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 |
|---|---|---|
| 33548 | Surgical ventricular restoration procedure, includes prosthetic patch, when performed (e.g., ventricular remodeling, SVR, SAVER, Dor procedures) | Operative report |
| 33800 | Aortic suspension (aortopexy) for tracheal decompression (e.g., for tracheomalacia) (separate procedure) | Copy of the patient’s history and physical (H&P), demonstrating the medical necessity for the service |
| 38230 | Bone marrow harvesting for transplantation | Clinical notes. |
| 43647 | Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum | Operative report |
| 43648 | revision or removal of gastric neurostimulator electrodes, antrum | Operative report |
| 43881 | Implantation or replacement of gastric neurostimulator electrodes, antrum, open | Operative report |
| 43882 | Revision or removal of gastric neurostimulator electrodes, antrum, open | Operative report |
| 61630 | Balloon angioplasty, intracranial (e.g., atherosclerotic stenosis), percutaneous | Operative report |
| 61635 | Transcatheter placement of intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed | Operative report |
| 61770 | Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source | Operative report |
| 63185 | Laminectomy with rhizotomy; one or two segments | Operative report |
| 63190 | more than two segments | Operative report |
| 95920 | Intraoperative neurophysiology testing, per hour | Operative report |
| Category III Codes | Description | Documentation Required |
|---|---|---|
| 0050T | Removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation | Clinical notes |
| 0051T | Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy | Clinical notes |
| 0052T | Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) | Operative report |
| 0053T | Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit | Operative report |
| 0075T | Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel | Clinical notes |
| 0076T | each additional vessel | Clinical notes |
| 0077T | Implanting and securing cerebral thermal perfusion probe, including twist drill or burr hole, to measure absolute cerebral tissue perfusion | Clinical notes, operative report |
| 0166T | Transmyocardial transcatheter closure of ventricular septal defect, with implant; without cardiopulmonary bypass | Clinical notes |
| 0167T | with cardiopulmonary bypass | Clinical notes |
| HCPCS Code | Description | Documentation Required |
|---|---|---|
| G0289 | Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee | Clinical notes |
| G0341 | Percutaneous islet cell transplant, includes portal vein catheterization and infusion | This must be precertified. If precertification is not requested and approved, a copy of the patient’s H&P must be submitted for review. |
| G0342 | Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion | This must be precertified. If precertification is not requested and approved, a copy of the patient’s H&P must be submitted for review. |
| G0343 | Laparotomy for islet cell transplant, includes portal vein catheterization and infusion | Please submit a copy of the patient’s H&P for review. |
| J7341 | Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter | Clinical notes |
| J7346 | Dermal (substitute) tissue of human origin, injectable, with or without other bioengineered or processed elements, but without metabolically active elements, 1 cc | Clinical notes |
| J7347 | Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (Integra Matrix), per square centimeter | Clinical notes |
| J7348 | Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (TissueMend), per square centimeter | Clinical notes |
| J7349 | Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (PriMatrix), per square centimeter. | Clinical notes |
| S2202 | Echosclerotherapy | Operative report |
| S2230 | Implantation of magnetic component of semi-implantable hearing device on ossicles in middle ear | Clinical notes |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |