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Page 5HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFER93565Insertion of new or replacement ofpermanent pacemaker withtransvenous electrode(s), ventricularInsertion of new or replacement ofpermanent pacemaker withtransvenous electrode(s), atrial andventricularInsertion of pacemaker pulse generatoronly, with existing single leadInsertion of pacemaker pulse generatoronly, with existing dual leadsUpgrade of implanted pacemakersystem, conversion of single chambersystem to dual chamber system(includes removal of previously placedpulse generator, testing of existinglead, insertion of new lead, insertion ofnew pulse generation)Removal of permanent pacemakerpulse generator with replacement ofpacemaker pulse generator, singlelead systemRemoval of permanent pacemakerpulse generator with replacement ofpacemaker pulse generator, dual leadsystemInject L Ventr/Atrial AngioX93566Inject R Ventr/Atrial AngioX93567Inject Suprvlv AortographyX93568Inject Pulm Art Heart CathX92920Prq Cardiac Angioplasty, 1 ArtX92921Prq Cardiac Angio, Add ArtX92924Prq Card Angio/Athrect, 1 ArtX92925Prq Card/Angio/Athrect, AddX92928Prq Card Stent with Angio, 1 VslX92929Prq Card Stent with Angio, AddX92933Prq Card Stent/Ath/AngioX92934Prq Card Stent/Ath/AngioX92937Prq Revasc Byp Graft, 1 VslX92938Prq Revasc Byp Graft, AddX92941Prq Card Revasc Mi, 1 VslX92943Prq Card Revasc Chronic, 1 VslX92944Prq Card Revasc Chronic, AddX92973Percut Coronary ThrombectomyPercutaneous TranscatheterPlacement of drug-elutingintracoronary stent(s), with coronaryangioplasty when performed, singlemajor coronary artery or AUTHREQHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY PROCEDUREPercutaneous TranscatheterPlacement of drug-elutingintracoronary stent(s), with coronaryangioplasty when performed, eachadditional branch of a major coronaryartery (list separately, in addition tocode for primary procedure)Percutaneous Transluminal CoronaryAtherectomy, with drug-elutingintracoronary stent, with coronaryangioplasty when performed, singlemajor coronary artery or branchPercutaneous Transluminal CoronaryAtherectomy, with drug-elutingintracoronary stent, with coronaryangioplasty when performed, eachadditional branch of a major coronaryartery (list separately in addition tocode for primary procedure)Percutaneous TransluminalRevascularization of or throughcoronary artery bypass graft (internalmammary, free arterial, venous), anycombination of drug-elutingintracoronary stent, atherectomy andangioplasty, including distal protectionwhen performed, single vesselPercutaneous TransluminalRevascularization of or throughcoronary artery bypass graft (internalmammary, free arterial, venous), anycombination of drug-elutingintracoronary stent, atherectomy andangioplasty, including distal protectionwhen performed, each additionalbranch subtended by the bypass graft(list separately in addition to code forprimary procedure)Percutaneous TransluminalRevascularization of acutetotal/subtotal occlusion during acutemyocardial infarction, coronary arteryor coronary artery bypass graft, anycombination of drug-elutingintracoronary stent, atherectomy andangioplasty, including aspirationthrombectomy when performed, singlevesselPercutaneous TransluminalRevascularization of chronic totalocclusion, coronary artery, coronaryartery branch, or coronary arterybypass graft, any combination of drugeluting intracoronary stent,atherectomy and angioplasty; singlevesselNO AUTHNOREFERNIAAUTHREQXXXXXXX7/22/14

