Line Diagnosis Treatment 1 PREGNANCY (See Guideline Notes 1,2) MATERNITY CARE 2 BIRTH OF INFANT NEWBORN CARE 3 PREVENTIVE SERVICES, BIRTH TO 10 YEARS OF AGE (See Prevention Tables) MEDICAL THERAPY 4 PREVENTIVE SERVICES, OVER AGE OF 10 (See Prevention Tables) (See Guideline Note 3) MEDICAL THERAPY 5 ABUSE OR DEPENDENCE OF PSYCHOACTIVE SUBSTANCE MEDICAL/PSYCHOTHERAPY 6 TOBACCO DEPENDENCE (See Guideline Notes 1,4) MEDICAL THERAPY/BRIEF COUNSELING NOT TO EXCEED 10 FOLLOW-UP VISITS OVER 3 MONTHS 7 REPRODUCTIVE SERVICES CONTRACEPTION MANAGEMENT; STERILIZATION 8 OBESITY (See Guideline Notes 1,5) INTENSIVE NUTRITIONAL/PHYSICAL ACTIVITY COUNSELING AND BEHAVIORAL INTERVENTIONS 9 MAJOR DEPRESSION, RECURRENT MEDICAL/PSYCHOTHERAPY 10 TYPE I DIABETES MELLITUS (See Guideline Note 1) MEDICAL THERAPY 11 ASTHMA (See Guideline Note 1) MEDICAL THERAPY 12 HYPERTENSION AND HYPERTENSIVE DISEASE (See Guideline Notes 1, 6) MEDICAL THERAPY 13 GALACTOSEMIA (See Guideline Note 1) MEDICAL THERAPY 14 OTHER RESPIRATORY CONDITIONS OF FETUS AND NEWBORN (See Guideline Note 1) MEDICAL THERAPY 15 HIV DISEASE (INCLUDING ACQUIRED IMMUNODEFICIENCY SYNDROME) AND RELATED OPPORTUNISTIC INFECTIONS (See Guideline Note 1) MEDICAL THERAPY 16 CONGENITAL HYPOTHYROIDISM (See Guideline Note 1) MEDICAL THERAPY 17 PHENYLKETONURIA (PKU) (See Guideline Note 1) MEDICAL THERAPY 18 CONGENITAL INFECTIOUS DISEASES (See Guideline Note 1) MEDICAL THERAPY 19 CONGENITAL SYPHILIS MEDICAL THERAPY 20 VERY LOW BIRTH WEIGHT (UNDER 1500 GRAMS) (See Guideline Note 1) MEDICAL THERAPY 21 NEONATAL MYASTHENIA GRAVIS (See Guideline Note 1) MEDICAL THERAPY 22 HYDROCEPHALUS AND BENIGN INTRACRANIAL HYPERTENSION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 23 "SYNDROME OF ""INFANT OF A DIABETIC MOTHER"" AND NEONATAL HYPOGLYCEMIA" MEDICAL THERAPY 24 OMPHALITIS OF THE NEWBORN AND NEONATAL INFECTIVE MASTITIS MEDICAL THERAPY 25 LOW BIRTH WEIGHT (1500-2500 GRAMS) (See Guideline Note 1) MEDICAL THERAPY 26 CYSTIC FIBROSIS (See Guideline Note 1) MEDICAL THERAPY 27 SCHIZOPHRENIC DISORDERS MEDICAL/PSYCHOTHERAPY 28 CONVULSIONS AND OTHER CEREBRAL IRRITABILITY IN NEWBORN (See Guideline Note 1) MEDICAL THERAPY 29 CEREBRAL DEPRESSION, COMA, AND OTHER ABNORMAL CEREBRAL SIGNS OF NEWBORN (See Guideline Note 1) MEDICAL THERAPY 30 VESICOURETERAL REFLUX MEDICAL THERAPY, REIMPLANTATION 31 DYSPLASIA OF CERVIX AND CERVICAL CARCINOMA IN SITU, CERVICAL CONDYLOMA MEDICAL AND SURGICAL TREATMENT 32 BIPOLAR DISORDERS MEDICAL/PSYCHOTHERAPY 33 TYPE II DIABETES MELLITUS (See Guideline Notes 1,7,8) MEDICAL THERAPY, BARIATRIC SURGERY WITH BMI = 35 (See Coding Specification Below) 34 DRUG WITHDRAWAL SYNDROME IN NEWBORN (See Guideline Note 1) MEDICAL THERAPY 35 REGIONAL ENTERITIS, IDIOPATHIC PROCTOCOLITIS, ULCERATION OF INTESTINE (See Guideline Notes 1,9) MEDICAL AND SURGICAL TREATMENT 36 EPILEPSY AND FEBRILE CONVULSIONS (See Guideline Note 1) MEDICAL THERAPY 37 SEVERE BIRTH TRAUMA FOR BABY (See Guideline Note 1) MEDICAL THERAPY 38 NEONATAL THYROTOXICOSIS MEDICAL THERAPY 39 HEMATOLOGICAL DISORDERS OF FETUS AND NEWBORN (See Guideline Note 1) MEDICAL THERAPY 40 SPINA BIFIDA (See Guideline Note 1) SURGICAL TREATMENT 41 TERMINATION OF PREGNANCY (See Guideline Note 1) (Note: This line item is not priced as part of the list.) INDUCED ABORTION 42 ACQUIRED HYPOTHYROIDISM, DYSHORMONOGENIC GOITER (See Guideline Note 1) MEDICAL THERAPY 43 ECTOPIC PREGNANCY MEDICAL AND SURGICAL TREATMENT 44 PRIMARY, AND SECONDARY SYPHILIS MEDICAL THERAPY 45 DISORDERS RELATING TO LONG GESTATION AND HIGH BIRTHWEIGHT MEDICAL THERAPY 46 PANHYPOPITUITARISM, IATROGENIC AND OTHER PITUITARY DISORDERS (See Guideline Note 1) MEDICAL THERAPY 47 HYPOCALCEMIA, HYPOMAGNESEMIA AND OTHER ENDOCRINE AND METABOLIC DISTURBANCES SPECIFIC TO THE FETUS AND NEWBORN (See Guideline Note 1) MEDICAL THERAPY 48 INTUSSCEPTION, VOLVULUS, INTESTINAL OBSTRUCTION, AND FOREIGN BODY IN STOMACH, INTESTINES, COLON AND RECTUM MEDICAL AND SURGICAL TREATMENT 49 CLEFT PALATE WITH AIRWAY OBSTRUCTION MEDICAL AND SURGICAL TREATMENT, ORTHODONTICS 50 COARCTATION OF THE AORTA (See Guideline Notes 1,6) SURGICAL TREATMENT 51 CORONARY ARTERY ANOMALY (See Guideline Note 6) REIMPLANTATION OF CORONARY ARTERY 52 RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY POLYARTHROPATHIES (See Guideline Notes 1,6) MEDICAL THERAPY, INJECTIONS 53 CHRONIC RESPIRATORY DISEASE ARISING IN THE NEONATAL PERIOD (See Guideline Note 1) MEDICAL THERAPY 54 CONGENITAL HYDRONEPHROSIS NEPHRECTOMY/REPAIR 55 TUBERCULOSIS (See Guideline Note 1) MEDICAL THERAPY 56 GONOCOCCAL INFECTIONS AND OTHER SEXUALLY TRANSMITTED DISEASES (See Guideline Note 1) MEDICAL THERAPY 57 ACUTE PELVIC INFLAMMATORY DISEASE MEDICAL AND SURGICAL TREATMENT 58 HYDATIDIFORM MOLE D & C, HYSTERECTOMY 59 DENTAL CONDITIONS (EG. INFECTIONS) (See Guideline Note 10) URGENT AND EMERGENT DENTAL SERVICES 60 CHOLELITHIASIS, CHOLECYSTITIS, COMMON BILIARY DUCT STONE MEDICAL AND SURGICAL TREATMENT 61 ULCERS, GASTRITIS, DUODENITIS, AND GI HEMORRHAGE (See Guideline Notes 1,9) MEDICAL AND SURGICAL TREATMENT 62 FLAIL CHEST MEDICAL AND SURGICAL TREATMENT 63 BURN FULL THICKNESS GREATER THAN 10% OF BODY SURFACE (See Guideline Notes 1,6) FREE SKIN GRAFT, MEDICAL THERAPY 64 BRONCHIECTASIS MEDICAL AND SURGICAL TREATMENT 65 END STAGE RENAL DISEASE (See Guideline Notes 1,7) MEDICAL THERAPY INCLUDING DIALYSIS 66 METABOLIC DISORDERS INCLUDING HYPERLIPIDEMIA (See Guideline Note 1) MEDICAL THERAPY 67 SUBSTANCE-INDUCED DELUSIONAL AND MOOD DISORDERS; INTOXICATION MEDICAL/PSYCHOTHERAPY 68 SPONTANEOUS ABORTION COMPLICATED BY INFECTION AND/OR HEMORRHAGE, MISSED ABORTION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 69 SUBSTANCE-INDUCED DELIRIUM MEDICAL THERAPY 70 CONGENITAL ANOMALIES OF UPPER ALIMENTARY TRACT, EXCLUDING TONGUE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 71 TERMINAL ILLNESS REGARDLESS OF DIAGNOSIS [Entire line deleted as of 10-1-07] COMFORT CARE (See Guideline Notes 7, 11, 12) [Entire line deleted as of 10-1-07] 72 CANCRUM ORIS MEDICAL THERAPY 73 DISSEMINATED INFECTIONS WITH LOCALIZED SITES MEDICAL THERAPY 74 VENTRICULAR SEPTAL DEFECT (See Guideline Notes 1,6) CLOSURE 75 ACUTE BACTERIAL MENINGITIS (See Guideline Note 6) MEDICAL THERAPY 76 ACUTE AND SUBACUTE ISCHEMIC HEART DISEASE, MYOCARDIAL INFARCTION (See Guideline Notes 1,6,13) MEDICAL AND SURGICAL TREATMENT 77 CONGENITAL PULMONARY VALVE STENOSIS PULMONARY VALVE REPAIR 78 NEUROLOGICAL DYSFUNCTION IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL CAUSED BY CHRONIC CONDITIONS (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT (EG. G-TUBES, J-TUBES, RESPIRATORS, TRACHEOSTOMY, UROLOGICAL PROCEDURES) 79 AGRANULOCYTOSIS (See Guideline Notes 1,7,11,14) BONE MARROW TRANSPLANTATION 80 BURN, PARTIAL THICKNESS GREATER THAN 30% OF BODY SURFACE OR WITH VITAL SITE; FULL THICKNESS WITH VITAL SITE, LESS THAN 10% OF BODY SURFACE (See Guideline Notes 1,6) FREE SKIN GRAFT, MEDICAL THERAPY 81 POLYCYTHEMIA NEONATORUM, SYMPTOMATIC MEDICAL THERAPY 82 DERMATOMYOSITIS, POLYMYOSITIS (See Guideline Note 1) MEDICAL THERAPY 83 ADDISON'S DISEASE MEDICAL THERAPY 84 DEEP ABSCESSES, INCLUDING APPENDICITIS AND PERIORBITAL ABSCESS (See Guideline Note 1) MEDICAL AND SURGICAL THREATMENT 85 PATENT DUCTUS ARTERIOSUS; AORTIC PULMONARY FISTULA (See Guideline Notes 1,6) LIGATION 86 INJURY TO MAJOR BLOOD VESSELS OF EXTREMITIES LIGATION 87 PHLEBITIS AND THROMBOPHLEBITIS, DEEP (See Guideline Note 1) MEDICAL THERAPY 88 INJURY TO INTERNAL ORGANS MEDICAL AND SURGICAL TREATMENT 89 FRACTURE OF HIP, CLOSED (See Guideline Notes 6,15) MEDICAL AND SURGICAL TREATMENT 90 MYOCARDITIS (NONVIRAL), PERICARDITIS (NONVIRAL) AND ENDOCARDITIS (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 91 DEEP OPEN WOUND OF NECK, INCLUDING LARYNX; FRACTURE OF LARYNX OR TRACHEA, OPEN REPAIR 92 DIABETES MELLITUS WITH END STAGE RENAL DISEASE (See Coding Specification Below) (See Guideline Notes 1,16) SIMULTANEOUS PANCREAS/KIDNEY (SPK) TRANSPLANT, PANCREAS AFTER KIDNEY (PAK) TRANSPLANT 93 DISORDERS OF PANCREATIC ENDOCRINE SECRETION MEDICAL AND SURGICAL TREATMENT 94 ENDOCARDIAL CUSHION DEFECTS (See Guideline Notes 1,6) REPAIR 95 CONGENITAL PULMONARY VALVE ATRESIA (See Guideline Note 6) SHUNT/REPAIR 96 CONGENITAL ANOMALIES OF URINARY SYSTEM (See Guideline Note 1) RECONSTRUCTION 97 NECROTIZING ENTEROCOLITIS IN FETUS OR NEWBORN MEDICAL AND SURGICAL TREATMENT 98 TRANSPOSITION OF GREAT VESSELS (See Guideline Notes 1,6) REPAIR 99 CONGENITAL MITRAL VALVE STENOSIS/INSUFFICIENCY (See Guideline Note 6) MITRAL VALVE REPAIR/REPLACEMENT 100 GUILLAIN-BARRE SYNDROME (See Guideline Notes 1,6) MEDICAL THERAPY 101 SEVERE/MODERATE HEAD INJURY: HEMATOMA/EDEMA WITH LOSS OF CONSCIOUSNESS, COMPOUND/DEPRESSED FRACTURES OF SKULL (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 102 ACUTE LYMPHOCYTIC LEUKEMIA (CHILD) (See Guideline Notes 1,7,11) MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 103 ACUTE LEUKEMIAS, MYELODYSPLASTIC SYNDROME (See Guideline Notes 1,7,11,14) BONE MARROW TRANSPLANT 104 UNDESCENDED TESTICLE SURGICAL TREATMENT 105 PREVENTIVE DENTAL SERVICES (See Guideline Note 17) CLEANING AND FLUORIDE 106 HEREDITARY IMMUNE DEFICIENCIES (See Guideline Notes 1,7,11,14) BONE MARROW TRANSPLANT 107 DIABETIC AND OTHER RETINOPATHY LASER SURGERY 108 BORDERLINE PERSONALITY DISORDER MEDICAL/PSYCHOTHERAPY 109 HEART FAILURE (See Guideline Notes 1,6,18) MEDICAL THERAPY 110 CARDIOMYOPATHY, HYPERTROPHIC MUSCLE (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 111 END STAGE RENAL DISEASE (See Guideline Note 1) RENAL TRANSPLANT 112 CONGENITAL ANOMALIES OF DIGESTIVE SYSTEM AND ABDOMINAL WALL EXCLUDING NECROSIS; CHRONIC INTESTINAL PSEUDO-OBSTRUCTION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 113 HEMOLYTIC DISEASE DUE TO ISOIMMUNIZATION, ANEMIA DUE TO TRANSPLACENTAL HEMORRHAGE, AND FETAL AND NEONATAL JAUNDICE MEDICAL THERAPY 114 POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTS (See Guideline Note 1) MEDICAL THERAPY 115 BOTULISM MEDICAL THERAPY 116 TETRALOGY OF FALLOT (TOF) (See Guideline Notes 1,6) TOTAL REPAIR TETRALOGY 117 CONGENITAL STENOSIS AND INSUFFICIENCY OF AORTIC VALVE (See Guideline Note 6) SURGICAL VALVE REPLACEMENT/VALVULOPLASTY 118 GIANT CELL ARTERITIS, KAWASAKI DISEASE, THROMBOANGIITIS OBLITERANS MEDICAL THERAPY 119 FRACTURE OF RIBS AND STERNUM, OPEN MEDICAL AND SURGICAL TREATMENT 120 SUBACUTE MENINGITIS (EG. TUBERCULOSIS, CRYPTOCOCCOSIS) (See Guideline Note 1) MEDICAL THERAPY 121 PNEUMOCYSTIS CARINII PNEUMONIA MEDICAL THERAPY 122 COAGULATION DEFECTS MEDICAL THERAPY 123 CONGENITAL HEART BLOCK; OTHER OBSTRUCTIVE ANOMALIES OF HEART (See Guideline Notes 1,6) MEDICAL THERAPY 124 CANCER OF TESTIS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 125 CANCER OF EYE AND ORBIT, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY 126 HODGKIN'S DISEASE (See Guideline Notes 7,11,14,19) BONE MARROW TRANSPLANT 127 FOREIGN BODY IN PHARYNX, LARYNX, TRACHEA, BRONCHUS AND ESOPHAGUS REMOVAL OF FOREIGN BODY 128 IRON DEFICIENCY ANEMIA AND OTHER NUTRITIONAL DEFICIENCIES MEDICAL THERAPY 129 PERNICIOUS AND SIDEROBLASTIC ANEMIA (See Guideline Note 1) MEDICAL THERAPY 130 ATRIAL SEPTAL DEFECT, SECUNDUM (See Guideline Note 6) REPAIR SEPTAL DEFECT 131 AMEBIASIS MEDICAL THERAPY 132 OTHER SPECIFIED APLASTIC ANEMIAS (See Guideline Notes 7,11,14) BONE MARROW TRANSPLANT 133 PHYSICAL AND SEXUAL ABUSE INCLUDING RAPE MEDICAL THERAPY 134 ATTENTION DEFICIT DISORDERS WITH HYPERACTIVITY OR UNDIFFERENTIATED (See Guideline Note 20) MEDICAL/PSYCHOTHERAPY 135 PYODERMA; MODERATE/SEVERE PSORIASIS (See Guideline Notes 1,21) MEDICAL THERAPY 136 MALARIA AND RELAPSING FEVER (See Guideline Note 1) MEDICAL THERAPY 137 THYROTOXICOSIS WITH OR WITHOUT GOITER, ENDOCRINE EXOPHTHALMOS; CHRONIC THYROIDITIS MEDICAL AND SURGICAL TREATMENT, INCLUDING RADIATION THERAPY 138 BENIGN NEOPLASM OF THE BRAIN (See Guideline Note 1) CRANIOTOMY/CRANIECTOMY, LINEAR ACCELERATOR, MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY 139 ACUTE GLOMERULONEPHRITIS: WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS (See Guideline Notes 1,7) MEDICAL THERAPY INCLUDING DIALYSIS 140 COMMON TRUNCUS (See Guideline Note 6) TOTAL REPAIR/REPLANT ARTERY 141 WEGENER'S GRANULOMATOSIS (See Guideline Note 1) MEDICAL THERAPY AND RADIATION THERAPY 142 TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION (See Guideline Notes 1,6) COMPLETE REPAIR 143 CRUSH INJURIES OTHER THAN DIGITS (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 144 OPEN FRACTURE/DISLOCATION OF EXTREMETIES (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 145 CANCER OF CERVIX, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 146 INTERRUPTED AORTIC ARCH (See Guideline Note 6) TRANSVERSE ARCH GRAFT 147 TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 148 OPPORTUNISTIC INFECTIONS IN IMMUNOCOMPROMISED HOSTS; CANDIDIASIS OF STOMA; PERSONS RECEIVING CONTINUOUS ANTIBIOTIC THERAPY (See Guideline Note 1) MEDICAL THERAPY 149 EBSTEIN'S ANOMALY REPAIR SEPTAL DEFECT/VALVULOPLASTY/REPLACEMENT 150 GLAUCOMA, OTHER THAN PRIMARY ANGLE-CLOSURE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 151 MYASTHENIA GRAVIS (See Guideline Note 1) MEDICAL THERAPY, THYMECTOMY 152 SYSTEMIC LUPUS ERYTHEMATOSUS, OTHER DIFFUSE DISEASES OF CONNECTIVE TISSUE (See Guideline Note 1) MEDICAL THERAPY 153 CONDITIONS INVOLVING THE TEMPERATURE REGULATION OF NEWBORNS MEDICAL THERAPY 154 PNEUMOTHORAX AND HEMOTHORAX TUBE THORACOSTOMY/THORACOTOMY, MEDICAL THERAPY 155 HYPOTHERMIA MEDICAL THERAPY, EXTRACORPOREAL CIRCULATION 156 ANEMIA OF PREMATURITY OR TRANSIENT NEONATAL NEUTROPENIA MEDICAL THERAPY 157 ENTERIC INFECTIONS AND OTHER BACTERIAL FOOD POISONING MEDICAL THERAPY 158 ACQUIRED HEMOLYTIC ANEMIAS MEDICAL THERAPY 159 CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; OTHER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY (See Guideline Notes 1,6,22) MEDICAL AND SURGICAL TREATMENT 160 CHORIOCARCINOMA, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 161 DISORDERS OF MINERAL METABOLISM, OTHER THAN CALCIUM MEDICAL THERAPY 162 PYOGENIC ARTHRITIS (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 163 BENIGN NEOPLASM OF PITUITARY GLAND MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY 164 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE SURGICAL TREATMENT 165 HERPES ZOSTER; HERPES SIMPLEX AND WITH NEUROLOGICAL AND OPHTHALMOLOGICAL COMPLICATIONS (See Guideline Note 1) MEDICAL THERAPY 166 TRAUMATIC AMPUTATION OF ARM(S), HAND(S), THUMB(S), AND FINGER(S) (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 167 HODGKIN'S DISEASE (See Guideline Notes 1,7,11,14) MEDICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 168 CANCER OF COLON, RECTUM, SMALL INTESTINE AND ANUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,23) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 169 CHRONIC GRANULOMATOUS DISEASE (See Guideline Notes 1,7,11) MEDICAL THERAPY 170 BILIARY ATRESIA (See Guideline Note 1,16) LIVER TRANSPLANT 171 NON-HODGKIN'S LYMPHOMAS (See Guideline Notes 7,11,14,19) BONE MARROW TRANSPLANT 172 LEUKOPLAKIA AND CARCINOMA IN SITU OF ORAL MUCOSA, INCLUDING TONGUE INCISION/EXCISION, MEDICAL THERAPY 173 PREVENTIVE FOOT CARE IN HIGH RISK PATIENTS MEDICAL AND SURGICAL TREATMENT OF TOENAILS AND HYPERKERATOSES OF FOOT 174 ANAL, RECTAL AND COLONIC POLYPS (See Guideline Note 1) EXCISION OF POLYP 175 GONOCOCCAL AND CHLAMYDIAL INFECTION OF TH EYE MEDICAL THERAPY 176 COMPLICATED HERNIAS; UNCOMPLICATED HERNIA IN CHILDREN UNDER AGE 18 (See Guideline Note 24) REPAIR 177 NON-DIABETIC HYPOGLYCEMIC COMA MEDICAL THERAPY 178 RUPTURED SPLEEN REPAIR/SPLENECTOMY/INCISION 179 ACUTE MASTOIDITIS MASTOIDECTOMY, MEDICAL THERAPY 180 HYPERTENSIVE HEART AND RENAL DISEASE (See Guideline Notes 1,6) MEDICAL THERAPY 181 POSTTRAUMATIC STRESS DISORDER (See Guideline Note 25) MEDICAL/PSYCHOTHERAPY 182 ACUTE NON-LYMPHOCYTIC LEUKEMIAS (See Guideline Notes 1,7,11) MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 183 GENERALIZED CONVULSIVE OR PARTIAL EPILEPSY WITHOUT MENTION OF IMPAIRMENT OF CONSCIOUSNESS (See Guideline Notes 1,19) SINGLE FOCAL SURGERY 184 POLYARTERITIS NODOSA AND ALLIED CONDITIONS (See Guideline Note 1) MEDICAL THERAPY 185 COMMON VENTRICLE (See Guideline Note 6) TOTAL REPAIR 186 INTRACEREBRAL HEMORRHAGE (See Guideline Notes 1,6) MEDICAL THERAPY 187 URETERAL STRICTURE OR OBSTRUCTION; HYDRONEPHROSIS; HYDROURETER MEDICAL AND SURGICAL TREATMENT 188 CONDITIONS INVOLVING EXPOSURE TO NATURAL ELEMENTS (EG. LIGHTNING STRIKE, HEATSTROKE) MEDICAL THERAPY, BURN TREATMENT 189 SEPTICEMIA MEDICAL THERAPY 190 FRACTURE OF PELVIS, OPEN AND CLOSED (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 191 ACUTE OSTEOMYELITIS (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 192 DIVERTICULITIS OF COLON (See Guideline Note 1) COLON RESECTION, MEDICAL THERAPY 193 MULTIPLE VALVULAR DISEASE (See Guideline Note 6) SURGICAL TREATMENT 194 CUSHING'S SYNDROME; HYPERALDOSTERONISM, OTHER CORTICOADRENAL OVERACTIVITY, MEDULLOADRENAL HYPERFUNCTION (See Guideline Note 1) MEDICAL THERAPY/ADRENALECTOMY 195 CONGENITAL TRICUSPID ATRESIA AND STENOSIS (See Guideline Note 6) REPAIR 196 CHRONIC ISCHEMIC HEART DISEASE (See Guideline Notes 1,6,13) MEDICAL AND SURGICAL TREATMENT 197 NEOPLASMS OF ISLETS OF LANGERHANS (See Guideline Note 1) EXCISION OF TUMOR 198 CANCER OF BREAST, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Coding Specification Below) (See Guideline Notes 1,3,7,11,26) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY, RADIATION THERAPY AND BREAST RECONSTRUCTION 199 MULTIPLE MYELOMA (See Guideline Notes 7,11,14) BONE MARROW TRANSPLANT 200 HEREDITARY ANEMIAS, HEMOGLOBINOPATHIES, AND DISORDRES OF THE SPLEEN (See Guideline Note 1) MEDICAL THERAPY 201 ACUTE PANCREATITIS MEDICAL THERAPY 202 SUBARACHNOID AND INTRACEREBRAL HEMORRHAGE/HEMATOMA; COMPRESSION OF BRAIN (See Guideline Notes 1,6) BURR HOLES, CRANIECTOMY/CRANIOTOMY 203 BURN, PARTIAL THICKNESS WITHOUT VITAL SITE, 10-30% OF BODY SURFACE (See Guideline Notes 1,6) FREE SKIN GRAFT, MEDICAL THERAPY 204 TETANUS NEONATORUM MEDICAL THERAPY 205 CONGENITAL CYSTIC LUNG - MILD AND MODERATE LUNG RESECTION, MEDICAL THERAPY 206 CHRONIC HEPATITIS; VIRAL HEPATITIS (See Guideline Note 1) MEDICAL THERAPY 207 CONSTITUTIONAL APLASTIC ANEMIAS (See Guideline Notes 7,11,14) BONE MARROW TRANSPLANT 208 CANCER OF SOFT TISSUE, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 209 CANCER OF BONES, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,6,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 210 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS (See Guideline Note 1) CONSULTATION/MEDICATION MANAGEMENT/LIMITED BEHAVIORAL MODIFICATION 211 SLEEP APNEA (See Guideline Notes 1,27) MEDICAL AND SURGICAL TREATMENT 212 ERYSIPELAS MEDICAL THERAPY 213 DEPRESSION AND OTHER MOOD DISORDERS, MILD OR MODERATE (See Guideline Note 28) MEDICAL/PSYCHOTHERAPY 214 PNEUMOCOCCAL PNEUMONIA, OTHER BACTERIAL PNEUMONIA, BRONCHOPNEUMONIA MEDICAL THERAPY 215 SUPERFICIAL ABSCESSES AND CELLULITIS (See Coding Specification Below) MEDICAL AND SURGICAL TREATMENT 216 ZOONOTIC BACTERIAL DISEASES MEDICAL THERAPY 217 DEEP OPEN WOUND, WITH OR WITHOUT TENDON OR NERVE INVOLVEMENT (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 218 CHOANAL ATRESIA REPAIR OF CHOANAL ATRESIA 219 CANCER OF UTERUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 220 RUPTURE OF LIVER SUTURE/REPAIR 221 CANCER OF THYROID, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 222 NON-HODGKIN'S LYMPHOMAS (See Guideline Notes 1,7,11,19,29) MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 223 PATHOLOGICAL GAMBLING (Note: This line is not priced as part of the list as funding comes from non-OHP sources.) MEDICAL/PSYCHOTHERAPY 224 BULLOUS DERMATOSES OF THE SKIN MEDICAL THERAPY 225 ESOPHAGEAL VARICES (See Guideline Note 1) MEDICAL THERAPY/SHUNT/SCLEROTHERAPY 226 TOXIC EPIDERMAL NECROLYSIS AND STAPHYLOCOCCAL SCALDED SKIN SYNDROME; STEVENS-JOHNSON SYNDROME; ECZEMA HERPETICUM MEDICAL THERAPY 227 ACUTE PULMONARY HEART DISEASE AND PULMONARY EMBOLI (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 228 CANDIDIASIS OF LUNG, DISSEMINATED CANDIDIASIS, CANDIDAL ENDOCARDITIS AND MENINGITIS (See Guideline Note 1) MEDICAL THERAPY 229 CANCER OF KIDNEY AND OTHER URINARY ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 230 CANCER OF STOMACH, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 231 PORTAL VEIN THROMBOSIS MEDICAL AND SURGICAL TREATMENT 232 TESTICULAR CANCER (See Guideline Notes 7,11,14,30) BONE MARROW RESCUE AND TRANSPLANT 233 PULMONARY FIBROSIS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 234 OCCUPATIONAL LUNG DISEASES (See Guideline Note 1) MEDICAL THERAPY 235 ANAPHYLACTIC SHOCK; EDEMA OF LARYNX MEDICAL THERAPY 236 DISORDERS OF FLUID, ELECTROLYTE, AND ACID-BASE BALANCE (See Guideline Notes 1,7) MEDICAL THERAPY, DIALYSIS 237 DISEASES AND DISORDERS OF AORTIC VALVE (See Guideline Notes 1,6) AORTIC VALVE REPLACEMENT, VALVULOPLASTY, MEDICAL THERAPY 238 DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLAND; DISORDERS OF CALCIUM METABOLISM (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 239 ACUTE INFLAMMATION OF THE HEART DUE TO RHEUMATIC FEVER (See Guideline Note 6) MEDICAL THERAPY 240 RUPTURED VISCUS REPAIR 241 INTESTINAL MALABSORPTION MEDICAL THERAPY 242 FRACTURE OF FACE BONES; INJURY TO OPTIC AND OTHER CRANIAL NERVES SURGICAL TREATMENT 243 MALIGNANT MELANOMA OF SKIN, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 7,11,19) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 244 LEPTOSPIROSIS (See Guideline Note 1) MEDICAL THERAPY 245 URINARY FISTULA SURGICAL TREATMENT 246 UNSPECIFIED DISEASES DUE TO MYCOBACTERIA, ACTINOMYCOTIC INFECTIONS, AND TOXOPLASMOSIS (See Guideline Note 1) MEDICAL THERAPY 247 HYPOPLASTIC LEFT HEART SYNDROME REPAIR 248 ADULT RESPIRATORY DISTRESS SYNDROME; RESPIRATORY CONDITIONS DUE TO PHYSICAL AND CHEMICAL AGENTS MEDICAL THERAPY 249 ACUTE LYMPHOCYTIC LEUKEMIAS (ADULT) AND MULTIPLE MYELOMA (See Guideline Notes 1,7,11) MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 250 PERIPHERAL VASCULAR DISEASE, LIMB THREATENING INFECTIONS, AND VASCULAR COMPLICATIONS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 251 TETANUS MEDICAL THERAPY 252 CANCER OF OVARY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 253 SHORT BOWEL SYNDROME - AGE 5 OR UNDER (See Guideline Notes 1,16) INTESTINE AND INTESTINE/LIVER TRANSPLANT 254 DEFICIENCIES OF CIRCULATING ENZYMES (ALPHA 1-ANTITRYPSIN DEFICIENCY); CYSTIC FIBROSIS; EMPHYSEMA (See Guideline Notes 1,16) HEART-LUNG AND LUNG TRANSPLANT 255 ACUTE AND SUBACUTE NECROSIS OF LIVER; SPECIFIED INBORN ERRORS OF METABOLISM (EG. MAPLE SYRUP URINE DISEASE, TYROSINEMIA) (See Guideline Notes 1,16) LIVER TRANSPLANT 256 RESPIRATORY FAILURE DUE TO PRIMARY PULMONARY HYPERTENSION, PRIMARY PULMONARY FIBROSIS, LYMPHANGIOLEIOMYOMATOSIS, EISENMENGER'S DISEASE (See Guideline Note 1,16) HEART-LUNG AND LUNG TRANSPLANTS 257 DERMATOLOGICAL PREMALIGNANT LESIONS AND CARCINOMA IN SITU DESTRUCT/EXCISION/MEDICAL THERAPY 258 PRIMARY ANGLE-CLOSURE GLAUCOMA IRIDECTOMY, LASER SURGERY 259 CORNEAL ULCER; SUPERFICIAL INJURY OF EYE AND ADNEXA CONJUNCTIVAL FLAP; MEDICAL THERAPY 260 TORSION OF OVARY OOPHORECTOMY, OVARIAN CYSTECTOMY 261 TORSION OF TESTIS ORCHIECTOMY, REPAIR 262 LIFE-THREATENING EPISTAXIS SEPTOPLASTY/REPAIR/CONTROL HEMORRHAGE 263 RETAINED INTRAOCULAR FOREIGN BODY, MAGNETIC AND NONMAGNETIC FOREIGN BODY REMOVAL 264 GLYCOGENOSIS MEDICAL THERAPY 265 METABOLIC BONE DISEASE (See Guideline Note 1) MEDICAL THERAPY 266 PARKINSON'S DISEASE (See Guideline Note 1) MEDICAL THERAPY 267 CHRONIC PANCREATITIS (See Guideline Note 1) MEDICAL THERAPY 268 MULTIPLE SCLEROSIS AND OTHER DEMYELINATING DISEASES OF CENTRAL NERVOUS SYSTEM (See Guideline Note 1) MEDICAL THERAPY 269 PSYCHOLOGICAL FACTORS AGGRAVATING PHYSICAL CONDITION (EG. ASTHMA, CHRONIC GI CONDITIONS, HYPERTENSION) MEDICAL/PSYCHOTHERAPY 270 ARTERIAL EMBOLISM/THROMBOSIS: ABDOMINAL AORTA, THORACIC AORTA (See Guideline Note 6) SURGICAL TREATMENT 271 CHRONIC OSTEOMYELITIS (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 272 MULTIPLE ENDOCRINE NEOPLASIA (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 273 DEFORMITIES OF HEAD (See Guideline Notes 1,6) CRANIOTOMY/CRANIECTOMY 274 DISEASES OF MITRAL VALVE AND TRICUSPID VALVES (See Guideline Notes 1,6) VALVULOPLASTY, VALVE REPLACEMENT, MEDICAL THERAPY 275 CANCER OF PENIS AND OTHER MALE GENITAL ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 276 CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL; CARCINOID SYNDROME (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 277 CANCER OF RETROPERITONEUM, PERITONEUM, OMENTUM AND MESENTERY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 278 CANCER OF LUNG, BRONCHUS, PLEURA, TRACHEA, MEDIASTINUM AND OTHER RESPIRATORY ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,19) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 279 CONGESTIVE HEART FAILURE, CARDIOMYOPATHY, TRANSPOSITION OF GREAT VESSELS, HYPOPLASTIC LEFT HEART SYNDROME (See Guideline Notes 1,6,16,18) CARDIAC TRANSPLANT 280 CHRONIC NON-LYMPHOCYTIC LEUKEMIA (See Guideline Notes 7,11,14) BONE MARROW TRANSPLANT 281 TRACHOMA MEDICAL THERAPY 282 ACUTE, SUBACUTE, CHRONIC AND OTHER TYPES OF IRIDOCYCLITIS MEDICAL THERAPY 283 RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASES MEDICAL THERAPY 284 DIABETES INSIPIDUS (See Guideline Note 1) MEDICAL THERAPY 285 SYMPATHETIC UVEITIS AND DEGENERATIVE DISORDERS AND CONDITIONS OF GLOBE ENUCLEATION 286 CANCER OF BLADDER AND URETER, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 287 TRAUMATIC AMPUTATION OF FOOT/FEET (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 288 ACUTE POLIOMYELITIS (See Guideline Note 6) MEDICAL THERAPY 289 LEPROSY, YAWS, PINTA (See Guideline Note 1) MEDICAL THERAPY 290 UROLOGIC INFECTIONS MEDICAL THERAPY 291 CANCER OF SKIN, EXCLUDING MALIGNANT MELANOMA, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 292 INJURY TO BLOOD VESSELS OF THE THORACIC CAVITY (See Guideline Note 6) REPAIR 293 RUPTURE OF BLADDER, NONTRAUMATIC MEDICAL AND SURGICAL TREATMENT 294 OTHER PSYCHOTIC DISORDERS MEDICAL/PSYCHOTHERAPY 295 HYDROPS FETALIS MEDICAL THERAPY 296 DEFORMITY/CLOSED DISLOCATION OF JOINT (See Guideline Note 6) SURGICAL TREATMENT 297 SENSORINEURAL HEARING LOSS - AGE 5 OR UNDER (See Guideline Note 31) COCHLEAR IMPLANT 298 RETINAL DETACHMENT AND OTHER RETINAL DISORDERS RETINAL REPAIR, VITRECTOMY 299 ARTHROPOD-BORNE VIRAL DISEASES MEDICAL THERAPY 300 HYPOPLASIA AND DYSPLASIA OF LUNG MEDICAL THERAPY 301 CHRONIC RHEUMATIC PERICARDITIS, RHEUMATIC MYOCARDITIS (See Guideline Notes 1,6) MEDICAL THERAPY 302 BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSIS THROMBECTOMY/LIGATION 303 LIFE-THREATENING CARDIAC ARRHYTHMIAS (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT 304 ANOREXIA NERVOSA MEDICAL/PSYCHOTHERAPY 305 CHRONIC OBSTRUCTIVE PULMONARY DISEASE; CHRONIC RESPIRATORY FAILURE (See Guideline Note 1) MEDICAL THERAPY 306 DISSECTING OR RUPTURED AORTIC ANEURYSM (See Guideline Note 6) SURGICAL TREATMENT 307 COMPLICATIONS OF A PROCEDURE ALWAYS REQUIRING TREATMENT (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 308 RUPTURE OF PAPILLARY MUSCLE (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 309 CHRONIC LEUKEMIAS; POLYCYTHEMIA RUBRA VERA (See Guideline Notes 1,7,11) MEDICAL THERAPY, WHICH INCLUDES CHEMOTHERAPY, RADIATION AND RADIONUCLEIDE THERAPY 310 CANCER OF VAGINA, VULVA AND OTHER FEMALE GENITAL ORGANS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 311 CANCER OF ORAL CAVITY, PHARYNX, NOSE AND LARYNX, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 312 CONSTITUTIONAL APLASTIC ANEMIA (See Guideline Note 1) MEDICAL THERAPY 313 OSTEOPETROSIS (See Guideline Notes 1,7,11,14) BONE MARROW RESCUE AND TRANSPLANT 314 CRUSH INJURIES OF DIGITS MEDICAL AND SURGICAL TREATMENT 315 ACUTE STRESS DISORDER MEDICAL/PSYCHOTHERAPY 316 ADRENAL OR CUTANEOUS HEMORRHAGE OF FETUS OR NEONATE MEDICAL THERAPY 317 NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS (See Guideline Notes 1,6) MEDICAL AND SURGICAL TREATMENT (EG. DURABLE MEDICAL EQUIPMENT AND ORTHOPEDIC PROCEDURE) 318 ANOMALIES OF GALLBLADDER, BILE DUCTS, AND LIVER MEDICAL AND SURGICAL TREATMENT 319 CANCER OF BRAIN AND NERVOUS SYSTEM, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) LINEAR ACCELERATOR, MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 320 CATARACT, EXCLUDING CONGENITAL (See Guideline Note 32) EXTRACTION OF CATARACT 321 AFTER CATARACT DISCISSION, LENS CAPSULE 322 FISTULA INVOLVING FEMALE GENITAL TRACT CLOSURE OF FISTULA 323 VITREOUS DISORDERS VITRECTOMY 324 CLEFT PALATE AND/OR CLEFT LIP EXCISION AND REPAIR VESTIBULE OF MOUTH, ORTHODONTICS 325 GOUT AND CRYSTAL ARTHROPATHIES (See Guideline Note 1) MEDICAL THERAPY 326 PERTUSSIS AND DIPTHERIA MEDICAL THERAPY 327 THROMBOCYTOPENIA MEDICAL AND SURGICAL THREATMENT 328 DISORDERS OF AMINO-ACID TRANSPORT AND METABOLISM (NON PKU) MEDICAL THERAPY 329 PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3 MEDICAL THERAPY 330 DISORDERS OF ARTERIES, OTHER THAN CAROTID OR CORONARY (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 331 PARALYTIC ILEUS MEDICAL AND SURGICAL TREATMENT 332 CIRRHOSIS OF LIVER OR BILIARY TRACT; BUDD-CHIARI SYNDROME; HEPATIC VEIN THROMBOSIS; INTRAHEPATIC VASCULAR MALFORMATIONS; CAROLI'S DISEASE (See Coding Specification Below) (See Guideline Notes 1,16) LIVER TRANSPLANT, LIVER-KIDNEY TRANSPLANT 333 CHRONIC INFLAMMATORY DISORDER OF ORBIT MEDICAL THERAPY 334 CONGENITAL DISLOCATION OF HIP; COXA VARA AND VALGA (See Guideline Note 6) SURGICAL TREATMENT 335 CORNEAL OPACITY AND OTHER DISORDERS OF CORNEA KERATOPLASTY 336 DISORDERS INVOLVING THE IMMUNE SYSTEM (See Guideline Note 1) MEDICAL THERAPY 337 CANCER OF ESOPHAGUS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,33) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 338 CANCER OF LIVER, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,33) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 339 CANCER OF PANCREAS, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,33) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 340 STROKE (See Guideline Notes 1,6) MEDICAL THERAPY 341 HEREDITARY ANGIOEDEMA; ANGIONEUROTIC EDEMA MEDICAL THERAPY 342 PURULENT ENDOPHTHALMITIS VITRECTOMY 343 FOREIGN BODY IN CORNEA AND CONJUNCTIVAL SAC REMOVAL CONJUNCTIVAL FOREIGN BODY 344 OTHER ANEURYSM OF PERIPHERAL ARTERY SURGICAL TREATMENT 345 SIALOADENITIS, ABSCESS, FISTULA OF SALIVARY GLANDS MEDICAL AND SURGICAL TREATMENT 346 CYSTICERCOSIS, OTHER CESTODE INFECTION, TRICHINOSIS MEDICAL THERAPY 347 NON-DISSECTING ANEURYSM WITHOUT RUPTURE (See Guideline Note 6) SURGICAL TREATMENT 348 ARTERIAL ANEURYSM OF NECK (See Guideline Note 6) REPAIR 349 FUNCTIONAL AND MECHANICAL DISORDERS OF THE GENITOURINARY SYSTEM INCLUDING BLADDER OUTLET OBSTRUCTION (See Coding Specification Below) MEDICAL AND SURGICAL TREATMENT 350 ACUTE GLOMERULONEPHRITIS AND OTHER ACUTE RENAL FAILURE (See Guideline Notes 1,7) MEDICAL THERAPY INCLUDING DIALYSIS 351 VESICULAR FISTULA MEDICAL AND SURGICAL TREATMENT 352 COCCIDIOIDOMYCOSIS, HISTOPLASMOSIS, BLASTOMYCOTIC INFECTION, OPPORTUNISTIC AND OTHER MYCOSES (See Guideline Note 1) MEDICAL THERAPY 353 DISSEMINATED INTRAVASCULAR COAGULATION MEDICAL AND SURGICAL TREATMENT 354 CANCER OF PROSTATE GLAND, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 355 SYSTEMIC SCLEROSIS (See Guideline Note 1) MEDICAL THERAPY 356 ANAEROBIC INFECTIONS REQUIRING HYPERBARIC OXYGEN HYPERBARIC OXYGEN 357 DENTAL CONDITIONS (EG. DENTAL CARIES, FRACTURED TOOTH) (See Guideline Note 34) BASIC RESTORATIVE 358 BENIGN CEREBRAL CYSTS DRAINAGE 359 ALCOHOLIC FATTY LIVER OR ALCOHOLIC HEPATITIS, CIRRHOSIS OF LIVER (See Guideline Note 1) MEDICAL THERAPY 360 SCLERITIS MEDICAL THERAPY 361 RUBEOSIS IRIDIS LASER SURGERY 362 DISEASES OF ENDOCARDIUM (See Guideline Note 6) MEDICAL THERAPY 363 WOUND OF EYE GLOBE SURGICAL REPAIR 364 ACUTE NECROSIS OF LIVER MEDICAL THERAPY 365 NEPHROTIC SYNDROME AND OTHER RENAL DISORDERS (See Guideline Notes 1,7) MEDICAL THERAPY INCLUDING DIALYSIS 366 IDIOPATHIC OR VIRAL MYOCARDITIS AND PERICARDITIS (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 367 HEREDITARY HEMORRHAGIC TELANGIECTASIA EXCISION 368 RHEUMATIC FEVER (See Guideline Note 6) MEDICAL THERAPY 369 HEREDITARY FRUCTOSE INTOLERANCE, INTESTINAL DISACCHARIDASE AND OTHER DEFICIENCIES (See Guideline Note 1) MEDICAL THERAPY 370 ACROMEGALY AND GIGANTISM, OTHER AND UNSPECIFIED ANTERIOR PITUITARY HYPERFUNCTION, BENIGN NEOPLASM OF THYROID GLAND AND OTHER ENDOCRINE GLANDS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES RADIATION THERAPY 371 RETROLENTAL FIBROPLASIA CRYOSURGERY 372 NEUROLOGICAL DYSFUNCTION IN COMMUNICATION CAUSED BY CHRONIC CONDITIONS (See Guideline Notes 1,6) MEDICAL THERAPY 373 CARDIAC ARRHYTHMIAS (See Guideline Notes 1,6) MEDICAL THERAPY, PACEMAKER 374 MILD/MODERATE BIRTH TRAUMA FOR BABY (See Guideline Note 1) MEDICAL THERAPY 375 ATHEROSCLEROSIS, PERIPHERAL (See Guideline Note 6) SURGICAL TREATMENT 376 URINARY TRACT CALCULUS CYSTOURETHROSCOPY WITH FRAGMENTATION OF CALCULUS, MEDICAL THERAPY 377 CONGENITAL ABSENCE OF VAGINA ARTIFICIAL VAGINA 378 PENETRATING WOUND OF ORBIT MEDICAL AND SURGICAL TREATMENT 379 CLOSED FRACTURE OF EXTREMITIES (EXCEPT TOES) (See Guideline Note 6) OPEN OR CLOSED REDUCTION 380 HEARING LOSS - AGE 5 OR UNDER MEDICAL THERAPY INCLUDING HEARING AIDS 381 RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE (See Guideline Notes 6,15) ARTHROPLASTY/RECONSTRUCTION 382 ANEURYSM OF PULMONARY ARTERY (See Guideline Note 6) SURGICAL TREATMENT 383 BODY INFESTATIONS (EG. LICE, SCABIES) MEDICAL THERAPY 384 LYME DISEASE AND OTHER ARTHROPOD BORNE DISEASES (See Guideline Notes 1,6) MEDICAL THERAPY 385 DYSTONIA (UNCONTROLLABLE); LARYNGEAL SPASM AND STENOSIS MEDICAL THERAPY 386 CYST AND PSEUDOCYST OF PANCREAS DRAINAGE OF PANCREATIC CYST 387 CONVERSION DISORDER, CHILD MEDICAL/PSYCHOTHERAPY 388 ACUTE SINUSITIS (See Guideline Note 35) MEDICAL AND SURGICAL TREATMENT 389 HYPHEMA REMOVAL OF BLOOD CLOT 390 ENTROPION REPAIR 391 SPONTANEOUS ABORTION (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 392 STREPTOCOCCAL SORE THROAT AND SCARLET FEVER; VINCENT'S DISEASE; HYPERTROPHY OF TONSILS AND ADENOIDS; ULCER OF TONSIL (See Guideline Note 36) MEDICAL THERAPY, TONSILLECTOMY/ADENOIDECTOMY 393 GIARDIASIS, INTESTINAL HELMINTHIASIS MEDICAL THERAPY 394 AMBLYOPIA MEDICAL AND SURGICAL TREATMENT 395 SOMATIZATION DISORDER; SOMATOFORM PAIN DISORDER CONSULTATION/BEHAVIORAL MANAGEMENT 396 TOXIC EFFECT OF GASES, FUMES, AND VAPORS REQUIRING HYPERBARIC OXYGEN HYPERBARIC OXYGEN 397 DISORDERS OF SPINE WITH NEUROLOGIC IMPAIRMENT (See Guideline Notes 1,6,37) MEDICAL AND SURGICAL TREATMENT 398 ENCEPHALOCELE SURGICAL TREATMENT 399 BENIGN NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANS LOBECTOMY, MEDICAL THERAPY, WHICH INCLUDES RADIATION THERAPY 400 IMPERFORATE HYMEN, ABNORMALITIES OF VAGINAL SEPTUM SURGICAL TREATMENT 401 RETINAL TEAR LASER PROPHYLAXIS 402 CHOLESTEATOMA; INFECTIONS OF THE PINNA MEDICAL AND SURGICAL TREATMENT 403 DISRUPTIONS OF THE LIGAMENTS AND TENDONS OF THE ARMS AND LEGS, EXCLUDING THE KNEE, GRADE II AND III (See Guideline Note 6) REPAIR 404 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF-DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION (See Guideline Notes 1,6,38) MEDICAL THERAPY (SHORT TERM REHABILITATION WITH DEFINED GOALS) 405 ANEMIAS DUE TO DISEASE OR TREATMENT AND OTHER APLASTIC ANEMIAS MEDICAL THERAPY 406 ESOPHAGEAL STRICTURE MEDICAL AND SURGICAL TREATMENT 407 CHRONIC ULCER OF SKIN (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 408 ESOPHAGITIS; ESOPHAGEAL AND INTRAESPHAGEAL HERNIAS SURGICAL TREATMENT 409 BULIMIA NERVOSA MEDICAL/PSYCHOTHERAPY 410 SUPERFICIAL INJURIES WITH INFECTION MEDICAL AND SURGICAL TREATMENT 411 PITUITARY DWARFISM MEDICAL THERAPY 412 SEPARATION ANXIETY DISORDER MEDICAL/PSYCHOTHERAPY 413 ACUTE OTITIS MEDIA MEDICAL AND SURGICAL TREATMENT 414 PANIC DISORDER; AGORAPHOBIA MEDICAL/PSYCHOTHERAPY 415 CROUP SYNDROME, EPIGLOTTITIS, ACUTE LARYNGOTRACHEITIS MEDICAL THERAPY, INTUBATION, TRACHEOTOMY 416 ACHALASIA, NON-NEONATAL (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 417 ENDOMETRIOSIS AND ADENOMYOSIS (See Guideline Notes 1,39) MEDICAL AND SURGICAL TREATMENT 418 CALCULUS OF BLADDER OR KIDNEY OPEN RESECTION, PERCUTANEOUS NEPHROSTOLITHOTOMY, NEPHROLITHOTOMY, LITHOTRIPSY 419 ESOPHAGITIS (See Guideline Note 1) MEDICAL THERAPY 420 ANOGENITAL VIRAL WARTS (See Guideline Note 1) MEDICAL THERAPY 421 EATING DISORDER NOS MEDICAL/PSYCHOTHERAPY 422 LYMPHADENITIS MEDICAL AND SURGICAL TREATMENT 423 UTERINE LEIOMYOMA (See Guideline Note 40) TOTAL HYSTERECTOMY OR MYOMECTOMY 424 APHAKIA AND OTHER DISORDERS OF LENS INTRAOCULAR LENS 425 BILATERAL ANOMALIES OF EXTERNAL EAR WITH IMPAIRMENT OF HEARING RECONSTRUCT OF EAR CANAL 426 DISSOCIATIVE DISORDERS MEDICAL/PSYCHOTHERAPY 427 EPIDERMOLYSIS BULLOSA (See Guideline Note 1) MEDICAL THERAPY 428 DELIRIUM DUE TO MEDICAL CAUSES MEDICAL THERAPY 429 SPINAL DEFORMITY, CLINICALLY SIGNIFICANT (See Guideline Notes 1,6,41) MEDICAL AND SURGICAL TREATMENT 430 MIGRAINE HEADACHES (See Guideline Note 1) MEDICAL THERAPY 431 SCHIZOTYPAL PERSONALITY DISORDERS MEDICAL/PSYCHOTHERAPY 432 BALANOPOSTHITIS AND OTHER DISORDERS OF PENIS MEDICAL AND SURGICAL TREATMENT 433 SICCA SYNDROME; POLYMYALGIA RHEUMATICA (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 434 TRANSIENT CEREBRAL ISCHEMIA; OCCLUSION/STENOSIS OF PRECEREBRAL ARTERIES WITHOUT OCCLUSION MEDICAL THERAPY; THROMBOENDARTERECTOMY 435 PERIPHERAL NERVE ENTRAPMENT (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 436 MENIERE'S DISEASE (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 437 DISORDERS OF SHOULDER (See Guideline Note 6) REPAIR/RECONSTRUCTION 438 INCONTINENCE OF FECES (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 439 OPPOSITIONAL DEFIANT DISORDER (See Guideline Note 42) MEDICAL/PSYCHOTHERAPY 440 SARCOIDOSIS (See Guideline Note 1) MEDICAL THERAPY 441 COMPLICATIONS OF A PROCEDURE USUALLY REQUIRING TREATMENT (See Guideline Notes 6,43) MEDICAL AND SURGICAL TREATMENT 442 MENSTRUAL BLEEDING DISORDERS (See Guideline Notes 1,44) MEDICAL AND SURGICAL TREATMENT 443 ADRENOGENITAL DISORDERS MEDICAL AND SURGICAL TREATMENT 444 NON-MALIGNANT OTITIS EXTERNA MEDICAL THERAPY 445 VAGINITIS, TRICHOMONIASIS MEDICAL THERAPY 446 STRABISMUS WITHOUT AMBLYOPIA AND OTHER DISORDERS OF BINOCULAR EYE MOVEMENTS; CONGENITAL ANOMALIES OF EYE MEDICAL AND SURGICAL TREATMENT 447 NONINFLAMMATORY DISORDERS AND BENIGN NEOPLASMS OF OVARY, FALLOPIAN TUBES AND UTERUS; OVARIAN CYSTS; STREAK OVARIES MEDICAL AND SURGICAL TREATMENT 448 URETHRAL FISTULA EXCISION, MEDICAL THERAPY 449 INTERNAL DERANGEMENT OF KNEE AND LIGAMENTOUS DISRUPTIONS OF THE KNEE, GRADE II AND III (See Guideline Note 6) REPAIR, MEDICAL THERAPY 450 OPEN WOUND OF EAR DRUM TYMPANOPLASTY 451 CHRONIC DEPRESSION (DYSTHYMIA) MEDICAL/PSYCHOTHERAPY 452 HYPOSPADIAS AND EPISPADIAS REPAIR 453 CANCER OF GALLBLADDER AND OTHER BILIARY, WHERE TREATMENT WILL RESULT IN A GREATER THAN 5% 5-YEAR SURVIVAL (See Guideline Notes 1,7,11,33) MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY 454 DYSTROPHY OF VULVA MEDICAL THERAPY 455 RECURRENT EROSION OF THE CORNEA CORNEAL TATTOO, REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION 456 STEREOTYPY/HABIT DISORDER AND SELF-ABUSIVE BEHAVIOR DUE TO NEUROLOGICAL DYSFUNCTION (See Guideline Note 1) CONSULTATION/MEDICATION MANAGEMENT/LIMITED BEHAVIORAL MODIFICATION 457 FOREIGN BODY IN UTERUS, VULVA AND VAGINA MEDICAL AND SURGICAL TREATMENT 458 RESIDUAL FOREIGN BODY IN SOFT TISSUE REMOVAL 459 VENOUS TRIBUTARY (BRANCH) OCCLUSION; CENTRAL RETINAL VEIN OCCLUSION LASER SURGERY 460 TRIGEMINAL AND OTHER NERVE DISORDERS (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT, RADIATION THERAPY 461 MALUNION AND NONUNION OF FRACTURE (See Guideline Note 6) SURGICAL TREATMENT 462 ADJUSTMENT DISORDERS (See Coding Specification Below) (See Guideline Note 45) MEDICAL/PSYCHOTHERAPY 463 HEARING LOSS - OVER AGE OF FIVE (See Guideline Note 1) MEDICAL THERAPY INCLUDING HEARING AIDS 464 TOURETTE'S DISORDER AND TIC DISORDERS (See Guideline Note 1) MEDICAL/PSYCHOTHERAPY 465 ATHEROSCLEROSIS, AORTIC AND RENAL (See Guideline Note 1) MEDICAL AND SURGICAL TREATMENT 466 DEGENERATION OF MACULA AND POSTERIOR POLE (See Guideline Note 46) VITRECTOMY, LASER SURGERY 467 REACTIVE ATTACHMENT DISORDER OF INFANCY OR EARLY CHILDHOOD MEDICAL/PSYCHOTHERAPY 468 DISORDERS OF REFRACTION AND ACCOMMODATION MEDICAL THERAPY 469 EXOPHTHALMOS AND CYSTS OF THE EYE AND ORBIT SURGICAL TREATMENT 470 URINARY INCONTINENCE (See Guideline Notes 1,47) MEDICAL AND SURGICAL TREATMENT 471 DISORDERS OF PLASMA PROTEIN METABOLISM MEDICAL THERAPY 472 FACTITIOUS DISORDERS CONSULTATION 473 NEONATAL CONJUNCTIVITIS, DACRYOCYSTITIS AND CANDIDA INFECTION MEDICAL THERAPY 474 DENTAL CONDITIONS (EG. TOOTH LOSS) (See Guideline Note 48) SPACE MAINTENANCE AND PERIODONTAL MAINTENANCE 475 SIMPLE AND SOCIAL PHOBIAS MEDICAL/PSYCHOTHERAPY 476 ACUTE BRONCHITIS AND BRONCHIOLITIS MEDICAL THERAPY 477 CENTRAL PTERYGIUM EXCISION OR TRANSPOSITION OF PTERYGIUM WITHOUT GRAFT, RADIATION THERAPY 478 BRANCHIAL CLEFT CYST; THYROGLOSSAL DUCT CYST; CYST OF PHARYNX OR NASOPHARYNX EXCISION, MEDICAL THERAPY 479 OBSESSIVE-COMPULSIVE DISORDERS MEDICAL/PSYCHOTHERAPY 480 OVERANXIOUS DISORDER; GENERALIZED ANXIETY DISORDER; ANXIETY DISORDER, UNSPECIFIED MEDICAL/PSYCHOTHERAPY 481 OSTEOARTHRITIS AND ALLIED DISORDERS (See Guideline Notes 1,6) MEDICAL THERAPY, INJECTIONS 482 ATELECTASIS (COLLAPSE OF LUNG) MEDICAL THERAPY 483 SENSORINEURAL HEARING LOSS - OVER AGE OF FIVE (See Guideline Notes 1,49) COCHLEAR IMPLANT 484 BRACHIAL PLEXUS LESIONS MEDICAL THERAPY 485 UTERINE PROLAPSE; CYSTOCELE (See Guideline Note 50) SURGICAL REPAIR 486 OVARIAN DYSFUNCTION, GONADAL DYSGENISIS, MENOPAUSAL MANAGEMENT OOPHORECTOMY, ORCHIECTOMY, HORMONAL REPLACEMENT FOR PURPOSES OTHER THAN INFERTILITY 487 FUNCTIONAL ENCOPRESIS (See Guideline Note 1) MEDICAL/PSYCHOTHERAPY 488 PTOSIS (ACQUIRED) WITH VISION IMPAIRMENT PTOSIS REPAIR 489 CHRONIC SINUSITIS (See Guideline Note 35) MEDICAL AND SURGICAL TREATMENT 490 KERATOCONJUNCTIVITIS, CORNEAL ABSCESS AND NEOVASCULARIZATION MEDICAL AND SURGICAL TREATMENT 491 SELECTIVE MUTISM MEDICAL/PSYCHOTHERAPY 492 THROMBOSED AND COMPLICATED HEMORRHOIDS HEMORRHOIDECTOMY, INCISION 493 CHRONIC OTITIS MEDIA (See Guideline Note 51) PE TUBES/ADENOIDECTOMY/TYMPANOPLASTY, MEDICAL THERAPY 494 RECTAL PROLAPSE PARTIAL COLECTOMY 495 OTOSCLEROSIS MEDICAL AND SURGICAL TREATMENT 496 FOREIGN BODY IN EAR AND NOSE REMOVAL OF FOREIGN BODY 497 CHRONIC ANAL FISSURE (See Guideline Note 52); ANAL FISTULA SPHINCTEROTOMY, FISSURECTOMY, FISTULECTOMY, MEDICAL THERAPY 498 CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY (See Guideline Notes 6,22) MEDICAL AND SURGICAL TREATMENT 499 DENTAL CONDITIONS (EG. SEVERE TOOTH DECAY) (See Guideline Note 53) STABILIZATION OF PERIODONTAL HEALTH, COMPLEX RESTORATIVE, AND REMOVABLE PROSTHODONTICS 500 CONDUCT DISORDER, AGE 18 OR UNDER (See Guideline Note 54) MEDICAL/PSYCHOTHERAPY 501 BREAST CYSTS AND OTHER DISORDERS OF THE BREAST MEDICAL AND SURGICAL TREATMENT 502 CERVICITIS, ENDOCERVICITIS, HEMATOMA OF VULVA, AND NONINFLAMMATORY DISORDERS OF THE VAGINA MEDICAL AND SURGICAL TREATMENT 503 CYSTS OF BARTHOLIN'S GLAND AND VULVA INCISION AND DRAINAGE, MEDICAL THERAPY 504 LICHEN PLANUS MEDICAL THERAPY 505 DENTAL CONDITIONS (EG. BROKEN APPLIANCES) PERIODONTICS AND COMPLEX PROSTHETICS 506 RUPTURE OF SYNOVIUM REMOVAL OF BAKER'S CYST 507 ENOPHTHALMOS ORBITAL IMPLANT 508 BELL'S PALSY, EXPOSURE KERATOCONJUNCTIVITIS TARSORRHAPHY 509 PERIPHERAL ENTHESOPATHIES (See Guideline Note 6) MEDICAL THERAPY 510 DERMATOPHYTOSIS OF NAIL, GROIN, AND FOOT AND OTHER DERMATOMYCOSIS MEDICAL AND SURGICAL TREATMENT 511 CONVERSION DISORDER, ADULT MEDICAL/PSYCHOTHERAPY 512 FRACTURES OF RIBS AND STERNUM, CLOSED MEDICAL THERAPY 513 SPASTIC DIPLEGIA RHIZOTOMY 514 GENDER IDENTIFICATION DISORDER, PARAPHILIAS AND OTHER PSYCHOSEXUAL DISORDERS MEDICAL/PSYCHOTHERAPY 515 HEPATORENAL SYNDROME MEDICAL THERAPY 516 ECTROPION, TRICHIASIS OF EYELID, BENIGN NEOPLASM OF EYELID ECTROPION REPAIR 517 PHIMOSIS SURGICAL TREATMENT 518 CERUMEN IMPACTION REMOVAL OF EAR WAX 519 SIALOLITHIASIS, MUCOCELE, DISTURBANCE OF SALIVARY SECRETION, OTHER AND UNSPECIFIED DISEASES OF SALIVARY GLANDS MEDICAL AND SURGICAL TREATMENT 520 CHRONIC CONJUNCTIVITIS, BLEPHAROCONJUNCTIVITIS MEDICAL THERAPY 521 OTHER DISORDERS OF SYNOVIUM, TENDON AND BURSA, COSTOCHONDRITIS, AND CHONDRODYSTROPHY MEDICAL THERAPY 522 TOXIC ERYTHEMA, ACNE ROSACEA, DISCOID LUPUS MEDICAL THERAPY 523 PERIPHERAL ENTHESOPATHIES SURGICAL TREATMENT 524 NASAL POLYPS, OTHER DISORDERS OF NASAL CAVITY AND SINUSES MEDICAL AND SURGICAL TREATMENT 525 CIRCUMSCRIBED SCLERODERMA MEDICAL THERAPY 526 PERIPHERAL NERVE DISORDERS MEDICAL THERAPY 527 CLOSED FRACTURE OF GREAT TOE MEDICAL AND SURGICAL TREATMENT 528 DYSFUNCTION OF NASOLACRIMAL SYSTEM, LACRIMAL SYSTEM LACERATION MEDICAL AND SURGICAL TREATMENT 529 BENIGN NEOPLASM OF KIDNEY AND OTHER URINARY ORGANS MEDICAL AND SURGICAL TREATMENT 530 VERTIGINOUS SYNDROMES AND OTHER DISORDERS OF VESTIBULAR SYSTEM MEDICAL AND SURGICAL TREATMENT 531 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF THE FOOT, NOT INCLUDING THE GREAT TOE MEDICAL AND SURGICAL TREATMENT 532 PHLEBITIS AND THROMBOPHLEBITIS, SUPERFICIAL MEDICAL THERAPY 533 DISORDERS OF SWEAT GLANDS MEDICAL THERAPY 534 SEXUAL DYSFUNCTION PSYCHOTHERAPY, MEDICAL AND SURGICAL TREATMENT 535 PARALYSIS OF VOCAL CORDS OR LARYNX INCISION/EXCISION/ENDOSCOPY 536 DELUSIONAL DISORDER MEDICAL/PSYCHOTHERAPY 537 CYSTIC ACNE MEDICAL AND SURGICAL TREATMENT 538 UNCOMPLICATED HERNIA REPAIR 539 BENIGN NEOPLASM OF NASAL CAVITIES, MIDDLE EAR AND ACCESSORY SINUSES EXCISION, RECONSTRUCTION 540 BENIGN NEOPLASM BONE AND ARTICULAR CARTILAGE INCLUDING OSTEOID OSTEOMAS; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT, RADIATION THERAPY 541 OTHER NONINFECTIOUS GASTROENTERITIS AND COLITIS (See Hospitalization for Acute Viral Infections Statement of Intent) MEDICAL THERAPY 542 DEFORMITIES OF UPPER BODY AND ALL LIMBS REPAIR/REVISION/RECONSTRUCTION/RELOCATION/MEDICAL THERAPY 543 DISORDERS OF FUNCTION OF STOMACH AND OTHER FUNCTIONAL DIGESTIVE DISORDERS MEDICAL THERAPY 544 PELVIC PAIN SYNDROME, DYSPAREUNIA (See Guideline Note 55) MEDICAL AND SURGICAL TREATMENT 545 ATOPIC DERMATITIS MEDICAL THERAPY 546 CONTACT DERMATITIS AND OTHER ECZEMA MEDICAL THERAPY 547 HYPOTENSION MEDICAL THERAPY 548 VIRAL, SELF-LIMITING ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS (See Hospitalization for Acute Viral Infections Statement of Intent) MEDICAL THERAPY 549 PERIPHERAL NERVE DISORDERS SURGICAL TREATMENT 550 ICHTHYOSIS MEDICAL THERAPY 551 LESION OF PLANTAR NERVE; PLANTAR FASCIAL FIBROMATOSIS MEDICAL THERAPY, EXCISION 552 ACUTE AND CHRONIC DISORDERS OF SPINE WITHOUT NEUROLOGIC IMPAIRMENT (See Guideline Notes 6, 56) MEDICAL AND SURGICAL TREATMENT 553 RAYNAUD'S SYNDROME MEDICAL THERAPY 554 TENSION HEADACHES MEDICAL THERAPY 555 MILD PSORIASIS (See Guideline Note 57); DERMATOPHYTOSIS: SCALP, HAND, BODY, DEEP-SEATED MEDICAL THERAPY 556 DEFORMITIES OF FOOT FASCIOTOMY/INCISION/REPAIR/ARTHRODESIS 557 GRANULOMA OF MUSCLE, GRANULOMA OF SKIN AND SUBCUTANEOUS TISSUE REMOVAL OF GRANULOMA 558 HYDROCELE MEDICAL THERAPY, EXCISION 559 SYMPTOMATIC URTICARIA MEDICAL THERAPY 560 IMPULSE DISORDERS EXCLUDING PATHOLOGICAL GAMBLING (See Guideline Note 58) MEDICAL/PSYCHOTHERAPY 561 SUBLINGUAL, SCROTAL, AND PELVIC VARICES VENOUS INJECTION, VASCULAR SURGERY 562 ASEPTIC MENINGITIS (See Hospitalization for Acute Viral Infections Statement of Intent) MEDICAL THERAPY 563 TMJ DISORDER TMJ SPLINTS 564 XEROSIS MEDICAL THERAPY 565 CHRONIC DISEASE OF TONSILS AND ADENOIDS TONSILLECTOMY AND ADENOIDECTOMY 566 SHYNESS DISORDER OF CHILDHOOD OR ADOLESCENCE MEDICAL/PSYCHOTHERAPY 567 HEMATOMA OF AURICLE OR PINNA AND HEMATOMA OF EXTERNAL EAR DRAINAGE 568 KERATODERMA, ACANTHOSIS NIGRICANS, STRIAE ATROPHICAE, AND OTHER HYPERTROPHIC OR ATROPHIC CONDITIONS OF SKIN MEDICAL THERAPY 569 CHRONIC PROSTATITIS, OTHER DISORDERS OF PROSTATE MEDICAL THERAPY 570 CHONDROMALACIA (See Guideline Note 6) MEDICAL THERAPY 571 MACROMASTIA SUBCUTANEOUS TOTAL MASTECTOMY, BREAST REDUCTION 572 DYSMENORRHEA (See Guideline Note 59) MEDICAL AND SURGICAL TREATMENT 573 OPEN WOUND OF EAR DRUM MEDICAL THERAPY 574 ALLERGIC RHINITIS AND CONJUNCTIVITIS, CHRONIC RHINITIS MEDICAL THERAPY 575 CANCER OF LIVER AND INTRAHEPATIC BILE DUCTS (See Guideline Note 16) LIVER TRANSPLANT 576 POSTCONCUSSION SYNDROME MEDICAL THERAPY 577 BENIGN NEOPLASM OF EXTERNAL FEMALE GENITAL ORGANS EXCISION 578 RUMINATION DISORDER OF INFANCY MEDICAL/PSYCHOTHERAPY 579 HORDEOLUM AND OTHER DEEP INFLAMMATION OF EYELID; CHALAZION INCISION AND DRAINAGE, MEDICAL THERAPY 580 CONDUCTIVE HEARING LOSS AUDIANT BONE CONDUCTORS 581 ACUTE ANAL FISSURE FISSURECTOMY, MEDICAL THERAPY 582 PLEURISY MEDICAL THERAPY 583 CENTRAL SEROUS RETINOPATHY LASER SURGERY 584 PERITONEAL ADHESION SURGICAL TREATMENT 585 DERMATITIS DUE TO SUBSTANCES