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UnitedHealthcare OxfordPolicy Appendix: Applicable Code ListMaximum Frequency Per Day Code ListThis list of codes applies to the Reimbursement Policy titledMaximum Frequency Per Day.Effective Date: August 1, 2021Applicable CodesThe following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefitcoverage for health services is determined by the member specific benefit plan document and applicable laws that may requirecoverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment.Other Policies may apply.These lists designate the maximum frequency per day value assignments for CDT, CPT, and HCPCS codes.CDT CodeD0120MFD Value1CDT CodeD2941MFD Value20CDT CodeD5954MFD Value1CDT CodeD7411MFD 4032D75501Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 1 of 94Effective 08/01/2021

CDT CodeD0322MFD Value8CDT CodeD3222MFD Value32CDT CodeD6050MFD Value16CDT CodeD7560MFD 9102Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 2 of 94Effective 08/01/2021

CDT CodeD0476MFD Value1CDT CodeD4211MFD Value4CDT CodeD6097MFD Value32CDT CodeD7911MFD 21D625332D80201Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 3 of 94Effective 08/01/2021

CDT CodeD1515MFD Value2CDT CodeD5213MFD Value1CDT CodeD6545MFD Value2CDT CodeD8030MFD 6121D263032D57611D6930100D96131Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 4 of 94Effective 08/01/2021

CDT CodeD2642MFD Value32CDT CodeD5810MFD Value1CDT CodeD6940MFD Value2CDT CodeD9630MFD 2D59531D74104CDT is a registered trademark of the American Dental AssociationMaximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 5 of 94Effective 08/01/2021

CPT Code0001AMFD Value1CPT Code28118MFD Value1CPT Code51703MFD Value2CPT Code81307MFD 2828845221418134710024U1282891522241813481Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 6 of 94Effective 08/01/2021

CPT Code0025UMFD Value1CPT Code28291MFD Value1CPT Code52234MFD Value1CPT Code81350MFD 47025235618141620062U1284755524001814171Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 7 of 94Effective 08/01/2021

CPT Code0063UMFD Value1CPT Code28476MFD Value4CPT Code52402MFD Value1CPT Code81419MFD 76015344018151310099U1288001534421815141Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 8 of 94Effective 08/01/2021

CPT Code0100TMFD Value1CPT Code28805MFD Value1CPT Code53444MFD Value1CPT Code81518MFD 945015411118210410132U1295051541121821051Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 9 of 94Effective 08/01/2021

CPT Code0133UMFD Value1CPT Code29515MFD Value1CPT Code54115MFD Value1CPT Code82106MFD 84515440118234010171U1298461544051823552Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 10 of 94Effective 08/01/2021

CPT Code0172UMFD Value1CPT Code29847MFD Value1CPT Code54406MFD Value1CPT Code82360MFD 990125490018257510202U1299022549011825851Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 11 of 94Effective 08/01/2021

CPT Code0203UMFD Value1CPT Code29904MFD Value1CPT Code55000MFD Value1CPT Code82595MFD 054515586218277610228T1305601558651827771Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 12 of 94Effective 08/01/2021

CPT Code0228UMFD Value1CPT Code30580MFD Value2CPT Code55866MFD Value1CPT Code82784MFD 3123815702318302120267T1312391570611830261Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 13 of 94Effective 08/01/2021

CPT Code0268TMFD Value1CPT Code31240MFD Value1CPT Code57065MFD Value1CPT Code83030MFD 51215729618363310358T1315131573001836552Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 14 of 94Effective 08/01/2021

CPT Code0362TMFD Value16CPT Code31515MFD Value1CPT Code57305MFD Value1CPT Code83661MFD 3160315780018394520425T1316051581001839501Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 15 of 94Effective 08/01/2021

CPT Code0426TMFD Value1CPT Code31610MFD Value1CPT Code58110MFD Value1CPT Code83951MFD 73015854218415720468T1317501585431841602Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 16 of 94Effective 08/01/2021

CPT Code0469TMFD Value1CPT Code31755MFD Value1CPT Code58544MFD Value1CPT Code84163MFD 44515875218443010511T1324801587601844311Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 17 of 94Effective 08/01/2021

CPT Code0512TMFD Value1CPT Code32482MFD Value1CPT Code58770MFD Value1CPT Code84432MFD 66315913018462010553T2326641591351846302Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 18 of 94Effective 08/01/2021

CPT Code0554TMFD Value1CPT Code32665MFD Value1CPT Code59136MFD Value1CPT Code84681MFD 12015986618528020596T1331301598701852902Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 19 of 94Effective 08/01/2021

CPT Code0597TMFD Value1CPT Code33140MFD Value1CPT Code59871MFD Value1CPT Code85291MFD 25116107028553610638T1332541611051855401Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 20 of 94Effective 08/01/2021

CPT Code0639TMFD Value1CPT Code33255MFD Value1CPT Code61107MFD Value1CPT Code85547MFD 61483Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 21 of 94Effective 08/01/2021

CPT Code10030MFD Value2CPT Code33405MFD Value1CPT Code61522MFD Value1CPT Code86152MFD um Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 22 of 94Effective 08/01/2021

CPT Code11303MFD Value3CPT Code33511MFD Value1CPT Code61592MFD Value1CPT Code86343MFD 336761617081866182116222336771617101866192Maximum Frequency Per Day Code ListUnitedHealthcare Oxford Policy Appendix: Applicable Code List 1996-2021, Oxford Health Plans, LLCPage 23 of 94Effective 08/01/2021

CPT Code11623MFD Value2CPT Code33681MFD Value1CPT Code61711MFD Value1CPT Code86622MFD 371618501

coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. These lists designate the maximum frequency per day value assignments for CDT, CPT, and HCPCS codes. CDT Code MFD Value CDT Code MFD Value CDT Code MFD Value CDT Code MFD Value D0120 . 1