Page 6HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFERNIAAUTHREQHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODE76950Percutaneous TransluminalRevascularization of chronic totalocclusion, coronary artery, coronaryartery branch, or coronary arterybypass graft, any combination of drugeluting intracoronary stent,atherectomy and angioplasty; eachadditional coronary artery, coronaryartery branch, or bypass graft (listseparately in addition to code forprimary procedure)Drug-eluting Stents, singleApplicator Insertion Breast (breastsurgeon)Applicator Insertion Breast (breastsurgeon)Applicator Insertion Breast (breastsurgeon)Ultrasonic Guidance77014Computed Tomography Guidance7726177263Clinical Treatment Planning - simpleClinical Treatment Planning intermediateClinical Treatment Planning - complex77280Simulation – simpleX77285Simulation - intermediateX77290Simulation - complexX772953D - Isodose PlanDosimetry - Basic RadiationCalculationLMRT - Isodose PlanXTeletherapy Isodose Plan - simpleTeletherapy Isodose Plan intermediateTeletherapy Isodose Plan - complexXX77331Isodose Plan - specialBrachytherapy Isodose Calculation simpleBrachytherapy Isodose Calculation intermediateBrachytherapy Isodose Calculation complexDosimetry - special77332Treatment Devices - simpleX77333Treatment Devices - intermediateX7743577334Treatment Devices - complexX7746977336Weekly Physics ConsultationX77338X77371MLC Devices for LMRTSpecial Medical Radiation PhysicsConsultationRadiation Treatment Delivery SRS77372Radiation Treatment Delivery 31077315773217732677327773287737077418Intensity Modulated Treatment 20Stereoscopic X-ray GuidanceHigh Energy Neutron RadiationTreatment DeliveryHigh Energy Neutron RadiationTreatment DeliveryIntra-Operative Radiation TreatmentDelivery, X-ray or electron singletreatment sessionIntra-Operative Radiation TreatmentDelivery, X-ray or electron singletreatment sessionRadiation Therapy Management, 5treatmentsRadiation Therapy Management, 1 or 2sessions for complete treatmentStereotactic Radiation TreatmentManagementStereotactic Body Radiation TherapyManagementIntra-Operative Radiation TreatmentManagementSpecial Treatment ProcedureManagementRadiation Therapy Management,unlistedProton Treatment DeliveryX77522Proton Treatment DeliveryXXXXXXXNIAAUTHREQ7741777399XNO AUTHNOREFERStereotactic Body Radiation TherapyDeliveryUnlisted Procedure for PhysicsDosimetry and DevicesExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryExternal Beam Radiation TreatmentDeliveryPort 7743277470XXXXXXXXXXXXXXXXXXXXXXXXXXXX7/22/14

Page 7HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIANIAAUTHREQCODEProton Treatment DeliveryX7048877525Proton Treatment DeliveryX77600Hyperthermia, externally generatedX77605X70491X70492X7049670498CT Angiography, NeckX77761Hyperthermia, externally generatedHyperthermia, generated by interstitialprobeHyperthermia, generated by interstitialprobeHyperthermia, generated byintracavitary probeIntracavitary Radiation - simpleCT Face, jaw or mandible,maxillofacial, without/with contrastCT Neck soft tissues, larynx, thyroid,etc., no contrastCT Neck soft tissues, larynx, thyroid,etc., with contrastCT Neck soft tissues, larynx, thyroid,etc., without/with contrastCT Angiography, head70540MRI Face, neck, orbitX77762Intracavitary Radiation - intermediateX70542MRI Orbit, face, neck with dyeX77763Intracavitary Radiation - complexX70543MRI Orbit, face, neck without/with dyeX77776Interstitial Radiation - simpleX70544MR Angiography, head without dyeX77777Interstitial Radiation - intermediateX70545X77778XXX70450Interstitial Radiation- complexHigh Dose Rate BrachytherapyDeliveryHigh Dose Rate BrachytherapyDeliveryHigh Dose Rate BrachytherapyDeliveryBrachytherapy Surface ApplicationDeliverySupervision Handling Loading RadSourceUnlisted Procedure ClinicalBrachytherapyCompensator-based ModulationTreatment DeliveryHigh Dose Rate ElectronicBrachytherapyIntrafraction TrackingLinear Accelerator StereotacticRadiosurgeryLINAC Stereotactic RadiosurgeryDeliveryStereotactic Body Radiation TherapyDeliveryStereotactic Body Radiation TherapyDeliveryCT Brain, HeadMR Angiography, head with dyeMR Angiography, head without/withdyeMR Angiography, neck without dye70460CT Head or Brain with ContrastX70470CT Head or Brain without/with ContrastCT Orbit, eye socket, sella turcica,posterior fossa, ear, etc.CT Orbit, eye socket, sella turcica,posterior fossa, ear with contrastCT Orbit, eye socket, sella turcica,posterior fossa, ear, with/withoutcontrastCT Sinus, face, jaw, mandible,maxillofacial, no contrastCT Face, jaw or mandible,maxillofacial, with 173G0251G0339G03407048070481704827048670487NO AUTHNOREFERHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIAXXX704907054670547NO AUTHNOREFERXXXXXXX70554X70555FMRI Brain by phys/psych93462L Heart Cath trnsptl punctureXXXXX70549705517055270553XXXXX93463Drug Admin and Hemodynmic MeasXX9346478012X78013X78014X78015Exercise with Hemodynamic MeasThyroid Uptake, single or multiplequantitative measurement(s)Thyroid Imaging, including vascularflow, when performedThyroid Imaging, with single or multiuptake measurementThyroid Carcinoma/Neoplasm Imaging,neck and chestThyroid Neoplasm Imaging, withadditional studiesThyroid Neoplasm Imaging, multipleareasThyroid Neoplasm Imaging, wholebodyThyroid Carcinoma Metastases Uptake(list separately in addition to code forinitial procedure)Parathyroid ScanParathyroid Planar Imaging, withtomographic (SPECT)XXXXXX78016780207807078071NIAAUTHREQXMR Angiography, neck with dyeMR Angiography, neck without/withdyeMRI Brain, head, brainstem withoutcontrastMRI Head, brain, brainstem withcontrastMRI Head, brain, brainstemwithout/with contrastFMRI Brain by techX70548PROCEDUREXXXXXXXXXXX7/22/14

Page 8HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFERNIAAUTHREQHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODE78075Parathyroid Planar Imaging, withtomographic (SPECT) andconcurrently acquired CTAdrenal Scan or Isotope Imaging78099Endocrine Nuclear ProcedureX78102Bone Marrow, limited areaX78103Bone Marrow, multiple areasX78104Bone Marrow, whole bodyX7827078110Plasma VolumeX7827178111Nuclear Exam, Plasma VolumeRBC or Red Blood Cell Mass orVolume or Survival StudyRed Cell Volume Determination,multiple samplingsWhole Blood Volume or Plasma, RBCor red blood cell volumeRed Cell Survival ExamDifferential Organ/Tissue Kinetics (EG,splenic and/or hepatic sequestration)RBC or Red Blood Cell SequestrationStudyPlasma Radioiron Disappearance(Turnover) RateSpleen Imaging Only, with or withoutvascular flowKinetics, study of platelet survival, withor without differential organ/tissuePlatelet Survival StudyWhite Blood Cell or WBC localization,limited areaWhite Blood Cell or WBC localization,whole bodyLymphatics and lymph glands or lymphor lymphatic systemBlood/Lymph Nuclear ExamXHepatic or Liver Scan, static onlyHepatic or Liver Scan, with vascularflowHepatic or Liver Scan, SPECTLiver Imaging (SPECT), with vascularflowHepatic or Liver and Spleen Imaging orScan, static onlyHepatic or Liver and Spleen Imaging orScan, with vascular flowLiver Function with hepatobiliaryagentsHepatobiliary, TC HIDA scan - biliarytract, gall bladderHepatobiliary System ImagingHepatobiliary System Imaging withdrugSalivary Gland ImagingSalivary Gland Imaging, with 78232X78258X782617826278264PROCEDURENO AUTHNOREFERSalivary Gland Function StudyEsophageal Motility or EsophagealScanStomach or Gastric Mucosa or LiningStudyGastro-esophageal Reflux StudyXXXXXX78272X78276Stomach or Gastric Emptying StudyVitamin B-12 Absorption Study orSchilling Test, no intrinsic factorVitamin B-12 Absorption Study orSchilling Test, with intrinsic factorVitamin B-12 Absorption Study orSchilling Test, combined without andwithNuclear Exam, GI Blood Loss78278Nuclear Scan, GI Blood LossX78280GI Blood Loss ExamXXXXXXX78282GI Protein Loss ExamXX78290Nuclear Scan of BowelXX78291Test Venous Drain, abdomenX78299GI Nuclear ProcedureXXNIAAUTHREQ78300Bone Scan and/or Joint Limited AreaXX78305Bone Scan and/or Joint Multiple AreasXX78306Bone or Skeleton Scan, whole bodyX78315X78459Nuclear Scan of BoneBone and/or Joint Multiple Areas,tomographic or SPECTBone Mineral, single photonBone Density Dual Photon,osteoporosis studyMusculoskeletal Nuclear ExamVascular Flow Imaging or IsotopeAngiography or Isotope VenographyAcute Venous Thrombus ImageVenous Thrombosis or Blood ClotImaging, unilateralVenous Thrombosis or Blood ClotImaging, bilateralMyocardial Imaging, PET78491Heart Image (PET), singleX78492Heart Image (PET), multipleX78579Lung Ventilation ImagingX78580LungLung Ventilation and PerfusionImagingLung PerfusionLung Perfusion Imaging, rebreathingand washout, with/without XXXXXX7/22/14

Page 9HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIANO AUTHNOREFERCODEPROCEDURE78587X78599LungPulmonary Perfusion Imaging,particulate, with ventilation imaging,aerosolLungLung Ventilation Imaging, gaseous,with rebreathing and washout, singleproLung Ventilation Imaging, gaseous,with rebreathing and washout, multipleproLung Scan Differential Function(Ventilation/Perfusion) StudyLung Perfusion DifferentialLung Perfusion and VentilationDifferentialUnlisted Respiratory ProcedureX78600Nervous System, BrainX78601Nervous System, BrainX78605Nervous System, BrainBrain Scan or Imaging, with vascularflowBrain Scan or Imaging SPECT ortomographicBrain PET [Positron EmissionTomography]Brain PET [Positron EmissionTomography] 860678607786087860978610NIAAUTHREQHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFER78740Ureteral Reflux StudyX78761Scan of Testes/Blood FlowX78799Genitourinary Nuclear ExamX78800Nuclear Tumor Localization, limitedX78801Nuclear Tumor Localization, multipleNuclear Tumor Localization, wholebodyTomographic (SPECT)XX78807Tumor Imaging, whole bodyAbscess Localization or Gallium Scan,limited areaAbscess Localization or Gallium Scan ,whole bodyTomographic (SPECT)78811Tumor Imaging (PET), limitedX78812Tumor Image (PET), skull-thighX78813Tumor Image (PET), full bodyXX78814Tumor Image PET/CT, limitedXX78815Tumor Image PET/CT, skull-thighX78816Tumor Image PET/CT, full bodyX78999Nuclear, Unlisted ExamX79000Initial Hyperthyroid TherapyX79005Nuclear Rx, Oral