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wdt_ID wdt_created_by wdt_created_at wdt_last_edited_by wdt_last_edited_at Effective Termed Code type Code Brand name Code description Vendor Authorization is Required When:
1 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0100 CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE SHP Prior Authorization Required
2 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0105 CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL M SHP Prior Authorization Required
3 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OF VARIOUS MA SHP Prior Authorization Required
4 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0111 CRUTCH FOREARM, INCLUDES CRUTCHES OF VARIOUS MATER SHP Prior Authorization Required
5 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0112 CRUTCHES UNDERARM, WOOD, ADJUSTABLE OR FIXED, PAIR SHP Prior Authorization Required
6 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0113 CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED, EACH, SHP Prior Authorization Required
7 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0114 CRUTCHES UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR SHP Prior Authorization Required
8 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0116 CRUTCH UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FI SHP Prior Authorization Required
9 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0117 CRUTCH, UNDERARM, ARTICULATING, SPRING ASSISTED, E SHP Prior Authorization Required
10 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WIT SHP Prior Authorization Required
11 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0130 WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT SHP Prior Authorization Required
12 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0135 WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIG SHP Prior Authorization Required
13 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0140 WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HE SHP Prior Authorization Required
14 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 HCPC E0141 WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT SHP Prior Authorization Required
15 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 03/31/2024 HCPC J3262 ACTEMRA INJECTION, TOCILIZUMAB 1 MG Magellan Billed with one of the following Places of Service or Types of Bill 01,03,04,05,06,07,08,09,11,12,13,14,15,16,17,18,19,20,22,24,25,26,31,32,33,34,41,42,49,50,51,52,53,54,55,56,57,60,62,65,71,72,81,99,831,137,135,131,132,133,134,138,631,832,833,834,835,837
16 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2014 03/31/2024 HCPC J0129 ORENCIA INJECTION, ABATACEPT 10 MG USED MEDICARE ADM SUPV PHYS Magellan Billed with one of the following Places of Service or Types of Bill 01,03,04,05,06,07,08,09,11,12,13,14,15,16,17,18,19,20,22,24,25,26,31,32,33,34,41,42,49,50,51,52,53,54,55,56,57,60,62,65,71,72,81,99,831,137,135,131,132,133,134,138,631,832,833,834,835,837
17 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 12/02/2016 CPT 0001U RED BLOOD CELL ANTIGEN TYPING, DNA, HUMAN ERYTHROCYTE ANTIGEN GENE ANALYSIS OF 35 ANTIGENS FROM 11 BLOOD GROUPS, UTILIZING WHOLE BLOOD, COMMON RBC ALLELES REPORTED SHP Prior Authorization Required
18 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 12/02/2016 CPT 0002U ONCOLOGY (COLORECTAL), QUANTITATIVE ASSESSMENT OF THREE URINE METABOLITES (ASCORBIC ACID, SUCCINIC ACID AND CARNITINE) BY LIQUID CHROMATOGRAPHY WITH TANDEM MASS SPECTROMETRY (LC-MS/MS) USING MULTIPLE REACTION MONITORING ACQUISITION, ALGORITHM REPORTED AS SHP Prior Authorization Required
19 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0022 SKILLED NURSING FACILITY - PPS SHP Prior Authorization Required
20 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0024 IP REHAB FACILITY - PPS SHP Prior Authorization Required
21 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0100 ALL- INCLUSIVE ROOM & BOARD PLUS ANCILLARY SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
22 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0101 ALL-INCLUSIVE R andB SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
23 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0110 PVT - GENERAL CLASSIFICATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
24 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0111 PVT - MEDICAL/SURGICAL/GYN SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
25 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0112 PVT - OB SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
26 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0113 PVT - PEDIATRIC SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
27 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0117 PVT - ONCOLOGY SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
28 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0118 PVT - REHABILITATION SHP Prior Authorization Required
29 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0119 PVT - OTHER SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
30 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0120 SEMI - GENERAL CLASSIFICATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
31 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0121 SEMI - MEDICAL/SURGICAL/GYN SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
32 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0122 SEMI - OB SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
33 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0123 SEMI - PEDIATRIC SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
34 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0124 SEMI - PSYCHIATRIC SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
35 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0127 SEMI - ONCOLOGY SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
36 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0128 SEMI - REHABILITATION SHP Prior Authorization Required
37 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0128 SEMI - REHABILITATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
38 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0129 SEMI - OTHER SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
39 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0130 3 and 4 BED - GENERAL CLASSIFICATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
40 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0131 3 and 4 BED - MEDICAL/SURGICAL/GYN SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
41 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0132 3 and 4 BED - OB SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
42 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0133 3 and 4 BED - PEDIATRIC SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
43 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0134 3 & 4 BED - PSYCHIATRIC SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,891,892,893,894,895,897,861,862,863,864,865,867
44 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0137 3 and 4 BED - ONCOLOGY SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
45 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0138 3 and 4 BED - REHABILITATION SHP Prior Authorization Required
46 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0138 3 and 4 BED - REHABILITATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
47 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0139 3 and 4 BED - OTHER SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
48 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0140 PVT/DLX - GENERAL CLASSIFICATION SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
49 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0141 PVT/DLX - MEDICAL/SURGICAL/GYN SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
50 aveak 02/12/2024 11:45 AM aveak 02/12/2024 11:45 AM 01/01/2017 REV 0142 PVT/DLX - OB SHP Billed with one of the following Types of Bill: 111,112,113,114,115,117,118,119,181,182,183,184,185,187,188,189,211,212,213,214,215,217,218,219,221,222,223,224,225,227,228,229,251,252,253,254,255,257,258,259,261,262,263,264,265,267,268,269,271,272,273,274
Effective Termed Code type Code Brand name Code description Vendor Authorization is Required When: