All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs)
Inclusion on this list indicates that service should not be billed using APGs; it does not guarantee alternative payment.
See codes removed from the Carve out list below.
*The following optional carved-out procedures may be billed as ordered ambulatory services when
an APG visit is not billed for the clinic patient on the same date of service.
Alternative Payment
Source/Notes
Effective Date
*J1055
Medrxyprogester acetate inj
435
Class I Pharmacotherapy
Procedure carve out
*86580
TB intradermal test
394
Level I Immunology Tests
Procedure carve out
9/1/2008 Ordered Ambulatory Fee
Schedule
4/1/2010 Laboratory Fee Schedule
*81025
Urine pregnancy test
410
Urinalysis
Procedure carve out
9/1/2008 Laboratory Fee Schedule
Select rate codes carved out of the APG reimbursement methodology: 1604, 1695, 1802, 1850, 2961, 2983, 3107, 3109, 3111, 3139. See list of subsumed rate codes for a complete
list of rate codes carved out of the APG reimbursement methodology.
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
58565
Hysteroscopy, sterilization
200
HYSTEROSCOPY
200
HYSTEROSCOPY
Procedure carve out
1/1/2011
83655
83890
Lead screen
Molecule isolate
404
395
Toxicology Tests
Level II Immunology Tests
404
395
Toxicology Tests
Level II Immunology Tests
Procedure carve out
Procedure carve out
1/1/2010
1/1/2010
83891
83892
Molecule isolate nucleic
Molecular diagnostics
395
395
Level II Immunology Tests
Level II Immunology Tests
395
395
Level II Immunology Tests
Level II Immunology Tests
Procedure carve out
Procedure carve out
1/1/2010
1/1/2010
83893
Molecule dot/slot/blot
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83894
Molecule gel electrophor
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83896
Molecular diagnostics
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83897
Molecule nucleic transfer
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83898
Molecule nucleic ampli, each
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83900
Molecule nucleic ampli 2 seq
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83901
Molecule nucleic ampli addon
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83902
Molecular diagnostics
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83903
Molecule mutation scan
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83904
83905
83906
Molecule mutation identify
Molecule mutation identify
Molecule mutation identify
395
395
395
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
395
395
395
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Procedure carve out
Procedure carve out
Procedure carve out
1/1/2010
1/1/2010
1/1/2010
83907
Lyse cells for nucleic ext
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
page 1 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
83908
Nucleic acid, signal ampli
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83909
Nucleic acid, high resolute
395
Level II Immunology Tests
395
Level II Immunology Tests
Procedure carve out
1/1/2010
83912
Genetic examination
400
Level I Chemistry Tests
400
Level I Chemistry Tests
Procedure carve out
1/1/2010
83913
83914
85004
85610
87536
87900
87901
87902
87903
87904
87999
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
90470
90473
90655
Molecular, rna stabilization
Mutation ident ola/sbce/aspe
Automated diff wbc count
Prothrombin time
HIV viral load testing
Virtual phenotype
HIV genotype, drug resistance test
Hepatitis C virus, genotype test
HIV drug resistance
Phenotype, dna hiv w/clt add
Microbiology procedure
Tissue culture, lymphocyte
Tissue culture, skin/biopsy
Tissue culture, placenta
Tissue culture, bone marrow
Tissue culture, tumor
Cell cryopreserve/storage
Frozen
F
cellll preparation
ti
Chromosome analysis, 20-25
Chromosome analysis, 50-100
Chromosome analysis, 100
Chromosome analysis, 5
Chromosome analysis, 15-20
Chromosome analysis, 45
Chromosome analysis, 20-25
Chromosome analys, placenta
Chromosome analys, amniotic
Cytogenetics, dna probe
Cytogenetics, 3-5
Cytogenetics, 10-30
Cytogenetics, 25-99
Cytogenetics, 100-300
Chromosome karyotype study
Chromosome banding study
Chromosome count, additional
Chromosome study, additional
Cyto/molecular report
Immune admin H1N1 im/nasal
Immune admin oral/nasal
Flu vaccine no preserv 6-35m
395
395
408
406
397
397
393
397
393
393
396
391
391
391
391
391
390
390
391
391
395
391
391
391
395
391
391
395
395
395
395
395
391
391
390
390
395
414
490
414
Level II Immunology Tests
Level II Immunology Tests
Level I Hematology Tests
Level I Clotting Tests
Level II Microbiology Tests
Level II Microbiology Tests
Blood And Tissue Typing
Level II Microbiology Tests
Blood And Tissue Typing
Blood And Tissue Typing
Level I Microbiology Tests
Level II Pathology
Level II Pathology
Level II Pathology
Level II Pathology
Level II Pathology
Level I Pathology
Level
L
l I Pathology
P th l
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level I Pathology
Level I Pathology
Level II Immunology Tests
Level I Immunization And Allergy
Incidental To Medical, Significant
Level I Immunization And Allergy
395
395
408
406
397
397
393
397
393
393
396
391
391
391
391
391
390
390
391
391
395
391
391
391
395
391
391
395
395
395
395
395
391
391
390
390
395
414
490
414
Level II Immunology Tests
Level II Immunology Tests
Level I Hematology Tests
Level I Clotting Tests
Level II Microbiology Tests
Level II Microbiology Tests
Blood And Tissue Typing
Level II Microbiology Tests
Blood And Tissue Typing
Blood And Tissue Typing
Level I Microbiology Tests
Level II Pathology
Level II Pathology
Level II Pathology
Level II Pathology
Level II Pathology
Level I Pathology
Level
L
l I Pathology
P th l
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Pathology
Level II Pathology
Level I Pathology
Level I Pathology
Level II Immunology Tests
Level I Immunization And Allergy
Incidental To Medical, Significant
Level I Immunization And Allergy
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
P
Procedure
d
carve outt
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
9/1/2009
9/1/2009
9/1/2009
page 2 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
90656
90657
90658
90660
90663
90669
90732
B4164
B4168
B4172
B4176
B4178
B4180
B4185
B4189
Flu vaccine no preserv 3 & >
Flu vaccine, 3 yrs, im
Flu vaccine, 3 yrs & >, im
Flu vaccine, nasal
Flu vacc pandemic
Pneumococcal vacc, ped <5
Pneumococcal vaccine
Parenteral 50% dextrose solu
Parenteral sol amino acid 3.
Parenteral sol amino acid 5.
Parenteral sol amino acid 7Parenteral sol amino acid >
Parenteral sol carb > 50%
Parenteral sol 10 gm lipids
Parenteral sol amino acid &
414
414
414
414
414
415
414
454
454
454
454
454
454
454
454
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level II Immunization
Level I Immunization And Allergy
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
414
414
414
414
414
415
414
454
454
454
454
454
454
454
454
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level I Immunization And Allergy
Level II Immunization
Level I Immunization And Allergy
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
9/1/2009
9/1/2009
9/1/2009
9/1/2009
9/1/2009
9/1/2009
9/1/2009
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
B4193
Parenteral sol 52-73 gm prot
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4197
Parenteral sol 74-100 gm pro
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4199
Parenteral sol > 100gm prote
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4216
Parenteral nutrition additiv
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4220
Parenteral supply kit premix
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4222
Parenteral supply kit homemi
454
Tpn Formulae
454
Tpn Formulae
APG carve out
12/1/2008
B4224
B5000
Parenteral administration ki
Parenteral sol renal-amirosy
454
454
Tpn Formulae
Tpn Formulae
454
454
Tpn Formulae
Tpn Formulae
APG carve out
APG carve out
12/1/2008
12/1/2008
B5100
B5200
B9000
B9002
B9004
B9006
B9998
B9999
C9259
D7650
D8050
D8060
D8070
D8080
D8090
D8210
Parenteral sol hepatic-fream
Parenteral sol stres-brnch c
Enter infusion pump w/o alrm
Enteral infusion pump w/ ala
Parenteral infus pump portab
Parenteral infus pump statio
Enteral supp not otherwise c
Parenteral supp not othrws c
Injection, pralatrexate, 1 mg
Open red simp malar/zygom fx
Intercep dental tx primary
Intercep dental tx transitn
Compre dental tx transition
Compre dental tx adolescent
Compre dental tx adult
Orthodontic rem appliance tx
454
454
454
454
454
454
454
454
432
371
371
371
371
371
371
371
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Class III Chemotherapy Drugs
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
454
454
454
454
454
454
454
454
463
371
371
371
371
371
371
371
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
Tpn Formulae
CLASS XI COMBINED
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
Procedure carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2011
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
page 3 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
D8660
D8670
D8680
D8690
D8692
D8999
E1220
E2227
E2228
E2300
Preorthodontic tx visit
Periodic orthodontc tx visit
Orthodontic retention
Orthodontic treatment
Replacement retainer
Orthodontic procedure
Whlchr special size/constrc
Gear reduction drive wheel
Mwc acc, wheelchair brake
Pwr seat elevation sys
371
371
371
371
371
371
453
453
453
456
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair Accessories
371
371
371
371
371
371
453
453
453
456
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Orthodontics
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair Accessories
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
E2301
Pwr standing
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2310
E2311
E2312
E2313
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2331
E2340
E2341
E2342
E2343
E2351
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2368
E2369
E2370
E2371
Electro connect btw control
Electro connect btw 2 sys
Mini-prop remote joystick
PWC harness, expand control
Hand interface joystick
Mult mech switches
Special joystick handle
Chin cup interface
Sip and puff interface
Breath tube kit
Head control interface mech
Head/extremity control inter
Head control nonproportional
Head control proximity switc
Attendant control
W/c wdth 20-23 in seat frame
W/c wdth 24-27 in seat frame
W/c dpth 20-21 in seat frame
W/c dpth 22-25 in seat frame
Electronic SGD interface
22nf nonsealed leadacid
22nf sealed leadacid battery
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Battery charger, dual mode
Power wc motor replacement
Pwr wc gear box replacement
Pwr wc motor/gear box combo
Gr27 sealed leadacid battery
456
456
453
453
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
456
456
453
453
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
page 4 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
E2372
Gr27 non-sealed leadacid
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2373
Hand/chin ctrl spec joystick
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2374
Hand/chin ctrl std joystick
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2375
Non-expandable controller
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2376
Expandable controller, repl
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2377