TAKEN INTERNALLY MEDICAL THERAPY 586 BLEPHARITIS MEDICAL THERAPY 587 UNSPECIFIED URINARY OBSTRUCTION AND BENIGN PROSTATIC HYPERPLASIA WITHOUT OBSTRUCTION MEDICAL THERAPY 588 OTHER COMPLICATIONS OF A PROCEDURE (See Guideline Note 6) MEDICAL AND SURGICAL TREATMENT 589 LYMPHEDEMA (See Guideline Note 43) MEDICAL THERAPY, OTHER OPERATION ON LYMPH CHANNEL 590 ACUTE NON-SUPPURATIVE LABYRINTHITIS MEDICAL THERAPY 591 DEVIATED NASAL SEPTUM, ACQUIRED DEFORMITY OF NOSE, OTHER DISEASES OF UPPER RESPIRATORY TRACT EXCISION OF CYST/RHINECTOMY/PROSTHESIS 592 STOMATITIS AND OTHER DISEASES OF ORAL SOFT TISSUES INCISION AND DRAINAGE, MEDICAL THERAPY 593 CAVUS DEFORMITY OF FOOT; FLAT FOOT; POLYDACTYLY AND SYNDACTYLY OF TOES MEDICAL THERAPY, ORTHOTIC 594 ERYTHEMA MULTIFORME MEDICAL THERAPY 595 INFECTIOUS MONONUCLEOSIS MEDICAL THERAPY 596 CONGENITAL ANOMALIES OF FEMALE GENITAL ORGANS EXCLUDING VAGINA SURGICAL TREATMENT 597 SPINAL DEFORMITY, NOT CLINICALLY SIGNIFICANT (See Guideline Note 60) ARTHRODESIS/REPAIR/RECONSTRUCTION, MEDICAL THERAPY 598 ANTI-SOCIAL PERSONALITY DISORDER MEDICAL/PSYCHOTHERAPY 599 SPASTIC DYSPHONIA MEDICAL THERAPY 600 URETHRITIS, NON-SEXUALLY TRANSMITTED MEDICAL THERAPY 601 PERSONALITY DISORDERS EXCLUDING BORDERLINE, SCHIZOTYPAL AND ANTI-SOCIAL MEDICAL/PSYCHOTHERAPY 602 CANDIDIASIS OF MOUTH, SKIN AND NAILS MEDICAL THERAPY 603 BENIGN NEOPLASM OF MALE GENITAL ORGANS: TESTIS, PROSTATE, EPIDIDYMIS MEDICAL AND SURGICAL TREATMENT 604 ATROPHY OF EDENTULOUS ALVEOLAR RIDGE VESTIBULOPLASTY, GRAFTS, IMPLANTS 605 OLD LACERATION OF CERVIX AND VAGINA MEDICAL THERAPY 606 VULVAL VARICES VASCULAR SURGERY 607 DISEASE OF NAILS, HAIR AND HAIR FOLLICLES MEDICAL THERAPY 608 OBESITY (See Guideline Note 61) NUTRITIONAL/PHYSICAL ACTIVITY COUNSELING AND BEHAVIORAL INTERVENTIONS; BARIATRIC SURGERY FOR OBESITY WITHOUT COMORBID TYPE II DIABETES & BMI = 35 609 ACUTE TONSILLITIS OTHER THAN BETA-STREPTOCOCCAL MEDICAL THERAPY 610 CORNS AND CALLUSES MEDICAL THERAPY 611 SYNOVITIS AND TENOSYNOVITIS (See Guideline Note 6) MEDICAL THERAPY 612 PROLAPSED URETHRAL MUCOSA SURGICAL TREATMENT 613 MEDICAL CONDITIONS WHERE TREATMENT OF THE CONDITION WILL NOT RESULT IN A 5% 5 YEAR SURVIVAL (See Guideline Notes 7, 11) [Entire line deleted as of 10-1-07] MEDICAL AND SURGICAL TREATMENT [Entire line deleted as of 10-1-07] 614 GANGLION EXCISION 615 EPISCLERITIS MEDICAL THERAPY 616 DIAPER RASH MEDICAL THERAPY 617 TONGUE TIE AND OTHER ANOMALIES OF TONGUE FRENOTOMY, TONGUE TIE 618 CYSTS OF ORAL SOFT TISSUES INCISION AND DRAINAGE 619 CONGENITAL DEFORMITIES OF KNEE MEDICAL AND SURGICAL TREATMENT 620 CHRONIC PANCREATITIS SURGICAL TREATMENT 621 HERPES SIMPLEX WITHOUT COMPLICATIONS, EXCLUDING GENITAL HERPES MEDICAL THERAPY 622 CONGENITAL ANOMALIES OF THE EAR WITHOUT IMPAIRMENT OF HEARING; UNILATERAL ANOMALIES OF THE EAR OTOPLASTY, REPAIR AND AMPUTATION 623 KELOID SCAR; OTHER ABNORMAL GRANULATION TISSUE INTRALESIONAL INJECTIONS/DESTRUCTION/EXCISION, RADIATION THERAPY 624 DISORDERS OF SOFT TISSUE MEDICAL THERAPY 625 MINOR BURNS MEDICAL THERAPY 626 DISORDERS OF SLEEP WITHOUT SLEEP APNEA MEDICAL THERAPY 627 ORAL APHTHAE MEDICAL THERAPY 628 SPRAINS OF JOINTS AND ADJACENT MUSCLES, GRADE I (See Guideline Note 6) MEDICAL THERAPY 629 ASYMPTOMATIC URTICARIA MEDICAL THERAPY 630 DENTAL CONDITIONS (EG. ORTHODONTICS) COSMETIC DENTAL SERVICES 631 FINGERTIP AVULSION REPAIR WITHOUT PEDICLE GRAFT 632 MINOR HEAD INJURY: HEMATOMA/EDEMA WITH NO LOSS OF CONSCIOUSNESS MEDICAL THERAPY 633 VIRAL WARTS EXCLUDING VENEREAL WARTS MEDICAL AND SURGICAL TREATMENT, CRYOSURGERY 634 ACUTE UPPER RESPIRATORY INFECTIONS AND COMMON COLD MEDICAL THERAPY 635 OTHER VIRAL INFECTIONS, EXCLUDING PNEUMONIA DUE TO RESPIRATORY SYNCYTIAL VIRUS IN PERSONS UNDER AGE 3 (See Hospitalization for Acute Viral Infections Statement of Intent) MEDICAL THERAPY 636 PHARYNGITIS AND LARYNGITIS AND OTHER DISEASES OF VOCAL CORDS MEDICAL THERAPY 637 ANOMALIES OF RELATIONSHIP OF JAW TO CRANIAL BASE, MAJOR ANOMALIES OF JAW SIZE, OTHER SPECIFIED AND UNSPECIFIED DENTOFACIAL ANOMALIES OSTEOPLASTY, MAXILLA/MANDIBLE 638 GALACTORRHEA, MASTODYNIA, ATROPHY, BENIGN NEOPLASMS AND UNSPECIFIED DISORDERS OF THE BREAST MEDICAL AND SURGICAL TREATMENT 639 HYPERTELORISM OF ORBIT ORBITOTOMY 640 OPEN WOUND OF INTERNAL STRUCTURES OF MOUTH WITHOUT COMPLICATION REPAIR SOFT TISSUES 641 SEBACEOUS CYST MEDICAL AND SURGICAL TREATMENT 642 SEBORRHEIC KERATOSIS, DYSCHROMIA, AND VASCULAR DISORDERS, SCAR CONDITIONS, AND FIBROSIS OF SKIN MEDICAL AND SURGICAL TREATMENT 643 REDUNDANT PREPUCE ELECTIVE CIRCUMCISION 644 STENOSIS OF NASOLACRIMAL DUCT (ACQUIRED) DACRYOCYSTORHINOSTOMY 645 CONJUNCTIVAL CYST EXCISION OF CONJUNCTIVAL CYST 646 BENIGN NEOPLASMS OF SKIN AND OTHER SOFT TISSUES MEDICAL THERAPY 647 DISEASE OF CAPILLARIES EXCISION 648 NONINFLAMMATORY DISORDERS OF CERVIX; HYPERTROPHY OF LABIA MEDICAL THERAPY 649 CYST, HEMORRHAGE, AND INFARCTION OF THYROID SURGICAL TREATMENT 650 PICA MEDICAL/PSYCHOTHERAPY 651 ACUTE VIRAL CONJUNCTIVITIS MEDICAL THERAPY 652 MUSCULAR CALCIFICATION AND OSSIFICATION MEDICAL THERAPY 653 SUPERFICIAL WOUNDS WITHOUT INFECTION AND CONTUSIONS MEDICAL THERAPY 654 CHRONIC BRONCHITIS MEDICAL THERAPY 655 BENIGN POLYPS OF VOCAL CORDS MEDICAL THERAPY, STRIPPING 656 BENIGN NEOPLASMS OF DIGESTIVE SYSTEM SURGICAL TREATMENT 657 VARICOSE VEINS OF LOWER EXTREMITIES WITHOUT ULCER OR INFLAMMATION STRIPPING/SCLEROTHERAPY, MEDICAL THERAPY 658 CYST OF KIDNEY, ACQUIRED MEDICAL AND SURGICAL TREATMENT 659 GALLSTONES WITHOUT CHOLECYSTITIS MEDICAL THERAPY, CHOLECYSTECTOMY 660 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT (See Guideline Note 62) ELECTIVE DENTAL SERVICES 661 GYNECOMASTIA MASTECTOMY 662 TMJ DISORDERS TMJ SURGERY 663 EDEMA AND OTHER CONDITIONS INVOLVING THE INTEGUMENT OF THE FETUS AND NEWBORN MEDICAL THERAPY 664 CONGENITAL CYSTIC LUNG - SEVERE LUNG RESECTION 665 AGENESIS OF LUNG MEDICAL THERAPY 666 CENTRAL RETINAL ARTERY OCCLUSION PARACENTESIS OF AQUEOUS 667 BENIGN LESIONS OF TONGUE EXCISION 668 UNCOMPLICATED HEMORRHOIDS HEMORRHOIDECTOMY, MEDICAL THERAPY 669 MENTAL DISORDERS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 670 INTRACRANIAL CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 671 INFECTIOUS DISEASES WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 672 ENDOCRINE AND METABOLIC CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 673 CARDIOVASCULAR CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 674 SENSORY ORGAN CONDITIONS WITH NO EFFECTIVE TREATMENT OR NO TREATMENT NECESSARY EVALUATION 675 NEUROLOGIC CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 676 DERMATOLOGICAL CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSAR (See Guideline Note 29) EVALUATION 677 RESPIRATORY CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 678 GENITOURINARY CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 679 MUSCULOSKELETAL CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION 680 GASTROINTESTINAL CONDITIONS WITH NO EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY EVALUATION