Issues • Apr 2003 • Rationing

Oregon Prioritized Health Services List

The official Oregon Health Plan list includes conditions, treatments, ICD-9 codes (International Classification of Disease, Ninth Edition) and CPT codes (Common Procedural Terminology). For easy of comparison, only conditions and a few treatments are included on this format of the list. For recipients of the Oregon Health Plan, coverage is provided for conditions 1 through 549. Treatment for conditions 550 through 730 are not covered for some state recipients, but covered for others. CCHC has bolded some conditions on this list to enhance comparison of the state-determined priority position of various more common or interesting conditions on the list.

Severe/Moderate Head Injury: Hematoma/Edema with loss of consciousness
Type I Diabetes Mellitus
Peritonitis
Acute Glomerulonephritis
Pneumothorax and Hemothorax
Complicated Hernia with Obstruction and/or Gangrene
Torsion of Ovary
Torsion of Testis
Addison's Disease
Injury to Internal Organs
Flail Chest
Appendicitis
Ruptured Spleen
Tuberculosis
Deep Open Wound of Neck, including Larynx, Fracture of Larynx or Trachea, Open
Croup Syndrome, Epiglottitis, Acute Laryngotracheitis
Pneumococcal Pneumonia, Other Bacterial Pneumonia, Bronchopneumonia
Pertussis and Diphtheria
Rupture of Papillary Muscle
Coagulation Defects
Dissecting or Ruptured Aortic Aneurysm
Injury to Major Blood Vessels of Extremities
Intussception, Volvulus, Intestinal Obstruction and Foreign Body in Stomach,/Intestines/Colon/Rectum
Non-Dissecting Aneurysm without Rupture
Ruptured Viscus
Acute Bacterial Meningitis
Hodgkin's Disease
Acute Pyelonephritis, Renal & Perinephric Abscess
Arterial Embolism/Thrombosis: Abdominal Aorta, Thoracic Aorta
Liver Abscess
Subarachnoid/Intracerebral Hemorrhage/Hematoma; Compression of Brain (burr holes, craniectomy…)
Foreign Body in Pharynx, Larynx, Trachea, Bronchus & Esophagus
Neoplasms of Islets of Langerhans
Non-Diabetic Hypoglycemic Coma
Acute Osteomyelitis
Acute Mastoiditis
Pyogenic Arthritis
Acute Inflammation of the Heart due to Rheumatic Fever
Budd-Chiari Syndrome/Venous Emboli
Burn, Partial Thickness Greater Than 30% of Body Surface
Choanal Atresia
Burn, Partial Thickness with Vital Site; Full Thickness with Vital Site, less than 10% of body surface
Thrombocytopenia
Intra-Abdominal Abscess
Peripheral Vascular Disease, Limb Threatening Infections, and Vascular Complication
Rupture of Bladder, Nontraumatic
Erysipelas
Septicemia
Rickettsial and Other Arthropod-Borne Diseases
Acute Orbital Cellulitis
Anaphylactic Shock
Deformities of Head and Compound/Depressed Fractures of Skull
Congenital, Primary, and Secondary Syphilis
Birth Control (contraception management)
Pregnancy (maternity care)
Birth of Infant (newborn care)
Ectopic Pregnancy
Necrotizing Enterocolitis in Fetus or Newborn
Neonatal Thyrotoxicosis
Other Respiratory Conditions of Fetus and Newborn
Drug Reactions and Intoxications Specific to Newborn
Tetanus Neonatorum
Hydrops Fetalis
Galactosemia
Congenital Hypothyroidism
Phenylketonuria (PKU)
Neonatal Myasthenia Gravis
Convulsions and Other Cerebral Irritability in Newborn
Hematological Disorders of Fetus and Newborn
Cerebral Depression, Coma, & Other Abnormal Cerebral Signs of Newborn
Low Birth Weight (under 2500 grams)
Conditions Involving the Temperature Regulation of Newborns
Adrenal or Cutaneous Hemorrhage of Fetus or Neonate
Omphalitis of the Newborn and Neonatal Infective Mastitis
Birth Trauma for Baby
Polycythemia Neonatorum, Symptoms
Anemia of Prematurity or Transient Neonatal Neutropenia
Congenital Anomalies of Digestive System and Abdominal Wall excluding Necrosis…
Congenital Infectious Diseases
Disorders Relating to Long Gestation and High Birthweight
Feeding Problems in Newborn
Hemolytic Disease due to Isoimmunization, Anemia due to Transplacental Hemorrhage…Jaundice
Neonate Conjunctivitis, Dacryocystitis and Candida Infection