Expandable controller, initl
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2381
Pneum drive wheel tire
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2382
Tube, pneum wheel drive tire
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
E2383
E2384
E2385
E2386
E2387
E2388
Insert, pneum wheel drive
Pneumatic caster tire
Tube, pneumatic caster tire
Foam filled drive wheel tire
Foam filled caster tire
Foam drive wheel tire
456
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
456
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
E2389
E2390
Foam caster tire
Solid drive wheel tire
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
456
456
Motorized Wheelchair Accessories APG carve out
Motorized Wheelchair Accessories APG carve out
12/1/2008
12/1/2008
E2391
E2392
E2394
E2395
E2396
Solid caster tire
Solid caster tire, integrate
Drive wheel excludes tire
Caster wheel excludes tire
Caster fork
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
456
456
456
456
456
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
Motorized Wheelchair Accessories
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
E2397
G0008
Pwc acc, lith-based battery
Admin influenza virus vac
453
490
Motorized Wheelchair
Incidental To Medical, Significant
Procedure Or Therapy Visit
453
490
Motorized Wheelchair
Incidental To Medical, Significant
Procedure Or Therapy Visit
APG carve out
Procedure carve out
12/1/2008
9/1/2009
G0009
J0128
J0135
J0180
J0207
J0365
J0480
J0585
J0587
Admin pneumococcal vaccine
Abarelix injection
Adalimumab injection
Agalsidase beta injection
Amifostine
Aprotonin, 10,000 kiu
Basiliximab
Botulinum toxin a per unit
Botulinum toxin type B
490
434
433
442
433
434
433
438
436
Incidental To Medical, Significant
Class V Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class VII Combined
Class IV Chemotherapy Drugs
Class V Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class IV Pharmacotherapy
Class II Pharmacotherapy
490
461
441
464
434
461
460
439
439
Incidental To Medical, Significant
CLASS IX COMBINED
CLASS VI CHEMOTHERAPY
CLASS XII COMBINED
CLASS V CHEMOTHERAPY
CLASS IX COMBINED
CLASS VIII COMBINED
CLASS V PHARMACOTHERAPY
CLASS V PHARMACOTHERAPY
Procedure carve out
procedure carve out
APG carve out
APG carve out
APG carve out
procedure carve out
procedure carve out
Procedure carve out
Procedure carve out
9/1/2009
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
J0640
Leucovorin calcium injection
430
Class I Chemotherapy Drugs
430
CLASS I CHEMOTHERAPY
APG carve out
12/1/2008
page 5 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
CLASS IV CHEMOTHERAPY
DRUGS
CLASS VIII COMBINED
CHEMOTHERAPY AND
CLASS V CHEMOTHERAPY
DRUGS
CLASS IV CHEMOTHERAPY
CLASS V PHARMACOTHERAPY
CLASS V PHARMACOTHERAPY
CLASS V CHEMOTHERAPY
DRUGS
CLASS XIII COMBINED
CHEMOTHERAPY AND
PHARMACOTHERAPY
CLASS I CHEMOTHERAPY
CLASS II CHEMOTHERAPY
CLASS IV PHARMACOTHERAPY
CLASS IV PHARMACOTHERAPY
CLASS VII CHEMOTHERAPY
DRUGS
CLASS VII CHEMOTHERAPY
CLASS XII COMBINED
CLASS X COMBINED
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
DRUGS
APG
CLASS VIII COMBINED
CLASS VI CHEMOTHERAPY
CLASS XIII COMBINED
CLASS III CHEMOTHERAPY
CLASS XII COMBINED
CLASS III CHEMOTHERAPY
CLASS VII CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS IX COMBINED
CLASS VI CHEMOTHERAPY
CLASS IV PHARMACOTHERAPY
CLASS III CHEMOTHERAPY
CLASS IV CHEMOTHERAPY
CLASS X COMBINED
CLASS III CHEMOTHERAPY
CLASS XI COMBINED
CLASS III CHEMOTHERAPY
CLASS IV PHARMACOTHERAPY
CLASS II CHEMOTHERAPY
CLASS II PHARMACOTHERAPY
CLASS IX COMBINED
J0641
Levoleucovorin injection
431
Class II Chemotherapy Drugs
433
J0740
Cidofovir injection
432
Class III Chemotherapy Drugs
460
J0795
Corticorelin ovine triflutal
433
Class IV Chemotherapy Drugs
434
J0878
J0882
J0886
J1190
Daptomycin injection
Darbepoetin alfa, esrd use
Epoetin alfa 1000 units ESRD
Dexrazoxane HCl injection
431
432
431
431
Class II Chemotherapy Drugs
Class III Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
433
439
439
434
J1300
Eculizumab injection
442
465
J1325
J1327
J1440
J1441
J1451
Epoprostenol injection
Eptifibatide injection
Filgrastim 300 mcg injection
Filgrastim 480 mcg injection
Fomepizole, 15 mg
430
432
437
437
433
Class VII Combined
Chemotherapy &
Pharmacotherapy
Class I Chemotherapy Drugs
Class III Chemotherapy Drugs
Class III Pharmacotherapy
Class III Pharmacotherapy
Class IV Chemotherapy Drugs
430
431
438
438
443
J1457
J1458
J1566
J1620
J1626
Gallium nitrate injection
Galsulfase injection
Immune globulin, powder
Gonadorelin hydroch/ 100 mcg
Granisetron hcl injection
433
442
433
430
431
Class IV Chemotherapy Drugs
Class VII Combined
Class IV Chemotherapy Drugs
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
443
464
462
430
430
J1675
J1742
J1785
J1825
J1931
J1945
J1950
J2278
J2323
J2425
J2430
J2469
J2504
J2505
J2513
J2562
J2770
J2794
