NYS DOH - Never Pay Procedures Under APG Reimbursement
Revised for July 1, 2016 Updates:
Information revised during the quarterly update period stated above is highlighted.
Px Code
20696
20697
20983
20985
20986
20987
27412
28890
43257
55400
55706
58750
70554
74261
74262
74263
75571
75572
75573
75574
77082
77422
77423
81161
81200
81201
81202
81203
81205
81206
81207
81208
81209
81210
81211
81212
81213
81214
81215
81216
81217
81220
81221
81222
81223
81224
81225
81226
81227
81228
81229
81235
81240
81241
81242
81243
81244
81245
Alternative Payment Available*
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Procedure (Px) Description
Comp multiplane ext fixation
Comp ext fixate strut change
Ablate bone tumor(s) perq
Cptr‐asst dir ms px
Cptr‐asst dir ms px io img
Cptr‐asst dir ms px pre img
Autochondrocyte implant knee
High energy eswt, plantar f
Uppr gi scope w/thrml txmnt
Repair of sperm duct
Prostate saturation sampling
Repair oviduct
Fmri brain by tech
Ct colonography dx
Ct colonography dx w/dye
Ct colonography screening
Ct hrt w/o dye w/ca test
Ct hrt w/3d image
Ct hrt w/3d image congen
Ct angio hrt w/3d image
Dxa bone density vert fx
Neutron beam tx, simple
Neutron beam tx, complex
Dmd dup/delet analysis
Aspa gene
Apc gene full sequence
Apc gene known fam variants
Apc gene dup/delet variants
Bckdhb gene
Bcr/abl1 gene major bp
Bcr/abl1 gene minor bp
Bcr/abl1 gene other bp
Blm gene
Braf gene
Brca1&2 seq & com dup/del
Brca1&2 185&5385&6174 var
Brca1&2 uncom dup/del var
Brca1 full seq & com dup/del
Brca1 gene known fam variant
Brca2 gene full sequence
Brca2 gene known fam variant
Cftr gene com variants
Cftr gene known fam variants
Cftr gene dup/delet variants
Cftr gene full sequence
Cftr gene intron poly t
Cyp2c19 gene com variants
Cyp2d6 gene com variants
Cyp2c9 gene com variants
Cytogen micrarray copy nmbr
Cytogen m array copy no&snp
Egfr gene com variants
F2 gene
F5 gene
Fancc gene
Fmr1 gene detection
Fmr1 gene characterization
Flt3 gene
Page 1 of 8
Date added to Never Date Removed Pay List
from Never Pay List
01/01/13
01/01/13
07/01/16
12/01/08
12/01/08
12/01/08
07/01/10
12/01/08
07/01/10
04/01/13
07/01/10
10/01/09
12/01/08
04/01/11
04/01/11
04/01/11
04/01/11
04/01/11
04/01/11
04/01/11
10/01/12
04/01/09
04/01/09
01/01/15
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
07/01/16
07/01/10
07/01/10
Px Code
81246
81250
81251
81252
81253
81254
81255
81256
81257
81260
81261
81262
81263
81264
81265
81266
81267
81268
81270
81275
81280
81281
81282
81287
81288
81290
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81302
81303
81304
81310
81313
81315
81316
81317
81318
81319
81321
81322
81323
81324
81325
81326
81330
81331
81332
81340
81341
81342
81350
81355
81370
81371
Alternative Payment Available*
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
Yes
Yes
No
No
Procedure (Px) Description
Flt3 gene analysis
G6pc gene
Gba gene
Gjb2 gene full sequence
Gjb2 gene known fam variants
Gjb6 gene com variants
Hexa gene
Hfe gene
Hba1/hba2 gene
Ikbkap gene
Igh gene rearrange amp meth
Igh gene rearrang dir probe
Igh vari regional mutation
Igk rearrangeabn clonal pop
Str markers specimen anal
Str markers spec anal addl
Chimerism anal no cell selec
Chimerism anal w/cell select
Jak2 gene
Kras gene
Long qt synd gene full seq
Long qt synd known fam var
Long qt syn gene dup/dlt var
Mgmt gene methylation anal
Mlh1 gene
Mcoln1 gene
Mthfr gene
Mlh1 gene full seq
Mlh1 gene known variants
Mlh1 gene dup/delete variant
Msh2 gene full seq
Msh2 gene known variants
Msh2 gene dup/delete variant
Msh6 gene full seq
Msh6 gene known variants
Msh6 gene dup/delete variant
Microsatellite instability