AdminXX79101Nuclear Rx, IV AdminXIntracavitary Nuclear 78630Cerebrospinal FluidX7920078635Cerebrospinal FluidX79440Nuclear Joint TherapyX78645Cerebrospinal FluidX79445Nuclear Rx, Intra-ArterialX7864779999X0042TX0042T78660Tear Flow, 1 Not 8X0159TNuclear Medicine TherapyCT with Contrast, Cerebral PerfusionAnalysisCT with Contrast, Cerebral PerfusionAnalysisCAD Breast MRIX78655Cerebrospinal FluidCerebrospinal Fluid Leakage DetectionAnd LocalizationNuclear Exam of eye lesion78699Nervous System Nuclear ExamX3111FCT/MRI Brain done within 24 hrsX78700X3112FCT/MRI Brain done greater than 24 hrsXX3269FBone Scan B/4 Treatment/After DXX76375CT Multiplanar ReconstructionsX78708Renal or Kidney Imaging, staticRenal or Kidney Imaging, with vascularflowRenal or Kidney Imaging, with vascularflow and function studyKidney Flow and Function ImageA9503Tc99m MedronateX78709Kidney Flow and Function ImageXA9510X78710Renal or Kidney Imaging, SPECT78725Kidney, no pharmaceuticalsX78726Kidney, with pharmaceuticalsXA9521Technetium Tc99m DisofeninIodine I-123 Sodium Iodide, diagnostic,per 100 microcuries, up to 999microcuriesTechnetiumtc-99m Exametazine78727Renal or Kidney Transplant EvaluationXA9537Tc99m MebrofeninX78730Urinary Bladder Residual StudyXA9540Tc99m MAAX786507870178707NIAAUTHREQXXXXA9516XXXXX7/22/14

Page 10HORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFERNIAAUTHREQHORIZON NJ HEALTHPRE-AUTHORIZATION CODES MANAGED BY NIACODEPROCEDURENO AUTHNOREFERNIAAUTHREQA9548Indium In-111 Oxyquinoline,diagnostic, per 0.5 millicurieIn111 PentetateA9551Tc99m SuccimerXG0219A9552F18 FDGXG0235Fluorine-18 FluorodeoxyglucosePET Imaging Whole Body, melanomafor non-covered indicationsPET, not otherwise specifiedA9555XG0252PET Imaging, initial DXXXS8037MRCPXA9561RB82 RubidiumXenon Xe-133 Gas, diagnostic, per 10millicuriesTc99m OxidronateS8042MRI Low FieldXA9562Tc99m MertiatideXS8092Electron Beam Computed TomographyXA9567Technetium TC-99m AerosolXA9584Iodine I-123 IoflupaneXC8900MRA with contrast, abdomenXC8901MRA without contrast, abdomenXC8902MRA without/with contrast, abdomenXC8903MRI with contrast, breast, unilateralXC8904MRI without contrast, breast, unilateralMRI without/with contrast, breast,unilateralMRI with contrast, breast, bilateralXMRI without contrast, breast, bilateralMRI without/with contrast, breast,bilateralMRA with contrast, chestXMRA without contrast, chestMRA without/with contrast, chest exclmyocardiumMRA with contrast, lower extremityXXC8918MRA without contrast, lower extremityMRA without/with contrast, lowerextremityMRA with contrast, pelvisC8919MRA with contrast, pelvisXC8920MRA without/with contrast, pelvisMRA with contrast, spinal canal andcontentsMRA without contrast, spinal canal andcontentsMRA, without contrast followed by withcontrast, spinal canal and contentsMRA, with contrast, upper extremityXMRA, without contrast, upper extremityMRA, without contrast followed by withcontrast, upper extremityPeripheral Bone 936G0062G0063G0288S8035Central Bone DensitometryReconstruction, CTA of aorta forsurgical planning for vascular surgeryMagnetic

Page 3 7/22/14 HORIZON NJ HEALTH PRE-AUTHORIZATION CODES MANAGED BY NIA CODE PROCEDURE NO AUTH NO REFER NIA AUTH REQ 77073 X-Rays, Bone Length Studies X Duplex Scan of arterial inflow and 77074 X-Rays, Bone Survey, limited X 77075 X-Rays, Bone Survey, complete X 77076 X-Rays, Bone Survey, infant X 77077 Joint Survey, single view X 76506 Echo Exam of Head X