J2805
J2997
J3110
Histrelin acetate
Ibutilide fumarate injection
Injection imiglucerase /unit
Interferon beta-1a
Laronidase injection
Lepirudin
Leuprolide acetate /3.75 MG
Ziconotide injection
Natalizumab injection
Palifermin injection
Pamidronate disodium /30 MG
Palonosetron hcl
Pegademase bovine, 25 iu
Injection, pegfilgrastim 6mg
Pentastarch 10% solution
Injection, plerixafor, 1 mg
Quinupristin/dalfopristin
Risperidone, long acting
Sincalide injection
Alteplase recombinant
Teriparatide injection
434
432
442
431
434
431
434
441
439
433
431
431
431
439
431
437
430
436
430
437
434
Class V Chemotherapy Drugs
Class III Chemotherapy Drugs
Class VII Combined
Class II Chemotherapy Drugs
Class V Chemotherapy Drugs
Class II Chemotherapy Drugs
Class V Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class V Pharmacotherapy
Class IV Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class V Pharmacotherapy
Class II Chemotherapy Drugs
Class III Pharmacotherapy
Class I Chemotherapy Drugs
Class II Pharmacotherapy
Class I Chemotherapy Drugs
Class III Pharmacotherapy
Class V Chemotherapy Drugs
460
441
465
432
464
432
443
430
461
441
438
432
433
462
432
463
432
438
431
436
461
Carve out Type
Effective
Date
APG carve out
1/1/2009
procedure carve out
12/1/2008
APG carve out
12/1/2008
APG carve out
APG carve Now a
APG carve Now a
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
APG carve out
1/1/2010
APG carve out
APG carve out
Procedure carve out
Procedure carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
APG carve out
carve out
procedure carve out
APG carve out
APG carv
carve out
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
procedure carve out
APG carve out
APG carve out
APG carve out
procedure carve out
APG carve out
APG carve out
APG carve out
Procedure carve out APG carve out
APG carve out
APG carve out
APG carve out
Procedure carve out
APG carve out
Procedure carve out
APG carve out
Procedure carve out APG carve out
Procedure carve out
procedure carve out
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2011
12/1/2008
4/1/2009
12/1/2008
1/1/2010
12/1/2008
page 6 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
CLASS V CHEMOTHERAPY
CLASS IX COMBINED
CLASS V CHEMOTHERAPY
CLASS VII CHEMOTHERAPY
CLASS V CHEMOTHERAPY
CLASS I PHARMACOTHERAPY
CLASS I PHARMACOTHERAPY
CLASS VIII COMBINED
CHEMOTHERAPY AND
PHARMACOTHERAPY
CLASS XIII COMBINED
CLASS XIII COMBINED
CHEMOTHERAPY AND
CLASS XIII COMBINED
CLASS XIII COMBINED
CLASS XIII COMBINED
CLASS XIII COMBINED
CLASS XIII COMBINED
CLASS IV PHARMACOTHERAPY
J3246
J3285
J3315
J3396
J3487
J3490
J3590
J7187
Tirofiban HCl
Treprostinil injection
Triptorelin pamoate
Verteporfin injection
Zoledronic acid
Drugs unclassified injection
Unclassified biologics
Humate-P, inj
432
432
433
433
432
435
435
438
Class III Chemotherapy Drugs
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
Class I Pharmacotherapy
Class I Pharmacotherapy
Class IV Pharmacotherapy
434
461
434
443
434
435
435
460
J7189
J7190
Factor viia
Factor viii
438
439
Class IV Pharmacotherapy
Class V Pharmacotherapy
465
465
J7191
J7192
J7193
J7194
J7195
J7197
Factor VIII (porcine)
Factor viii recombinant
Factor IX non-recombinant
Factor ix complex
Factor IX recombinant
Antithrombin iii injection
439
439
439
437
439
436
Class V Pharmacotherapy
Class V Pharmacotherapy
Class V Pharmacotherapy
Class III Pharmacotherapy
Class V Pharmacotherapy
Class II Pharmacotherapy
465
465
465
465
465
438
J7198
J7199
J7300
J7302
J7307
J7501
J7504
J7505
J7520
J8498
J8501
J8510
J8515
Anti-inhibitor
Hemophilia clot factor noc
Intraut copper contraceptive
Levonorgestrel iu contracept
Etonogestrel
Et
t l implant
i l t system
t
Azathioprine parenteral
Lymphocyte immune globulin
Monoclonal antibodies
Sirolimus, oral
Antiemetic rectal/supp NOS
Oral aprepitant
Oral busulfan
Cabergoline, oral 0.25mg
439
436
490
436
436
433
432
433
431
430
431
430
430
Class V Pharmacotherapy
Class II Pharmacotherapy
Incidental To Medical, Significant
Class II Pharmacotherapy
Class
Cl
II Ph
Pharmacotherapy
th
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class II Chemotherapy Drugs
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
460
437
490
439
439
431
434
443
432
430
432
430
430
J8520
J8521
J8530
J8540
J8560
J8565
J8597
J8600
J8610
J8650
J8700
J8705
Capecitabine, oral, 150 mg
Capecitabine, oral, 500 mg
Cyclophosphamide oral 25 MG
Oral dexamethasone
Etoposide oral 50 MG
Gefitinib oral
Antiemetic drug oral NOS
Melphalan oral 2 MG
Methotrexate oral 2.5 MG
Nabilone oral
Temozolomide
Topotecan oral
432
433
430
430
431
432
430
430
430
430
432
433
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
Class III Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
461
443
430
430
433
434
430
430
430
430
433
443
Carve out Type
Effective
Date
APG carve out
procedure carve out
APG carve out
APG carve out
APG carve out
Procedure carve out
Procedure carve out
Procedure carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
4/1/2010
4/1/2010
12/1/2008
Procedure carve out
Procedure carve out
12/1/2008
12/1/2008
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
CLASS VIII COMBINED
CLASS III PHARMACOTHERAPY
Incidental To Medical, Significant
CLASS V PHARMACOTHERAPY
CLASS V PHARMACOTHERAPY
CLASS II CHEMOTHERAPY
CLASS V CHEMOTHERAPY
CLASS VII CHEMOTHERAPY
CLASS III CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS III CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
DRUGS
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
P
Procedure
d
carve outt
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
CLASS IX COMBINED
CLASS VII CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS IV CHEMOTHERAPY
CLASS V CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS IV CHEMOTHERAPY
CLASS VII CHEMOTHERAPY
procedure carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
page 7 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
J9000
J9001
J9010
Doxorubicin hcl injection
Doxorubicin hcl liposome inj
Alemtuzumab injection
431
434
434
Class II Chemotherapy Drugs
Class V Chemotherapy Drugs
Class V Chemotherapy Drugs
430
462
443
J9015
J9017
Aldesleukin injection
Arsenic trioxide injection
432
432
Class III Chemotherapy Drugs
Class III Chemotherapy Drugs
441
434
J9020
J9025
J9027
J9031
J9033
J9035
J9040
J9041
J9045
J9050
J9055
J9060
J9062
J9065
J9070
J9080
J9090
J9091
Asparaginase injection
Azacitidine injection
Clofarabine injection
Bcg live intravesical vac
Bendamustine injection
Bevacizumab injection
Bleomycin sulfate injection
Bortezomib injection
Carboplatin injection
Carmustine injection
Cetuximab injection
Cisplatin 10 MG injection
Cisplatin 50 MG injection
Inj cladribine per 1 MG
Cyclophosphamide 100 MG inj
Cyclophosphamide 200 MG inj
Cyclophosphamide 500 MG inj
Cyclophosphamide 1.0 grm inj
431
433
433
431
441
441
431
433
432
432
441
431
431
432
430
430
431
430
Class II Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class II Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class II Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
Class III Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class III Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
Class I Chemotherapy Drugs
432
441
465
431
462
461
430
443
431
434
461
430
431
433
430
430
430
430
J9092
Cyclophosphamide 2.0 grm inj
430
Class I Chemotherapy Drugs
430
J9093
J9094
Cyclophosphamide lyophilized
Cyclophosphamide lyophilized
430
430
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
430
430
J9095
J9096
J9097
J9098
J9100
J9110
J9120
J9130
Cyclophosphamide lyophilized
Cyclophosphamide lyophilized
Cyclophosphamide lyophilized
Cytarabine liposome inj
Cytarabine hcl 100 MG inj
Cytarabine hcl 500 MG inj
Dactinomycin injection
Dacarbazine 100 mg inj
430
430
430
434
430
430
433
430
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class V Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class I Chemotherapy Drugs
430
430
430
464
430
430
461
430
J9140
Dacarbazine 200 MG inj
430
Class I Chemotherapy Drugs
J9150
Daunorubicin injection
431
Class II Chemotherapy Drugs
v3.5 APG Description
CLASS I CHEMOTHERAPY
CLASS X COMBINED
CLASS VII CHEMOTHERAPY
DRUGS
CLASS VI CHEMOTHERAPY
CLASS V CHEMOTHERAPY
DRUGS
CLASS III CHEMOTHERAPY
CLASS VI CHEMOTHERAPY
CLASS XIII COMBINED
CLASS II CHEMOTHERAPY
CLASS X COMBINED
CLASS IX COMBINED
CLASS I CHEMOTHERAPY
CLASS VII CHEMOTHERAPY
CLASS II CHEMOTHERAPY
CLASS V CHEMOTHERAPY
CLASS IX COMBINED
CLASS I CHEMOTHERAPY
CLASS II CHEMOTHERAPY
CLASS IV CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
DRUGS
CLASS I CHEMOTHERAPY
DRUGS
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
DRUGS
Carve out Type
Effective
Date
APG carve out
procedure carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
APG carve out
APG carve out
12/1/2008
12/1/2008
APG carve out
APG carve out
APG Carve out
APG carve out
procedure carve out
procedure carve out
APG carve out
APG carve out
APG carve out
APG carve out
procedure carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
APG carve out
12/1/2008
APG carve out
APG carve out
12/1/2008
12/1/2008
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS XII COMBINED
CLASS I CHEMOTHERAPY
CLASS I CHEMOTHERAPY
CLASS IX COMBINED
CLASS I CHEMOTHERAPY
DRUGS
APG carve out
APG carve out
APG carve out
procedure carve out
APG carve out
APG carve out
procedure carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
430
CLASS I CHEMOTHERAPY
DRUGS
APG carve out
12/1/2008
432
CLASS III CHEMOTHERAPY
DRUGS
APG carve out
12/1/2008
page 8 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
J9151
Daunorubicin citrate inj
431
Class II Chemotherapy Drugs
432
CLASS III CHEMOTHERAPY
DRUGS
APG carve out
12/1/2008
J9155
Degarelix injection
434
Class V Chemotherapy Drugs
434