Mecp2 gene full seq
Mecp2 gene known variant
Mecp2 gene dup/delet variant
Npm1 gene
Pca3/klk3 antigen
Pml/raralpha com breakpoints
Pml/raralpha 1 breakpoint
Pms2 gene full seq analysis
Pms2 known familial variants
Pms2 gene dup/delet variants
Pten gene full sequence
Pten gene known fam variant
Pten gene dup/delet variant
Pmp22 gene dup/delet
Pmp22 gene full sequence
Pmp22 gene known fam variant
Smpd1 gene common variants
Snrpn/ube3a gene
Serpina1 gene
Trb@ gene rearrange amplify
Trb@ gene rearrange dirprobe
Trg gene rearrangement anal
Ugt1a1 gene
Vkorc1 gene
Hla i & ii typing lr
Hla i & ii type verify lr
Page 2 of 8
Date added to Never Date Removed Pay List
from Never Pay List
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
Px Code
81372
81373
81374
81375
81376
81377
81378
81379
81380
81381
81382
81383
81400
81401
81402
81403
81404
81405
81406
81407
81408
81410
81411
81415
81416
81417
81420
81425
81426
81427
81430
81431
81435
81436
81440
81445
81450
81455
81460
81465
81470
81471
81479
81500
81503
81504
81506
81507
81508
81509
81510
81511
81512
81519
81599
83655
83890
83891
83892
83893
83894
83896
83897
Alternative Payment Available*
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Procedure (Px) Description
Hla i typing complete lr
Hla i typing 1 locus lr
Hla i typing 1 antigen lr
Hla ii typing ag equiv lr
Hla ii typing 1 locus lr
Hla ii type 1 ag equiv lr
Hla i & ii typing hr
Hla i typing complete hr
Hla i typing 1 locus hr
Hla i typing 1 allele hr
Hla ii typing 1 loc hr
Hla ii typing 1 allele hr
Mopath procedure level 1
Mopath procedure level 2
Mopath procedure level 3
Mopath procedure level 4
Mopath procedure level 5
Mopath procedure level 6
Mopath procedure level 7
Mopath procedure level 8
Mopath procedure level 9
Aortic dysfunction/dilation
Aortic dysfunction/dilation
Exome sequence analysis
Exome sequence analysis
Exome re‐evaluation
Fetal chrmoml aneuploidy
Genome sequence analysis
Genome sequence analysis
Genome re‐evaluation
Hearing loss sequence analys
Hearing loss dup/del analys
Hereditary colon cancer
Hereditary colon ca synd
Mitochondrial gene
Targeted genomic seq analys
Targeted genomic seq analys
Targeted genomic seq analys
Whole mitochondrial genome
Whole mitochondrial genome
X‐linked intellectual dblt
X‐linked intellectual dblt
Unlisted molecular pathology
Onco (ovar) two proteins
Onco (ovar) five proteins
Oncology tissue of origin
Endo assay seven anal
Fetal aneuploidy trisom risk
Ftl cgen abnor two proteins
Ftl cgen abnor 3 proteins
Ftl cgen abnor three anal
Ftl cgen abnor four anal
Ftl cgen abnor five anal
Oncology breast mrna
Unlisted maaa
Assay of lead
Molecule isolate
Molecule isolate nucleic
Molecular diagnostics
Molecule dot/slot/blot
Molecule gel electrophor
Molecular diagnostics
Molecule nucleic transfer
Page 3 of 8
Date added to Never Date Removed Pay List
from Never Pay List
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
12/01/08
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
Px Code
83898
83900
83901
83902
83903
83904
83905
83906
83907
83908
83909
83912
83913
83914
85004
85610
86849
87536
87539
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
88299
90470
90473
90655
90656
90657
90658
90660
90663
90669
90732
90863
Alternative Payment Available*
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Procedure (Px) Description
Molecule nucleic ampli, each
Molecule nucleic ampli 2 seq
Molecule nucleic ampli addon
Molecular diagnostics
Molecule mutation scan
Molecule mutation identify
Molecule mutation identify
Molecule mutation identify
Lyse cells for nucleic ext
Nucleic acid, signal ampli
