower esophageal sphincter relaxes too often or weakens, allowing gastric contents to reflux into the esophagus

SourceACG-style definition in policy Definitions section

inv-105: Gastroparesis definition

TermGastroparesis

DefinitionA digestive disorder characterized by abnormal or absent stomach motility resulting in delayed gastric emptying

SourceCamilleri (2013; updated 2022)–based definition in policy Definitions section

inv-106: Humanitarian Use Device (HUD) definition

TermHumanitarian Use Device (HUD)

DefinitionAn FDA designation referenced by guidelines indicating a device may be considered for limited patient populations (example: GES for medically refractory diabetic or idiopathic gastroparesis)

SourceACG guideline text referenced in policy

inv-107: Clinical success (achalasia trials) definition

TermClinical success (achalasia trials)

DefinitionOften defined as an Eckardt symptom score of 3 or less at follow-up (used as the success endpoint in trials such as Werner et al.)

ContextUsed as the primary outcome measure in POEM versus LHM noninferiority trial

inv-108: POEM definition

TermPOEM (Per‑oral endoscopic myotomy)

DefinitionEndoscopic myotomy performed via a per‑oral submucosal approach to treat esophageal motility disorders including achalasia and spastic esophageal disorders

Evidence noteRandomized and meta-analytic evidence supports POEM effectiveness for achalasia subtypes; trials report clinical success and adverse event rates

inv-109: Z-POEM definition

TermZ-POEM

DefinitionZenker's per‑oral endoscopic myotomy — endoscopic septotomy/myotomy technique for symptomatic Zenker's diverticulum

Evidence noteCurrent evidence is limited, largely retrospective/single‑center, and long‑term comparative effectiveness remains uncertain

inv-110: G-POEM definition

TermG-POEM (Gastric POEM)

DefinitionEndoscopic pyloromyotomy (per‑oral) performed to treat refractory gastroparesis by dividing pyloric muscle fibers endoscopically

Evidence noteObservational series and meta-analyses report ~70% clinical success at 1 year but RCT data are limited and evidence quality is low

inv-111: Stretta definition (RF energy to GE junction)

TermStretta (radiofrequency at GE junction)

DefinitionEndoscopic delivery of radiofrequency energy to the gastroesophageal junction intended to improve GERD symptoms and reduce PPI use

Evidence noteRandomized sham-controlled trial (Zerbib et al.) found no significant benefit over sham at 24 and 48 weeks; overall evidence considered low quality with uncertainty

inv-112: Stretta alternative entry

Alternative entryStretta described alternatively as endoscopic radiofrequency energy delivery to distal esophagus to improve GERD symptoms and reduce PPI use

ContextPolicy includes both descriptive and trial‑level summaries (including Zerbib RCT) noting insufficient consistent benefit

ImplicationConsidered investigational/unproven for routine coverage due to inconsistent evidence

inv-113: EFTP/TIF/MUSE definition

TermEFTP / TIF / MUSE (Endoscopic full‑thickness fundoplication)

DefinitionEndoscopic or transoral procedures that create fundoplication‑like changes at the gastroesophageal junction to reduce reflux and medication dependence

Evidence noteSome randomized and prospective trials show symptom and PPI reductions; overall evidence quality and long‑term durability remain variable

inv-114: EsophyX / TIF definition

TermEsophyX / TIF

DefinitionTransoral Incisionless Fundoplication (TIF) system for transoral tissue approximation and full‑thickness plication to treat chronic GERD in selected patients

FDA noteCleared/modified generations (EsophyX2) and indications include reduction of hiatal hernia < 2 cm in symptomatic chronic GERD

inv-115: LINX / MSA definition

TermLINX / Magnetic Sphincter Augmentation (MSA)

DefinitionAn implanted ring of magnetic beads placed laparoscopically to augment the lower esophageal sphincter and reduce reflux

Evidence/inclusionTrials/meta-analyses show high rates of PPI discontinuation and symptom improvement; pivotal RCTs used selection criteria such as BMI < 35 kg/m2 and hiatal hernia < 3 cm

inv-116: LINX Reflux Management System / MSA (PMA) identifier

TermLINX Reflux Management System / MSA (PMA)

IdentifierPMA number referenced for LINX in policy: P100049

Regulatory noteListed in the FDA section as an implanted device intended to augment LES function

inv-117: Endoluminal antireflux devices definition

TermEndoluminal antireflux devices

DefinitionEndoscopic devices and procedures (e.g., EsophyX, Stretta, MUSE) intended to treat symptomatic chronic GERD via transoral fundoplication, radiofrequency ablation, or stapling/plication

Regulatory noteSeveral devices have FDA clearance or approval histories referenced in the policy supporting information

inv-118: GES definition (added as proven for refractory gastroparesis)

TermGastric Electrical Stimulation (GES)

DefinitionElectrical stimulation therapy of the stomach (Enterra system) indicated per policy as proven and medically necessary for refractory gastroparesis and chronic intractable nausea/vomiting of diabetic or idiopathic etiology

Regulatory contextPolicy references FDA Humanitarian Device Exemption (HDE) and InterQual clinical criteria for GES

inv-119: Pyloroplasty definition (added as proven for refractory gastroparesis)

TermPyloroplasty

DefinitionSurgical pyloroplasty (open or laparoscopic) — surgical widening of the pylorus considered proven and medically necessary for refractory gastroparesis after failure of other therapies

Policy noteAdded to policy as a covered proven treatment for refractory gastroparesis

inv-120: Gastroparesis updated definition (chunk range)

ItemGastroparesis definition updated in policy

ContextRevision history documents an updated definition of 'Gastroparesis' repeated across multiple policy history entries

ImplicationUpdated definition text relocated/clarified within the Definitions and Applicable Codes sections (exact revised wording appears in main policy text)

inv-121: Gastroparesis updated definition (repeated entry)

ItemGastroparesis definition revision noted repeatedly

ContextPolicy history entries across multiple chunks indicate the definition of gastroparesis was updated and emphasized in revisions

ActionRefer to the Definitions section of the policy for the current revised wording

inv-122: Gastroparesis definition revision noted

ItemGastroparesis definition revision recorded

ContextPolicy history explicitly lists 'Updated definition of Gastroparesis' in multiple revision lines

NoteExact new definition text is present in the Definitions section of the policy document

inv-123: (empty definition inventory slot)

SlotEmpty definition inventory slot — no content

NoteNo definition provided in the source for this inventory entry

ActionNo applicable source citation available

inv-124: InterQual defined as primary clinical criteria source

TermInterQual

DefinitionPrimary medical/surgical criteria source used by UnitedHealthcare to determine clinical coverage and medical necessity

Policy useProviders/reviewers are instructed to refer to InterQual CP: Procedures Gastric Stimulation for specific clinical criteria

inv-125: Ohio Administrative Code (OAC) reference

ReferenceOhio Administrative Code (OAC)

RoleState regulatory reference to be used when federal, state (OAC), or contractual benefit plan requirements differ from this policy; pediatric cases under 18 are evaluated using OAC 5160-1-01

Policy implicationIn event of conflict, federal/state/OAC or contractual requirements govern coverage determinations

Age-related policy change (material)

Removed notation limiting the policy to individuals 18 years and older; medical necessity for individuals under 18 will be evaluated per Ohio Administrative Code 5160-1-01.

InterQual reference updated (material)

Added and revised references to InterQual CP: Procedures Gastric Stimulation to support medical necessity criteria for GES and to reference minimally invasive GERD procedures rather than surgical procedures for GERD and achalasia.

Definition update (material)

Updated the definition of 'Gastroparesis' in the Definitions and Applicable Codes sections.

Documentation guidance clarified (operational)

Added/clarified that medical records documentation must fully support medical necessity, be legible, maintained in the patient record, and made available upon request.

Coding updates (material)

Added CPT codes 43647, 43648, 43659, 43881, 43882, 64590, and 64595 to the Applicable Codes and Supporting Information sections.