Drug Withdrawal Syndrome in Newborn
Hypocalcemia, Hypomagnesemia /Other Endocrine and Metabolic Disturbances-fetus and newborn
Adrenogenital Disorders
Encephalocele; Congenital Hydrocephalus
Spina Bifida
Congenital Dislocation of Hip; Coxa Vara & Valga
Syndrome of "Infant of Diabetic Mother" and Neonatal Hypoglycemia
Congenital Cystic Lung - Mild and Moderate
Rumination Disorder of Infancy
Sterilization - (vasectomy)
Sterilization - (tubal ligation)
Coarctation of the Aorta
Atrial Septal Defect, Primum
Ventricular Septal Defect
Subvalvular Aortic Stenosis, Right Ventricular Infundibular Obstruction…Anomalies of Heart
Congenital Anomalies of Upper Alimentary Tract, excluding Tongue
Congenital Anomalies of Urinary System
Coronary Artery Anomaly
Complete, Corrected and Other Transposition of Great Vessels
Tetralogy of Fallot (TOF)
Patent Ductus Arteriosus; Aortic Pulmonary Fistula (ligation)
Total Anomalous Pulmonary Venous Connection
Other and Unspecified Type Endocardial Cushion Defects
Biliary Atresia
Cystic Fibrosis
End Stage Renal Disease (renal transplant)
Cirrhosis of Liver or Biliary Tract; Budd-Chiari Syndrome; Hepatic Vein Thrombosis …
Cleft Palate with Airway Obstruction, Pierre Robin Deformity
Myocarditis (nonviral), Pericarditis (nonviral), Endocarditis
Cervical Vertebral Dislocations/Fractures, Open or Closed; Other…Spinal Cord Injuries…
Fracture of Pelvis, Open and Closed
Injury to Blood Vessels of the Thoracic Cavity
Toxic Epidermal Necrolysis and Staphylococcal Scalded Skin Syndrome; Stevens-Johnson…
Acquired Hemolytic Anemias
Acute Leukemias, Myelodysplastic Syndrome
Acute Lymphocytic Leukemia (child)
Hodgkin's Disease (transplant)
Constitutional Aplastic Anemia
Other Specified Aplastic Anemias
Non-Hodgkin's Lymphomas
Non-Hodgkin's Lymphomas(transplant)
Thalassemia, Osteopetrosis and Hemoglobinopathies (bone marrow rescue/transplant)
Hydatidiform Mole
Acute Vascular Insufficiency of Intestine
Short Bowel Syndrome - age 5 or under
Adult Respiratory Distress Syndrome; Respiratory Conditions due to Physical and Chemical Agents
Rupture of Liver
Subacute Meningitis (Tuberculosis, Cryptococcosis
Fracture of Joint, Open
Fracture of Shaft of Bone, Open
Open Fracture of Epiphysis of Lower Extremity
Diseases of Pharynx including Retropharyngeal Abscess
Arterial Aneurysm of Neck
Chronic Leukemias; Polycythemia Rubra Vera
Hypothermia
Benign Neoplasm of the Brain
Malignant Melanoma of Skin, Treatable
Multiple Endocrine Neoplasia
Diabetes Insipidus
Disorders of Spine with Neurologic Impairment
Preventive Services, Birth to 10 years of age
Anorexia Nervosa
Reactive Attachment Disorder
Coarctation of the Aorta
Complications of a Procedure Always Requiring Treatment
Crush Injuries: Trunk, Upper Limbs, Lower Limb including Blood Vessels
Congenital Mitral Valve Stenosis
Common Truncus
Congenital Tricuspid Atresia and Stenosis
Bulbus Cordis Anomalies & Anomalies of Cardiac Septal Closure: Double Outlet Right Ventricle
Common Ventricle
Congenital Pulmonary Valve Atresia
Interrupted Aortic Arch
Congestive Heart Failure, Cardiomyopathy, Transposition of Great Vessels, Hypoplastic Left Heart…
Disorders of Bile Duct
Asthma
Pneumonia due to Respiratory Syncytial Virus in Persons Under Age 3
Respiratory Failure
Schizophrenic Disorders
Major Depression, Recurrent
Bipolar Disorders
Burn Full Thickness Greater Than 10% of Body Surface
Disorders of Fluid, Electrolyte, and Acid-Base Balance
Thyrotoxicosis with or w/o Goiter, Endocrine Exophthalmos; Chronic Thyroiditis
Hypertensive Heart and Renal Disease
Benign Cerebral Cysts
HIV Disease (including AIDS) and related Opportunistic Infections
Opportunistic Infections in Immunocompromised Host; Candidiasis of Stoma; Persons Receiving…
Empyema and Abscess of Lung
Anemias due to Disease or Treatment and Other Aplastic Anemias
Malaria and Relapsing Fever
Heart Failure
Hereditary Anemias, Hemoglobinopathies, and Disorder of the Spleen