Nucleic acid, high resolute
Genetic examination
Molecular, rna stabilization
Mutation ident ola/sbce/aspe
Automated diff wbc count
Prothrombin time
Immunology procedure
Hiv‐1, dna, quant
Hiv‐2, dna, quant
Virtual phenotype
GeNo ‐ APG Carve Outtype, dna, hiv reverse t
GeNo ‐ APG Carve Outtype, dna, hepatitis C
PheNo ‐ APG Carve Outtype, dna hiv w/culture
PheNo ‐ APG Carve Outtype, 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 cell preparation
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
Cytogenetic study
H1N1 Administration
Immune admin oral/nasal
Flu vaccine no preserv 6‐35m
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
Pharmacologic mgmt w/psytx
Page 4 of 8
Date added to Never Date Removed Pay List
from Never Pay List
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
10/01/09
10/01/09
04/01/12
12/01/08
04/01/10
01/01/10
12/01/08
12/01/08
12/01/08
10/01/09
12/01/08
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/16
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
10/01/09
04/01/13
07/01/11
04/01/11
04/01/11
04/01/11
04/01/11
04/01/11
04/01/11
07/01/11
04/01/11
04/01/11
Px Code
90875
90876
90880
90901
90911
92145
93702
93895
95012
95800
95801
95806
95965
95966
96102
96119
96127
97012
97124
97150
97610
97810
97811
97813
97814
98940
98941
98942
98943
99002
0004M
0006M
0007M
0008M
0009M
0010M
0019T
0126T
0216T
0217T
0218T
0310T
0311T 1000F
4000F
A4459
C9137
C9138
C9259
C9287
C9471
C9716
D0421
D9210
D9211
D9212
D9215
D9221
D9242
D9920
G0008
G0009
G0398
Alternative Payment Available*
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
Yes
No
Procedure (Px) Description
Psychophysiological therapy
Psychophysiological therapy
Hypnotherapy
Biofeedback train, any meth
Biofeedback peri/uro/rectal
Corneal hysteresis deter
Bis xtracell fluid analysis
Carotid intima atheroma eval
Exhaled nitric oxide meas
Slp stdy unattended
Slp stdy unatnd w/anal
Sleep study unatt&resp efft
Meg, spontaneous
Meg, evoked, single
Psycho testing by technician
Neuropsych testing by tec
Brief emotional/behav assmt
Mechanical traction therapy
Massage therapy
Group therapeutic procedures
Low frequency non‐thermal us
Acupunct w/o stimul 15 min
Acupunct w/o stimul addl 15m
Acupunct w/stimul 15 min
Acupunct w/stimul addl 15m
Chiropractic manipulation
Chiropractic manipulation
Chiropractic manipulation
Chiropractic manipulation
Device Handling
Scoliosis dna alys
Onc hep gene risk classifier
Onc gastro 51 gene nomogram
Onc breast risk score
Fetal aneuploidy trisom risk
Onc Prostate prob score
Extracorp shock wv tx,ms nos
Chd risk imt study
Njx paravert w/us lumb/sac
Njx paravert w/us lumb/sac
Njx paravert w/us lumb/sac
Motor function mapping ntms
Cal & alys cntrl artl press
Tobacco use assessed
Tobacco use txmnt counseling
Manual pump enema, reusable
Adynovate Factor VIII recom
Nuwiq Factor VIII recomb
Injection, pralatrexate, 1 mg
Inj, brentuximab vedotin
Hymovis, 1 mg
Radiofrequency energy to anu
Gen tst suscept oral disease
Dent anesthesia w/o surgery
Regional block anesthesia
Trigeminal block anesthesia
Local anesthesia
General anesthesia ea ad 15m
IV sedation ea ad 30 m
Behavior management, by report
Admin influenza virus vac
Admin pneumococcal vaccine
Home sleep test/type 2 Porta
Page 5 of 8
Date added to Never Date Removed Pay List
from Never Pay List
07/01/10
07/01/10
04/01/09
07/01/10
07/01/10
07/01/16
07/01/16
07/01/16
12/01/08
01/01/13
01/01/13
01/01/13
12/01/08
12/01/08
04/01/09
04/01/09
07/01/16
04/01/13
04/01/09
04/01/09
07/01/16
04/01/09
04/01/09
04/01/09
04/01/09
01/01/12
04/01/11
01/01/12
01/01/12
04/01/11
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
04/01/10
01/01/13
01/01/13
01/01/13
01/01/13
04/01/13
04/01/13
12/01/08
12/01/08
07/01/16
07/01/16
07/01/16
01/01/11
07/01/12
07/01/16
07/01/10
01/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/11
07/01/11
12/01/08
10/01/09
10/01/09
01/01/13
07/01/16
07/01/16
04/01/10
04/01/10
07/01/10
04/01/10
07/01/11
04/01/11
04/01/11
Px Code
Procedure (Px) Description
G0399
G0400
G0464
G8402
G8403
G9016
G9141
G9142
G9143
G9481
G9482
G9483
G9484
G9485
G9486
G9487
G9488
G9489
G9490
G9678
H0018
H0023
H0032
H0037
H2029
J0128
J0365
J0480
J0585
J0587
J0740
J0882
J0886
J0890
J1440
J1441
J1566
J1675
J1725
J1931
J2315
Home sleep test/type 3 Porta
Home sleep test/type 4 Porta
Colorec ca scr, sto bas dna
Smoke preven interven counse
Smoke preven Outcounsel
Demo‐smoking cessation coun
Influenza A (H1N1) ‐ administration
Influenza A (H1N1) ‐ vaccine
Warfarin respon genetic test
Remote E/M new pt 10mins
Remote E/M new pt 20mins
Remote E/M new pt 30mins
Remote E/M new pt 45mins
Remote E/M new pt 60mins
Remote E/M est. pt 10mins
Remote E/M est. pt 15mins
Remote E/M est. pt 25mins
Remote E/M est. pt 40mins
Joint replac mod home visit
Oncology Care Model service
Alcohol and/or drug services
Behavioral health outreach service ‐ planned approach to reach a targeted population
MH svc plan dev by non‐md
Comm psy sup tx pgm per diem
Sex offend tx svc, per diem
Injection, abarelix, 10 mg
Injection, aprotonin, 10,000 kiu
Injection, basiliximab, 20 mg
Botulinum toxin a per unit
Botulinum toxin type B
Injection, cidofovir, 375 mg
Darbepoetin alfa, esrd use
Epoetin alfa 1000 units ESRD
Peginesatide injection
Filgrastim 300 mcg injection
Filgrastim 480 mcg injection
Injection, immune globulin, intravenous, lyophilized (e.g. Injection, histrelin acetate, 10 micrograms
Hydroxyprogesterone caproate
Injection, laronidase, 0.1 mg
Naltrexone, depot form
J2323
Natalizumab injection
J2358
J2426
J2505
J2562
J2794
J2997
J3110
J3285
J3490
J3590
J7187
J7189
J7190
J7191
J7192
J7193
J7194
Olanzapine long‐acting inj
Paliperidone palmitate inj
Injection, pegfilgrastim 6mg
Injection, plerixafor, 1 mg
Risperidone, long acting
Alteplase recombinant
Injection, teriparatide, 10 mcg
Injection, treprostinil, 1 mg
Drugs unclassified injection
Unclassified biologics
Humate‐P, inj
Factor viia
Factor viii
Factor VIII (porcine)
Factor viii recombinant
Factor IX No ‐ APG Carve Outn‐recombinant
Factor ix complex
Alternative Payment Available*
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Date added to Never Date Removed Pay List
from Never Pay List
01/01/13
01/01/13
01/01/16
12/01/08
12/01/08
12/01/08
10/01/09
10/01/09
01/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/16
07/01/10
10/01/10
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes ‐ Only for Article 32 providers
07/01/10
07/01/10
07/01/10
01/01/11
01/01/11
01/01/11
12/01/08
12/01/08
01/01/11
12/01/08
12/01/08
07/01/13
12/01/08
12/01/08
01/01/11
01/01/11
04/01/12
01/01/11
01/01/10
Yes ‐ only for TOUCH providers
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
01/01/10
Page 6 of 8
07/01/11
07/01/11
01/01/15
01/01/12
01/01/12
07/01/11
01/01/11
04/01/11
04/01/11
12/01/08
01/01/11
04/01/09
04/01/10
01/01/11
01/01/11
04/01/10
04/01/10
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
04/01/11
Px Code
Procedure (Px) Description
J7195
J7197
J7198
J7199
J7297
J7298
J7300
J7301
J7302
J7306
J7307
J8520
J9001
J9019
J9027
J9033
J9035
J9055
J9098
J9120
J9160
J9207
J9219
J9225
J9226
J9245
J9263
J9264
J9266
J9268
J9303
J9305
J9310
J9350
J9355
J9600
Q0091
Q2043
Q2049
Q4074
S0166
S0190
S0191
S3800
S3818
S3819
S3820
S3822
S3823
S3828
S3829
S3830
S3831
S3833
