| Name | Value |
|---|---|
| CODE | 114 |
| STATUS EFFECTIVE DATE |
|
| DESCRIPTION EFFECTIVE DATE |
|
| ASSOCIATED SUSPEND CODE | File: 161.27, IEN: 4 |
| SUSPENSION DESCRIPTION | Procedure/product not approved by the Food and Drug Administration. |
| REMITTANCE REMARK |
|
| CORE SCENARIO | Billed Service Not Covered |
| ADJUSTMENT GROUP |
|