Life-Threatening Cardiac Arrhythmias
End Stage Renal Disease (medical therapy, including dialysis)
Acute and Subacute Necrosis of Liver; Specified Inborn Errors of Metabolism (eg. Maple Syrup…)
Fracture of Hip, Closed
Hereditary Angioedema; Angioneurotic Edema
Pediatric Solid Malignancies, Seminoma
Chronic Non-Lymphocytic Leukemia
Preventive Services with Proven Effectiveness, over Age of 10
Tobacco Dependence
Preventive Foot Care in High Risk Patients
Abuse or Dependence of Psychoactive Substance
Major Depression, Single Episode or Mild
Brief Reactive Psychosis
Attention Deficit Disorders with Hyperactivity or Undifferentiated
Hypertension and Hypertensive Disease
Ulcers, Gastritis and Duodenitis
Cancer of Thyroid, Treatable
Cancer of Testis, Treatable
Cancer of Uterus, Treatable
Cancer of Eye and Orbit, Treatable
Ulcers, GI Hemorrhage
Congenital Stenosis and Insufficiency of Aortic Valve
Burn, Partial Thickness without vital site-10-30% of body surface
Agranulocytosis (bone marrow transplant)
Chronic Granulomatous Disease
Botulism
Disorders of Amino-Acid Transport and Metabolism (non PKU)
Chronic Respiratory Disease arising in the Neonatal Period
Gonococcal Infections and Other Sexually Transmitted Diseases
Herpes Simplex and Herpes Zoster with Neurological & Ophthalmological Complications
Pneumocysitis Carinii Pneumonia
Hypoplasia and Dysplasia of Lung
Cardiomyopathy, Hypertrophic Muscle
Glycogenosis
Chronic Osteomyelitis
Acute Lymphocytic Leukemias (Adult) and Multiple Myeloma
Multiple Myeloma (bone transplant)
Phlebitis & Thrombophlebitis, Deep
Diseases of Endocardium
Idiopathic or Viral Myocarditis and Pericarditis
Intraspinal and Intracranial Abscess
Fracture of Ribs and Sternum, Open
Neurological Dysfunction in Breathing, Eating, Swallowing, Bowel, or Bladder Control…
Esophageal Stricture
Spontaneous Abortion Complicated by Infection and/or Hemorrhage, Missed Abortion
Transient Nephrotic Syndrome with Lesion of Minimal Change Glomerulonephritis
Disorders of Pancreatic Endocrine Secretions
Erythroplakia, Leukoedema of Mouth or Tongue
Leukoplakia of Oral Mucosa, including Tongue
Dystrophy of Vulva
Cancer of Soft Tissue, Treatable
Cancer of Breast, Treatable
Cancer of the Ovary, Treatable
Undescended Testicle
Cancer of Penis and Other Male Genital Organs, Treatable
Cancer of Vagina, Vulva, and Other Female Genital Organs, Treatable
Choriocarcinoma, Treatable
Cancer of Bone, Treatable
Cancer of Bladder and Ureter, Treatable
Cancer of Retroperitoneum, Peritoneum, Omentum & Mesentery, Treatable
Cancer of Oral Cavity, Pharynx, Nose and Larynx, Treatable
Portal Vein Thrombosis
Paralytic Ileus
Traumatic Amputation or Leg(s) (complete) (Partial) with and without Complication
Traumatic Amputation of Arm(s), Hand(s), Thumb(s) and Finger(s) (complete)(Partial) w/ or w/o…
Iron Deficiency Anemia and Other Nutritional Deficiencies
Physical and Sexual Abuse including Rape
Acute Stress Disorder
Separation Anxiety Disorder
Peritonsillar Abscess
Cancrum Oris
Occlusion and Stenosis of Precerebral Arteries
Acute Glomerulonephritis and Other Acute Renal Failure
Nephrotic Syndrome and Other Renal Disorders
Cysticercosis, Other Cestode Infection, Trichinosis
Poisoning by Ingestion/Injection, and Non0Medicinal Agents
Metabolic Disorders including Hyperlipidemia
Hereditary Fructose Intolerance, Intestinal Disaccharidase and Other Deficiencies
Intestinal Malabsorption
Delirium Due to Medical Causes
Pernicious and Sideroblastic Anemia
Disseminated Intravascular Coagulation
Diverticulitis of Colon
Cyst and Pseudocyst of Pancreas
Acute Poliomyelitis
Systemic Sclerosis
Substance - Induced Delirium
Acute and Subacute Ischemic Heart Disease, Myocardial Infarction (Heart Attack)
Terminal Illness Regardless of Diagnosis (Comfort Care)
Adjustment Disorders
Oppositional Defiant Disorder
Tourette's Disorder and Tic Disorders
Anal, Rectal and Colonic Polyps
Transient Cerebral Ischemia