S3834
S3835
S3840
S3841
S3842
S3843
S3844
S3845
S3846
Factor IX recombinant
Antithrombin iii injection
Anti‐inhibitor
Hemophilia clot factor No ‐ APG Carve Outc
Levonorgestrel iu 52mg 3 yr
Levonorgestrel iu 52mg 5 yr
Intraut copper contraceptive
Levonorgestrel iu 13.5 mg
LevoNo ‐ APG Carve Outrgestrel iu contracept
Levonorgestrel implant sys
EtoNo ‐ APG Carve Outgestrel implant system
Capecitabine, oral, 150 mg
Injection, doxorubicin hydrochloride, all lipid formulations
Erwinaze injection
Clofarabine injection
Injection, bendamustine hcl, 1 mg
Injection, bevacizumab, 10 mg
Injection, cetuximab, 10 mg
Injection, cytarabine liposome, 10 mg
Injection, dactinomycin, 0.5 mg
Injection, denileukin diftitox, 300 micrograms
Injection, ixabepilone, 1 mg
Leuprolide acetate implant, 65 mg
Histrelin implant (vantas), 50 mg
Supprelin LA implant
Injection, melphalan hydrochloride, 50 mg
Injection, oxaliplatin, 0.5 mg
Injection, paclitaxel protein‐bound particles, 1 mg
Injection, pegaspargase, per single dose vial
Injection, pentostatin, 10 mg
Injection, panitumumab, 10 mg
Injection, pemetrexed, 10 mg
Injection, rituximab, 100 mg
Injection, topotecan, 4 mg
Injection, trastuzumab, 10 mg
Injection, porfimer sodium, 75 mg
Obtaining screen pap smear
Provenge
Imported lipodox inj
Iloprost, inhalation solution, fda‐approved final product, n
Inj olanzapine 2.5mg
Mifepristone, oral, 200 mg
Misoprostol, oral, 200 mcg
Genetic testing als
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 retinoblastoma
Gene test Hippel‐Lindau
DNA analysis factor v
DNA analysis deafness
Gene test alpha‐thalassemia
Gene test beta‐thalassemia
Page 7 of 8
Alternative Payment Available*
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Date added to Never Date Removed Pay List
from Never Pay List
12/01/08
12/01/08
12/01/08
12/01/08
07/01/16
07/01/16
12/01/08
07/01/16
12/01/08
07/01/16
12/01/08
01/01/11
01/01/11
07/01/14
12/01/08
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
10/01/10
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/11
01/01/12
07/01/14
01/01/16
01/01/11
04/01/11
12/01/08
12/01/08
01/01/16
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/16
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
Px Code
S3847
S3848
S3849
S3850
S3851
S3852
S3853
S3854
S3861
S3865
S3866
S3870
S3890
S4989
S8940
S9075
S9128
S9129
S9131
S9453
S9480
V5014
V5362
V5364
Alternative Payment Available*
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
Procedure (Px) Description
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
Gene profile panel breast
Genetic test brugada
Comp genet test hyp cardiomy
Spec gene test hyp cardiomy
Cgh test developmental delay
Fecal dna analysis
Contracept IUD
Hippotherapy per session
Smoking cessation treatment
Speech therapy, in the home,
Occupational therapy, in the
PT in the home per diem
Smoking cessation class
Intensive outpatient psychia
Hearing aid repair/modifying
Speech screening
Dysphagia screening
Date added to Never Date Removed Pay List
from Never Pay List
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/10
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
01/01/16
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
12/01/08
07/01/10
04/01/12
04/01/11
04/01/11
01/01/11
*Procedure codes listed as carve outs should not be billed using APGs. Indication as a carve out does not guarantee alternative payment.
Yes = Procedure code is not payable in APGs but is available for billing on ordered ambulatory fee schedule. No = Procedure code is not reimbursable by Medicaid. Service may be billable under an alternative procedure code. Page 8 of 8