Service Service Code Req. or Limit Code Req. or Limit 01999 IC 15878 CD; IC (covered with 11920 PA diagnosis of lipodystrophy 11921 PA associated with or secondary 11950 CD (covered with diagnosis to HIV only) of lipodystrophy associated 15879 CD; IC (covered with with or secondary to HIV diagnosis of lipodystrophy only) associated with or secondary 11951 CD (covered with diagnosis to HIV only) of lipodystrophy associated 15999 IC with or secondary to HIV 17380 PA (covered in preparation only) for gender affirming surgery 11952 CD (covered with diagnosis only) of lipodystrophy associated 17999 PA; IC with or secondary to HIV 19300 PA only) 19303 PA (for gender 11954 CD (covered with diagnosis related services only) of lipodystrophy associated 19304 PA (for gender with or secondary to HIV related services only) only) 11970 PA (for gender dysphoria- 19316 PA related services only) 19318 PA 11971 PA (for gender dysphoria- 19324 PA related services only) 19325 PA 15820 PA 19328 PA 15821 PA 19340 PA 15822 PA 19350 PA 15823 PA 19499 IC 15830 PA 20999 IC 15832 PA 21088 IC 15833 PA 21089 IC 15834 PA 21137 PA 15835 PA 21138 PA 15836 PA 21139 PA 15837 PA 21146 PA 15838 PA 21147 PA 15839 PA 21150 PA 15876 CD; IC (covered with 21151 PA diagnosis of lipodystrophy 21154 PA associated with or secondary 21155 PA to HIV only) 21159 PA 15877 CD; IC (covered with 21160 PA diagnosis of lipodystrophy 21172 PA associated with or secondary 21175 PA to HIV only) 21188 PA
Service Code Req. or Limit 01999 IC 11920 PA 11921 PA 11950 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11951 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11952 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11954 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11970 PA (for gender services only) 11971 PA (for gender services only) 15820 PA 15821 PA 15822 PA 15823 PA 15830 PA 15832 PA 15833 PA 15834 PA 15835 PA 15836 PA 15837 PA 15838 PA 15839 PA 15876 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15877 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) Service Code Req. or Limit 15878 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15879 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15999 IC 17380 PA (covered in preparation for gender affirming surgery only) 17999 PA; IC 19300 PA 19303 PA (for gender services only) 19304 PA (for gender services only) 19316 PA 19318 PA 19324 PA 19325 PA 19328 PA 19340 PA 19350 PA 19499 IC 20999 IC 21088 IC 21089 IC 21137 PA 21138 PA 21139 PA 21146 PA 21147 PA 21150 PA 21151 PA 21154 PA 21155 PA 21159 PA 21160 PA 21172 PA 21175 PA 21188 PA dysphoria- related dysphoria- related related related
PHY-155.docx