Dysplasia of Cervix and Cervical Carcinoma in Situ, Cervical Condyloma
Anogenital Viral Warts
Cancer of Colon, Rectum, Small Intestine and Anus, Treatable
Cancer of Cervix, Treatable
Cancer of Lung, Bronchus, Pleura, Trachea, Mediastinum & Other Respiratory Organs, Treatable
Cancer - Prostate Gland, Treatable
Cancer of Endocrine System excluding Thyroid, Treatable; Carcinoid Syndrome
Cancer of Kidney and Other Urinary Organs, Treatable
Cancer of Stomach, Treatable
Cancer of Brain and Nervous System, Treatable
Anaerobic Infection Requiring Hyperbaric Oxygen
Benign Neoplasm of Pituitary Gland
Cushing's Syndrome; Hyperaldosteronism, Other Corticoadrenal Overactivity, Medulloadrenal…
Chronic Obstructive Pulmonary Disease
Disorders of Mineral Metabolism
Intracerebral Hemorrhage
Stroke
Acute Pulmonary Heart Disease and Pulmonary Emboli
Dislocation Knee & Hip, Open
Dislocation of Elbow, Hand, Ankle, Foot, Clavicle and Shoulder, Open
Acute Bronchitis and Bronchiolitis
Acute Pelvic Inflammatory Disease
Urinary Fistula
Aneurysm of Pulmonary Artery
Epilepsy and Febrile Convulsions
Regional Enteritis, Idiopathic Proctocolitis, Ulceration of Intestine
Enteric Infections and Other Bacterial Food Poisoning
Giant Cell Arteritis, Kawaski Disease, Hypersensitivity Angiitis; Thromboangiitis Obliterans
Complications of Procedures Usually Requiring Treatment
Termination of Pregnancy (Induced Abortion)
Preventive Dental Services (cleaning and fluoride)
Hearing Loss - Age 5 or Under (hearing aids)
Sensorineural Hearing Loss - age 5 or under
Posttraumatic Stress Disorder
Obsessive-Compulsive Disorder
Bilateral Anomalies of External Ear with Impairment of Hearing
Generalized Convulsive Epilepsy/Partial Epilepsy without Mention of Impairment of Consciousness
Candidiasis of Lung, Disseminated Candidiasis, Candidal Endocarditis and Meningitis
Coccidioidomycosis, Histoplasmosis, Blastomycotic Infection, Opportunistic and Other Mycoses
Tetanus
Ebstein's Anomaly
Disseminated Infections with Localized Sites
Diseases and Disorders of Aortic Valve
Type II Diabetes Mellitus
Polyarteritis Nodosa and Allied Conditions
Sarcoidosis
Dermatomyositis, Polymyositis
------------ ($244.71)-----------------
Atrial Septal Defect, Secundum
Diseases of Mitral Valve
Atelectasis (collapse of lung)
Toxic Effect of Gases, Fumes, and Vapors Requiring Hyperbaric Oxygen
Acquired Hypothyroidism, Dyshormonogenic Goiter
Cardiac Arrhythmias
Multiple Vascular Disease
Traumatic Amputation of Foot/Feet (complete)(partial) w/ & w/o Complication
Brachial Plexus Lesions
Spinal Deformity, Clinically Significant
Disorders of Plasma Protein Metabolism
Acute Non-Lymphocytic Leukemias
Chronic Rheumatic Pericarditis, Rheumatic Myocarditis
Acute Necrosis of Liver
Chronic Hepatitis, including Viral Hepatitis B and C
Acute Pancreatitis
Dermatological Premalignant Lesions and Carcinoma in Situ
Esophagitis
Neurological Dysfunction in Posture and Movement Caused by Chronic Conditions
Acute Thyroiditis
Systemic Lupus Erythematosus, Other Diffuse Disease of Connective Tissue
Wegener's Granulomatosis
Panic Disorders, Agoraphobia
Disorders of Arteries, Visceral
Leptospirosis
Amebiasis
Zoonotic Bacterial Diseases
Fracture of Face Bones; Injury to Optic and Other Cranial Nerves
Benign Neoplasm of Respiratory & Intrathoracic Organs
Dystonia (Uncontrollable)
--------($ 251.12) -----------
Atherosclerosis, Aortic and Renal
Cancer of Skin, Excluding Malignant Melanoma, Treatable
Sleep Apnea
Deficiencies of Circulating Enzymes including Alpha 1-Antitrypsin Deficiency
Life-Threatening Epistaxis
Sialoadenitis, Abscess, Fistula of Salivary Glands
Chronic Ulcer of Skin
Abscess and Cellulitis, Non-Orbital
Breast Cysts and Other Disorders of the Breast
Pilonidal Cyst with Abscess
Dental Caries (Periapical Infection)
Dental Conditions (eg. Infections)
Abscess of Bursa or Tendon
Abscess of Prostate
Other Aneurysm of Peripheral Artery (surgery)
Pyoderma: Dermatophytosis: Scalp, Hand, Body, Deep-Seated
Urinary Tract Calculus; Hematuria
Conditions Involving Exposure to Natural Elements (eg. Lightning Strike, Heatstroke)
Vesicoureteral Reflux
Calculus of Bladder or Kidney
Cholelithiasis, Cholecystitus, Common Biliary Duct Stone
Ureteral Stricture or Obstruction; Hydronephrosis; Hydroureter
Congenital Hydronephrosis
Atherosclerosis, Peripheral
Hypoplastic Left Heart Syndrom
Congenital Pulmonary Valve Stenosis
Rheumatoid Arthritis and Other Inflammatory Polyarthropathies
Rheumatoid Arthritis, Osteoarthritis, Osteochrondritis Dissecans, and Aseptic Necrosis of Bone
Conduct Disorder, Age 18 or Under
Overanxious Disorder; Generalized Anxiety Disorder, Unspecified
---------($263.95) --------------
Bulimia Nervosa
Esophagitis
Deep Open Wounds
Epidermolysis Bullosa
Cleft Palate with Cleft Lip (excision and repair vestibule of mouth)
Cleft Palate (repair and palatoplasty, orthodontics)
Cleft Lip, Congenital Fistula of Lip
Trachoma
Histiocytosis
Leprosy, Yaws, Pinta
Rheumatic Fever
Unspecified Diseases due to Mycobacteria, Actinomycotic Infection, and Toxoplasmosis
Acute, Subacute, Chronic and other types of Iridocyclitis
Body Infestations (eg. Lice, Scabies)
Paranoid (Delusional) Disorder
Recurrent Erosion of the Cornea
Giardiasis, Intestinal Helminthiasis
Hyphema
Wound of Eye Globe
Diabetic and Other Retinopathy
Glaucoma
Primary and Other Angle-Closure Glaucoma
Retinal Tear
Retrolental Fibroplasia
Venous Tributary (Branch) Occlusion; Central Retinal Vein Occlusion
Sicca Syndrome; Polymyalgia Rheumatica
Purulent Endophthalmitis
Keratoconjunctivitis, Corneal Abscess and Neovascularization
Scleritis
Aphakia and Other Disorders of Lens
----------($266.63)-------------
Corneal Ulcer; Superficial Injury of Eye and Adnexa
Glaucoma Associated With Disorders of the Lens
Exophthalmos and Cysts of the Eye and Orbit
Primary and Open Angle Glaucoma
Rubeosis Iridis (laser surgery)
Sympathetic Uveitis and Degenerative Disorders and Conditions of Globe
Cataract (extraction)
After Cataract (discission, lens capsule)
Corneal Opacity and Other Disorders of Cornea
Degeneration of Macula and Posterior Pole (Vitrectomy, Laser Surgery)
Gonococcal Infection of Eye
Chronic Inflammatory Disorder of Orbit
Penetrating Wound of Orbit
Retained Intraocular Foreign Body, magnetic and nonmagnetic
Retinal Detachment and Other Retinal Disorders
Vitreous Disorders (vitrectomy)
Entropion
Chronic Depression
Substance-Induced Delusional and Mood Disorders; Intoxication
Borderline Personality Disorder
Identity Disorder
Schizotypal Personality Disorders
Acute Otitis Media
Superficial Injuries with Infection
Acromegaly & Gigantism, Other * Unspecified Anterior Pituitary Hyperfunction…
Conversion Disorder, Child
Functional Encopresis
Avoidant Disorder of Childhood or Adolescence; Elective Mutism
Psychological Factors Aggravating Physical Condition (Asthma, Chronic GI..Hypertension)
Noninflammatory Disorders and Benign Neoplasms of Ovary, Fallopian Tubes and Uterus…
-----------($272.04)----------------
Streak Ovaries
Urologic Infections
Functional and Mechanical Disorders of the Genitourinary System Including Bladder…
Guillain-Barre Syndrome
Deficiencies of Circulating Enzymes…Cystic Fibrosis; Emphysema (heart…and lung transplant)
Respiratory Failure Due to Primary Pulmonary Hypertension, Primary Pulmonary Fibrosis…
Diabetes Mellitus with End Stage Renal Disease (transplant)
Heritary Immune Deficiencies
Constitutional Aplastic Anemias
Alcoholic Fatty Liver Or Alcoholic Hepatitis, Cirrhosis of Liver
Vesicular Fistula
Disorders of Parathyroid Gland; Benign Neoplasm of Parathyroid Gland
Pituitary Disorders: Panhypopituitarism, Iatrogenic and Other
Multiple Sclerosis and Other Demyelinating Diseases of Central Nervous System
Hereditary Hemorrhagic Telangiectasia (excision)
Arthropod-Borne Viral Disease
Lyme Disease and Other Arthropod Borne Diseases
Dysfunction Resulting in Loss of Ability to Maximize Level of Independence in Self-Directed Care…
Neurological Dysfunction in Communication Caused by Chronic Conditions
Paralysis of Vocal Cords or Larynx, other Diseases of Larynx, Abscess, Cellulitis, and Leukoplakia…
Otosclerosis
Migraine Headaches
Fistula Involving Female Genital Tract (closure)
Streptococcal Sore Throat and Scarlet Fever; Hypertrophy of Tonsils and Adenoids; Ulcer of Tonsil
Eating Disorder Nos
Dissociative Disorders: Depersonalization Disorder; Multiple Personality Disorder, Dissociative…
Chronic Organic Mental Disorders Including Dementias
Lymphadenitis
Spontaneous Abortion
Menstrual Bleeding Disorders
-----($288.85)--------
Disorders Involving the Immune System
Fracture of Shaft of Bone, Closed
Closed Fracture of Physis of Lower Extremities
Closed Fracture of Physis of Upper Extremities
Chronic Pancreatitis
Strabismus and Other Disorders of Binocular Eye Movements; Congenital Anomalies of Eye
Imperforate Hymen: Abnormalities of Vaginal Septum
Congenital Absence of Vagina (artificial vagina)
Parkinson's Disease
Meniere's Disease
Stereotypy/Habit Disorder & Self-Abusive Behavior due to Neurological Dysfunction
Bullous Dermatosews of the Skin
Cholesteatoma; Infections of the Pinna
Acute Sinusitis
Uterine Leiomyoma (total hysterectomy or myomectomy)
Dislocation/Deformity Knee & Hip
Dislocation/Deformity of Elbow, Hand, Ankle, Foot, Jaw, Clavicle and Shoulder
Close Dislocations'Fractures of Non-Cervical Vertebral Column Without Spinal Cord Injury
Fracture of Joint, Closed (except Hip)
Achalasia, Non-Neonatal
Bronchiectasis
Occupational Lung Disease
Pulmonary Fibrosis
Anomalies of Gallbladder, Bile Ducts, and Liver
Chronic Sinusitis
Pituitary Dwarfism
Foreign Body in Cornea and Conjunctival Sac
Gout and Crystal Arthropathies
Endometriosis
Ovarian Dysfunction, Gonadal Dysgenisis, Menopausal Management
-----------($293.86)------------
Peripheral Nerve Injury with Open Wound
Myasthenia Gravis
Cancer of Esophagus, Treatable
Cancer of Liver, Treatable
Cancer of Pancreas, Treatable
Cancer of Gallbladder and Other Biliary, Treatable
Non-Malignant Otitis Externa
Esophageal Varices (shunt, sclerotherapy)
Episcleritis
Dental Conditions (eg. Dental caries, fractured tooth)
Dental Conditionals (eg severe Tooth Decay)
Disorders of Refraction and Accommodation
Central Pterygium
Hearing Loss - Over Age of Five
Open Wound of Ear Drum
Sensorineural hearing Loss - Over age of Five
Somatization Disorder; Somatoform Pain Disorder; Premenstrual Tension Syndromes
Trigeminal and Other Nerve Disorders
Disruptions of the Ligaments and Tendons of the Arms and Legs, excluding the Knee, Grade 11 & III
Disorders of Shoulder
Internal Derangement of Knee and Ligamentous Disruptions of the Knee, Grade II and III
Malunion & Nonunion of Fracture (surgery)
Foreign Body in Uterus, Vulva and Vagina
Uterine Prolapse; Cystocele
Osteoarthritis and Allied Disorders
Metabolic Bone Disease
Symptomatic Impacted Teeth
Unspecified Disease of Hard Tissues of Teeth (Avulsion)
Abscesses and Cysts of Bartholin's Gland and Vulva
Cervicitis, Endocervicitis, Hematoma of vulva, and Non…
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Dental Conditions (eg. Tooth loss)
Urinary Incontinence
Hypospadias and Epispadias
Residual Foreign Body in Soft Tissue
Branchial Cleft Cyst
Exfoliation of Teeth Due to Systemic Causes
Ptosis (acquired) with Vision Impairment
Simple and Social Phobias
Retained Dental Root
Peripheral Nerve Entrapment
Incontinence of Feces
Rectal Prolapse
Benign Neoplasm of Kidney and Other Urinary Organs
Urethral Fistula
Thrombosed and Complicated Hemorrhoids
Vaginitis, Trichonomiasis
Balanoposthitis and Other Disorders of Penis
Chronic Anal Fissure; Anal Fistula
Chronic Otitis Media
Acute Conjunctivitis
Cerumen Impaction, Foreign Body in Ear & Nose
Vertiginous Syndromes and other Disorders of Vestibular System
------($308.89)-----------