CLASS V CHEMOTHERAPY DRUGAPG carve out
1/1/2010
J9160
Denileukin diftitox inj
434
Class V Chemotherapy Drugs
463
12/1/2008
J9171
J9178
Docetaxel injection
Inj, epirubicin hcl, 2 mg
432
433
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
443
432
J9181
J9185
Etoposide injection
Fludarabine phosphate inj
430
432
Class I Chemotherapy Drugs
Class III Chemotherapy Drugs
430
432
J9190
Fluorouracil injection
430
Class I Chemotherapy Drugs
430
J9200
Floxuridine injection
432
Class III Chemotherapy Drugs
431
J9201
J9202
Gemcitabine hcl injection
Goserelin acetate implant
433
432
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
443
433
J9206
J9207
J9208
J9209
J9211
J9212
J9213
J9214
J9215
J9216
J9217
J9218
J9219
J9225
J9230
J9245
J9250
J9260
J9261
J9263
Irinotecan injection
Ixabepilone injection
Ifosfomide injection
j
Mesna injection
Idarubicin hcl injection
Interferon alfacon-1 inj
Interferon alfa-2a inj
Interferon alfa-2b inj
Interferon alfa-n3 inj
Interferon gamma 1-b inj
Leuprolide acetate suspnsion
Leuprolide acetate injeciton
Leuprolide acetate implant
Vantas implant
Mechlorethamine hcl inj
Inj melphalan hydrochl 50 MG
Methotrexate sodium inj
Methotrexate sodium inj
Nelarabine injection
Oxaliplatin
433
432
432
431
431
430
432
432
430
432
434
434
434
434
431
441
430
430
434
441
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
Class III Chemotherapy
py Drugs
g
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class I Chemotherapy Drugs
Class III Chemotherapy Drugs
Class III Chemotherapy Drugs
Class I Chemotherapy Drugs
Class III Chemotherapy Drugs
Class V Chemotherapy Drugs
Class V Chemotherapy Drugs
Class V Chemotherapy Drugs
Class V Chemotherapy Drugs
Class II Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class V Chemotherapy Drugs
Class VI Chemotherapy Drugs
433
463
432
432
432
430
434
433
430
434
434
430
463
460
432
460
430
430
441
461
J9264
Paclitaxel protein bound
433
Class IV Chemotherapy Drugs
461
J9265
Paclitaxel injection
432
Class III Chemotherapy Drugs
431
CLASS XI COMBINED
procedure carve out
CHEMOTHERAPY AND
PHARMACOTHERAPY
CLASS VII CHEMOTHERAPY DRU APG carve out
CLASS III CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
CLASS III CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS II CHEMOTHERAPY
APG carve out
DRUGS
CLASS VII CHEMOTHERAPY
APG carve out
CLASS IV CHEMOTHERAPY
APG carve out
DRUGS
CLASS IV CHEMOTHERAPY
APG carve out
CLASS XI COMBINED
procedure carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS IV CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS XI COMBINED
procedure carve out
CLASS VIII COMBINED
procedure carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS VIII COMBINED
procedure carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS VI CHEMOTHERAPY
APG carve out
CLASS IX COMBINED
procedure carve out
CHEMOTHERAPY AND
PHARMACOTHERAPY
CLASS IX COMBINED
procedure carve out
CHEMOTHERAPY AND
PHARMACOTHERAPY
CLASS II CHEMOTHERAPY
APG carve out
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
page 9 of 14
HCPCS
J9266
J9268
J9270
J9280
J9290
J9291
J9293
J9300
J9303
J9305
J9310
J9320
J9328
J9330
J9340
J9350
J9355
J9357
J9360
J9370
J9375
J9380
J9390
J9395
J9600
J9999
K0800
K0801
K0802
K0806
K0807
K0808
K0812
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
Description
Pegaspargase injection
Pentostatin injection
Plicamycin (mithramycin) inj
Mitomycin 5 MG inj
Mitomycin 20 MG inj
Mitomycin 40 MG inj
Mitoxantrone hydrochl / 5 MG
Gemtuzumab ozogamicin inj
Injection, panitumumab, 10 mg
Pemetrexed injection
Injection, rituximab, 100 mg
Streptozocin injection
Temozolomide injection
Temsirolimus injection
Thiotepa injection
Topotecan injection
Trastuzumab injection
Valrubicin injection
Vinblastine sulfate inj
Vincristine sulfate 1 MG inj
Vincristine sulfate 2 MG inj
Vincristine sulfate 5 MG inj
Vinorelbine tartrate inj
Injection, Fulvestrant
Porfimer sodium injection
Chemotherapy drug
POV group 1 std up to 300lbs
POV group 1 hd 301-450 lbs
POV group 1 vhd 451-600 lbs
POV group 2 std up to 300lbs
POV group 2 hd 301-450 lbs
POV group 2 vhd 451-600 lbs
Power operated vehicle NOC
PWC gp 1 std port seat/back
PWC gp 1 std port cap chair
PWC gp 1 std seat/back
PWC gp 1 std cap chair
PWC gp 2 std port seat/back
PWC gp 2 std port cap chair
PWC gp 2 std seat/back
PWC gp 2 std cap chair
PWC gp 2 hd seat/back
PWC gp 2 hd cap chair
PWC gp 2 vhd seat/back
PWC gp vhd cap chair
PWC gp 2 xtra hd seat/back
APG
APG Description
v3.5 APG
441
434
432
431
431
431
433
442
440
441
440
432
432
434
431
433
434
432
430
430
430
431
431
433
441
430
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
Class VI Chemotherapy Drugs
Class V Chemotherapy Drugs
Class III Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class VII Combined
CLASS VI PHARMACOTHERAPY
Class VI Chemotherapy Drugs
CLASS VI PHARMACOTHERAPY
Class III Chemotherapy Drugs
Class III Chemotherapy Drugs
Class V Chemotherapy Drugs
Class II Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class V Chemotherapy Drugs
Class III Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class I Chemotherapy Drugs
Class II Chemotherapy Drugs
Class II Chemotherapy Drugs
Class IV Chemotherapy Drugs
Class VI Chemotherapy Drugs
Class I Chemotherapy Drugs
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
462
463
434
432
433
432
433
465
462
463
463
434
434
443
433
460
460
434
430
430
430
430
430
441
463
430
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
v3.5 APG Description
Carve out Type
CLASS X COMBINED
procedure carve out
CLASS XI COMBINED
procedure carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS IV CHEMOTHERAPY
APG carve out
CLASS III CHEMOTHERAPY
APG carve out
CLASS IV CHEMOTHERAPY
APG carve out
CLASS XIII COMBINED
APG carve out
CLASS X COMBINED
Procedure carve out
CLASS XI COMBINED
procedure carve out
CLASS XI COMBINED
Procedure carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS V CHEMOTHERAPY DRUGAPG carve out
CLASS VII CHEMOTHERAPY
APG carve out
CLASS IV CHEMOTHERAPY
APG carve out
CLASS VIII COMBINED
procedure carve out
CLASS VIII COMBINED
procedure carve out
CLASS V CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS I CHEMOTHERAPY
APG carve out
CLASS VI CHEMOTHERAPY
APG carve out
CLASS XI COMBINED
procedure carve out
CLASS I CHEMOTHERAPY
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
APG carve out
Motorized Wheelchair
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Motorized Wheelchair
APG carve out
Effective
Date
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
1/1/2011
1/1/2010
1/1/2011
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
page 10 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
K0829
K0830
K0831
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0857
K0858
K0859
K0860
K0861
PWC gp 2 xtra hd cap chair
PWC gp2 std seat elevate s/b
PWC gp2 std seat elevate cap
PWC gp2 std sing pow opt s/b
PWC gp2 std sing pow opt cap
PWC gp 2 hd sing pow opt s/b
PWC gp 2 hd sing pow opt cap
PWC gp2 vhd sing pow opt s/b
PWC gp2 xhd sing pow opt s/b
PWC gp2 std mult pow opt s/b
PWC gp2 std mult pow opt cap
PWC gp2 hd mult pow opt s/b
PWC gp 3 std seat/back
PWC gp 3 std cap chair
PWC gp 3 hd seat/back
PWC gp 3 hd cap chair
PWC gp 3 vhd seat/back
PWC gp 3 vhd cap chair
PWC gp 3 xhd seat/back
PWC gp 3 xhd cap chair
PWC gp3 std sing pow opt s/b
PWC gp3 std sing pow opt cap
PWC gp3 hd sing pow opt s/b
PWC gp3 hd sing pow opt cap
PWC gp3 vhd sing pow opt s/b
PWC gp3 std mult pow opt s/b
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
453
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
Motorized Wheelchair
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
APG carve out
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
K0862
PWC gp3 hd mult pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0863
PWC gp3 vhd mult pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0864
PWC gp3 xhd mult pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0868
PWC gp 4 std seat/back
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0869
PWC gp 4 std cap chair
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0870
K0871
PWC gp 4 hd seat/back
PWC gp 4 vhd seat/back
453
453
Motorized Wheelchair
Motorized Wheelchair
453
453
Motorized Wheelchair
Motorized Wheelchair
APG carve out
APG carve out
12/1/2008
12/1/2008
K0877
PWC gp4 std sing pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0878
PWC gp4 std sing pow opt cap
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0879
PWC gp4 hd sing pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0880
PWC gp4 vhd sing pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
page 11 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
K0884
PWC gp4 std mult pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0885
PWC gp4 std mult pow opt cap
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0886
PWC gp4 hd mult pow s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0890
PWC gp5 ped sing pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0891
PWC gp5 ped mult pow opt s/b
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0898
Power wheelchair NOC
453
Motorized Wheelchair
453
Motorized Wheelchair
APG carve out
12/1/2008
K0899
Pow mobil dev no SADMERC
456
Motorized Wheelchair Accessories
456
Motorized Wheelchair Accessories APG carve out
12/1/2008
Q0166
Granisetron hcl 1 mg oral
431
Class II Chemotherapy Drugs
430
CLASS I CHEMOTHERAPY DRUG APG carve out
1/1/2010
Q0515
Sermorelin acetate injection
433
Class IV Chemotherapy Drugs
443
12/1/2008
Q4074
Iloprost non-comp unit dose
434
Class V Chemotherapy Drugs
461
Q9955
Inj perflexane lip micros,ml
430
Class I Chemotherapy Drugs
430
Q9956
Inj octafluoropropane mic,ml
430
Class I Chemotherapy Drugs
430
Q9957
Inj perflutren lip micros,ml
430
Class I Chemotherapy Drugs
431
S0091
Granisetron 1mg
431
Class II Chemotherapy Drugs
431
CLASS VII CHEMOTHERAPY
APG carve out
DRUGS
CLASS IX COMBINED
procedure carve out
CHEMOTHERAPY AND
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS II CHEMOTHERAPY
APG carve out
DRUGS
CLASS II CHEMOTHERAPY DRUGAPG carve out
S0108
Mercaptopurine 50 mg
430
Class I Chemotherapy Drugs
430
S0156
Exemestane, 25 mg
430
Class I Chemotherapy Drugs
430
S0170
Anastrozole 1 mg
430
Class I Chemotherapy Drugs
430
S0172
Chlorambucil 2 mg
430
Class I Chemotherapy Drugs
430
S0175
Flutamide 125 mg
431
Class II Chemotherapy Drugs
432
S0176
Hydroxyurea 500 mg
430
Class I Chemotherapy Drugs
430
S0178
Lomustine 10 mg
432
Class III Chemotherapy Drugs
434
S0179
Megestrol 20 mg
430
Class I Chemotherapy Drugs
430
S0182
Procarbazine 5 mg
430
Class I Chemotherapy Drugs
430
S0187
Tamoxifen 10 mg
430
Class I Chemotherapy Drugs
430
1/1/2010
12/1/2008
12/1/2008
12/1/2008
1/1/2010
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY DRUG APG carve out
12/1/2008
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS III CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS V CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY
APG carve out
DRUGS
CLASS I CHEMOTHERAPY DRUG APG carve out
12/1/2008
1/1/2010
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
12/1/2008
1/1/2010
page 12 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
S0190
Mifepristone, oral, 200 mg
435
Class I Pharmacotherapy
436
CLASS II PHARMACOTHERAPY
Procedure carve out
12/1/2008
S0191
S3818
S3819
S3820
S3822
S3823
S3828
S3829
S3830
S3831
S3833
S3834
S3835
S3840
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S3853
S4989
S5550
Misoprostol, oral, 200 mcg
BRCA1 gene anal
BRCA2 gene anal
Comp BRCA1/BRCA2
Sing mutation brst/ovar
3 mutation brst/ovar
Comp MLH1 gene
Comp MLH2 gene
Gene test HNPCC comp
Gene test HNPCC single
Comp APC sequence
Sing mutation APC
Gene test cystic fibrosis
DNA analysis RET-oncogene
Gene test Hippel-Lindau
DNA analysis factor v
DNA analysis deafness
Gene test alpha-thalassemia
Gene test beta-thalassemia
Gene test Tay-Sachs
Gene test Gaucher
Gene test Niemann-Pick
Gene test sickle cell
Gene test canavan
DNA analysis APOE alzheimer
Gene test myo musclr dyst
Contracept IUD
Insulin rapid 5 u
435
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
417
452
Class I Pharmacotherapy
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology
gy Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Minor Reproductive Procedures
Diabetes Supplies
435
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
395
417
452
CLASS I PHARMACOTHERAPY
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology
gy Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Level II Immunology Tests
Minor Reproductive Procedures
Diabetes Supplies
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
Procedure carve out
APG carve out
12/1/2008
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
1/1/2010
12/1/2008
12/1/2008
S5551
Insulin most rapid 5 u
452
Diabetes Supplies
452
Diabetes Supplies
APG carve out
12/1/2008
S5552
Insulin intermed 5 u
452
Diabetes Supplies
452
Diabetes Supplies
APG carve out
12/1/2008
S5553
Insulin long acting 5 u
452
Diabetes Supplies
452
Diabetes Supplies
APG carve out
12/1/2008
S5560
Insulin reuse pen 1.5 ml
452
Diabetes Supplies
452
Diabetes Supplies
APG carve out
12/1/2008
S5561
Insulin reuse pen 3 ml
452
Diabetes Supplies
452
Diabetes Supplies
APG carve out
12/1/2008
S5565
S5566
Insulin cartridge 150 u
Insulin cartridge 300 u
452
452
Diabetes Supplies
Diabetes Supplies
452
452
Diabetes Supplies
Diabetes Supplies
APG carve out
APG carve out
12/1/2008
12/1/2008
S5570
S5571
Insulin dispos pen 1.5 ml
Insulin dispos pen 3 ml
452
452
Diabetes Supplies
Diabetes Supplies
452
452
Diabetes Supplies
Diabetes Supplies
APG carve out
APG carve out
12/1/2008
12/1/2008
page 13 of 14
HCPCS
Description
APG
APG Description
v3.5 APG
v3.5 APG Description
Carve out Type
Effective
Date
Procedures Removed from the Procedure Carve out List
HCPCS
Description
APG
APG Description
Date
Added to
Carve out
List
APG - updated w/
v3.5 2011 drug APG Description - updated w/
groupings
v3.5 2011 drug groupings
Q4080
Iloprost non-comp unit dose
434
Class V Chemotherapy Drugs
NA
NA
APG carve out
12/1/2008
J3472
J0885
J9170
Ovine, 1000 USP units
Epoetin alfa, non-esrd
Docetaxel injection
433
432
433
Class IV Chemotherapy Drugs
Class III Chemotherapy Drugs
Class IV Chemotherapy Drugs
437
439
NA
CLASS III PHARMACOTHERAPY APG carve out
CLASS V PHARMACOTHERAPY APG carve out
NA
APG carve out
1/1/2011
1/1/2011
12/1/2008
E2393
Valve, pneumatic tire tube
456
Motorized Wheelchair Accessories
NA
NA
APG carve out
12/1/2008
E2399
Noc interface
456
Motorized Wheelchair Accessories
NA
NA
APG carve out
12/1/2008
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