Unspecified Urinary Obstruction and Benign Prostatic Hyperplasia without Obstruction
Phimosis (surgery)
Contact Dermatitis, Ectopic Dermatitis, Eczema
Psoriasis and Similar Disorders
Cystic Acne
Closed Fracture of Great Toe
Symptomatic Urticaria
Dysfunction of Nasolacrimal System
---------($309.48)------------
Nasal Polyps, Other Disorders of Nasal Cavity and Sinuses
Sialolithiasis, Mucocele, Disturbance - Salivary Secretion, Other/Unspecified Disease/Salivary Glands
Dental Conditions (eg. Broken appliances)
Impulse Disorders (psychotherapy)
Benign Neoplasm Bone & Articular Cartilage Including Osteoid Osteomas; Benign Neoplasm…
Sexual Dysfunction (medical and surgical treatment, psychotherapy)
Stomatitis and Diseases of Lips
Bell's Palsy, Exposure Keratoconjunctivitis
Hordeolum and Other Deep Inflammation of Eyelid; Chalazion
Ectropion, Trichiasis of Eyelid, Benign Neoplasm of Eyelid
Chondromalacia
Dysmenorrhea
pastic Diplegia
Atrophy of Edentulous Alveolar Ridge
Deformities of Upper Body & all Limbs
Deformities of Foot
Peritoneal Adhesion
Pelvic Pain Syndrome; Dyspareunia
Tension Headaches
Chronic Bronchitis
Disorders of Function of Stomach and Other Functional Digestive Disorders
TMJ Disorder
Urethritis, Non-Sexually Transmitted
Lesion of Plantar Nerve; Plantar Facial..
Granuloma of Muscle, Granuloma of Skin & Subcutaneous Tissue
Dermatophytosis of Nail, Groin, and Foot and Other Dermatomycosis
Internal Derangement of Joint Other than Knee
Stenosis of Nasolacrimal Duct (Acquired)
Peripheral Nerve Disorders
Cavus Deformity of Foot; Flat Foot, Polydactyly and Syndactyly of Toes
Peripheral Enthesopathies (surgery)
Peripheral Enthesopathies (Medical treatment)
Disorders of Soft Tissue
Enophthalmos
Macromastia
Galactorrhea, Mastodynia, Atrophy, Benign Neoplasms and Unspecified Disorders of the Breast
Acute and Chronic Disorders of Spine without Neurologic Impairment
Cysts of Oral Soft Tissues
Female Infertility, Male Infertility
Infertility Due to Annovulation
Postconcussion Syndrome
Simple and Unspecified Goiter, Nontoxic Nodular Goiter
Conductive Hearing Loss
Cancer of Liver and Intrahepatic Bile Ducts (transplant)
Hypotension
Viral Hepatitis, excluding Chronic Viral Hepatitis B and Viral Hepatitis C without Hepatic Coma
Benign Neoplasms of Skin and Other Soft Tissues
Redundant Prepuce
Benign Neoplasms of Digestive System
Other Noninfectious Gastroenteritis and Colitis
Factitious Disorders
Hypochondriasis; Somatoform Disorder; Nos and Undifferentiated
Conversion Disorder, Adult
Spinal Deformity, not Clinically significant
Asymptomatic Urticaria
Circumscribed Scleroderma; Senile Purpura
Dermatitis Due to Substances Taken Internally
Allergic Rhinitis and Conjunctivitis/Chronic Rhinitis
Pleurisy
Conjunctival Cyst
Hematoma of Auricle or Pinna/Hematoma of External Ear
Acute Non-Suppurative Labyrinthitis
Infectious Mononucleosis
Aseptic Meningitis
Congenital Anomalies of Female Genital Organs, excluding Vagina
Congenital Deformities of Knee
Uncomplicated Hernia in Adults age 18 or Over
Acute Anal Fissure
Cyst of Kidney, Acquired
PICA
Disorders of Sleep without Sleep Apnea
Cyst, Hemorrhage, and Infarction of Thyroid
Deviated Nasal Septum, Acquired Deformity of Nose, Other Disease of Upper Respiratory Tract
Erythema Multiforme
Herpes Simplex without Complications
Congenital Anomalies of the Ear without Impairment of Hearing; Unilateral Anomalies of the Ear
Blepharitis
Hypertelorism of Orbit
Infertility Due to Tubal Disease
Keratoderma, Acanthosis Nigricans, Striae Atrophicae/Other Hypertrophic/Atrophic Conditions - Skin
Lichen Planus
Obesity (nutritional/lifestyle counseling)
Morbid Obesity (gastroplasty)
Chronic Disease of Tonsils and Adenoids (Tonsillectomy and adenoidectomy)
Hydrocele
Keloid Scar; Other Abnormal Granulation Tissue
Noninflammatory Disorders of Cervix; Hypertrophy of Labia
Sprains of Joints and Adjacent Muscles, Grade 1
Synovitis and Tenosynovitis
Other Disorders of Synovium, Tendon and Bursa, Costochondritis, and Chondrodystrophy
Disease of Nails, Hair and Hair Follicles
Candidiasis of Mouth, Skin and Nails
Benign Lesions of Tongue
Minor Burns
Minor Head Injury: Hematoma/Edema with No Loss of Consciousness
Congenital Deformity of Knee
Phlebitis and Thrombophlebitis, Superficial
Prolapsed Urethral Mucosa
Rupture of Synovium (removal of baker's cyst)
Personality Disorders excluding Borderline, Schizotypal and Anti-Social
Gender Identification Disorder, Paraphilias and Other Psychosexual Disorders
Fingertip Avulsion
Anomalies of Relationship of Jaw to Cranial Base, Major Anomalies - Jaw Size, Other…Dentofacial
Cervical Rib
Gynecomastia (Mastectomy)
Viral, Self-Limiting Encephalitis, Myelitis and Encephalomyelitis
Gallstones without Cholecystitis
Benign Neoplasm of Nasal Cavities, Middle Ear & Accessory Sinuses
Acute Tonsillitis other than Beta-Streptococcal
Edema and Other Conditions Involving the Integument of the Fetus and Newborn
Acute Upper Respiratory Infections and Common Cold
Diaper Rash
Disorders of Sweat Glands
Other Viral Infections, excluding Pneumonia due to Respiratory Syncytial Virus - Persons under age 3
Pharyngitis and Laryngitis and Other Disease of Vocal Cords
Corns and Calluses
Viral Warts excluding Venereal Warts
Old Laceration of Cervix and Vagina
Tongue Tie and Other Anomalies of Tongue
Open Wound of Internal Structures of Mouth without Complication
Central Serous Retinopathy
Seborrheic Keratosis, Dyschromia and Vascular Disorders, Scar Conditions, and Fibrosis of Skin
Uncomplicated Hemorrhoids
Ganglion (excision)
Chronic Conjunctivitis, Blepharoconjunctivitis
Toxic Erythema, Acne Rosacea, Discoid Lupus
Peripheral Nerve Disorders
Other Complications of a Procedure
Raynaud's Syndrome
TMJ Disorders (TMJ surgery)
Varicose Veins of Lower Extremities without Ulcer or Inflammation
Vulval Varices
Chronic Pancreatitis
Chronic Prostatitis, other disorders of Prostate
Muscular Calcification and Ossification
Cancer of Various sites with Distant Metastases where treatment will not result in 5%- 5yr survival
Agenesis of Lung
Disease of Capillaries (excision)
Benign Polyps of Vocal Cords
Fractures of Ribs and Sternum, Closed
Closed Fracture of One or More Phalanges of the Foot not including the Great Toe
Disease of Thymus Gland
Dental Conditions where Treatment Results in Marginal Improvement
Anti-Social Personality Disorder
Sebaceous Cyst
Central Retinal Artery Occlusion
Oral Aphthae
Sublingual, Scrotal, and Pelvic Varices
Superficial Wounds without Infection and Contusions
Unspecified Retinal Vascular Occlusion
Benign Neoplasm of External Female Genital Organs
Benign Neoplasm of Male Genital Organs; Testis, Prostate, Epididymis
Xerosis
Congenital Cystic Lung - Severe
Ichthyosis
Lymphedema
Dermatological Conditions with no effective treatment or no treatment necessary
Infectious Conditions with no effective treatment or no treatment necessary
Respiratory Conditions with no effective treatment or no treatment necessary
Genitourinary Conditions with no effective treatment or no treatment necessary
Cardiovascular Conditions with no effective treatment or no treatment necessary
Musculoskeletal Conditions with no effective treatment or no treatment necessary
Intracranial Conditions with no effective treatment or no treatment necessary
Sensory Organ Conditions with no effective treatment or no treatment necessary
Endocrine and Metabolic Conditions with no effective treatment or no treatment necessary
Gastrointestinal Conditions with no effective treatment or no treatment necessary
Mental Conditions with no effective treatment or no treatment necessary
Neurologic Conditions with no effective treatment or no treatment necessary
Dental Conditions (cosmetic dental services)
Tubal Dysfunction and Other Causes of Infertility (in-vitro fertilization)
Hepatorenal Syndrome
Spastic Dysphonia
Disorders of Refraction and Accommodation (Radial Keratotomy)