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Medicare Pre-authorization List

This pre-authorization list includes services and supplies that require pre-authorization or notification for Medicare Advantage products.

How to submit a pre-authorization request or notification

Please use the online form or pre-authorization request form below to ensure the most current version is utilized as forms are subject to change. If your Medicare patient requests a service or item that you know or expect is non-covered, please follow our Medicare pre-authorization process to request a pre-service organization determination.

Expedited requests

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.

  • Availity Essentials: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request

  • Via fax using the appropriate pre-authorization request form below

Non-covered services

If your Medicare Advantage patient requests a service or item you expect to be non-covered, you can request a pre-service determination by submitting our pre-authorization request form by phone or fax. Note: Do not submit them via the Availity electronic authorization tool. You must follow our Medicare pre-authorization process for a pre-service organization determination in order for services to be considered for approval and for you to be able to bill the member for services that are not covered. This process replaces the former Advanced Beneficiary Notification (ABN) process for Medicare Advantage.

Within 14 calendar days, we will approve or deny the request, and provide notification to you and the member. A denial notice will include the reason and explain the appeal process. If you wish to appeal a denial on behalf of the member, you must also have a completed Appointment of Representative form (Form CMS-1696).

Online

  • Submit an electronic pre-authorization request, and supporting clinical documentation through Availity Essentials>Patient Registration>Authorizations & Referrals>Authorizations
  • Radiology and sleep medicine: Sign in to the Carelon Medical Benefits Management (Carelon) ProviderPortal

  • Physical medicine: Sign in to the eviCore portal or choose to be routed from Availity's electronic authorization tool via single sign on.

Note: Check the status of your requests using the same platform you used to submit the request:

  • Requests submitted through eviCore are updated on eviCore’s portal

  • Requests submitted through Availity Essentials are updated in Availity

Fax

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

Type of service

Online

Phone

Fax (only if unable to submit online)

Skilled nursing facility only

Submit an electronic pre-authorization request through Availity Essentials

1 (844) 600-4376

1 (855) 848-8220

Long term acute care and inpatient rehabilitation

1 (855) 238-9318

1 (855) 848-8220

Chemical dependency and mental health

1 (855) 522-8868

1 (888) 496-1540

Transplants

1 (855) 238-9318

1 (800) 584-0689

Professional services and DME

1 (855) 238-9318

1 (855) 207-1209

Expedited requests

1 (855) 238-9318

1 (855) 240-6498

Inpatient concurrent review

Concurrent review notification for:

  • Skilled nursing facilities (SNF)
  • Inpatient rehabilitation (IPR)
  • Long-term acute care hospitalizations (LTACH)

1 (855) 848-8220

Notifications for:

  • Inpatient admissions for SNF/IPRL/LTACH/IP Hospital
  • Inpatient discharges for SNF/IPRL/LTACH/IP Hospital

1 (855) 238-9318

1 (800) 453-4341

Clinical records for:

  • SNF stays
  • LTACH stays
  • IPR stays

1 (855) 238-9318

1 (844) 629-4404

Acute inpatient medical and behavioral health hospital stays require concurrent review.

Medical management program pre-authorization

Medical management program

Authorization

Cardiology/Radiology/Sleep programs

Codes requiring authorization are listed in the Radiology section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on Availity Essentials. View Carelon's clinical guidelines.

Obtain an order number with Carelon:

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View eviCore's clinical guidelines.

Obtain or verify an authorization with eviCore healthcare (eviCore):

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization and providing services, please verify member eligibility and benefits via the Availity Provider Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. Emergency services do not require pre-authorization, but notification should be provided for all hospital admissions or discharges within 24 hours of admission or discharge (or one business day, if the admission occurs on a weekend or a federal holiday).
  6. Our Medicare Medical Policy, MCG and CMS criteria may be used as the basis for medical necessity determinations, including length of stay and level of care.
  7. Experimental and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially experimental services and are subject to review. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Please refer to the Always Not Medically Necessary Denials list for additional information.
  8. Please note that a notification or pre-authorization does not guarantee payment for requested services. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
  9. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete information.
Pre-authorization review timeframes

Type of review

Timeframe

Additional time allowed for review if additional information is needed:

Urgent

72 hours

None

Standard initial

14 calendar days

Asuris provider: None
Non-Asuris provider: 14 calendar days

Concurrent

24 hours
Effective September 1, 2022: Must notify within 24 hours for newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission.
Exception:
Maternity notifications are required on day 6.

72 hours

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

We will respond to your notification with the date clinical records are due. If you have granted our clinical team access to your electronic medical records (EMR) system, please ensure these records are available in your EMR system.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Notification of inpatient admission should be provided to the health plan. Urgent/emergent services are subject to review post-service for medical necessity; please submit proper clinical documentation with claim.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient. Additionally, the pre-authorization should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  • A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.
  • If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility/provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

Pre-authorization exception

There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):

  1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
  4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
  5. A surgery which requires pre-authorization occurs in an urgent or emergent situation. Services are subject to review post-service for medical necessity.

  6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Learn how to notify us about an extenuating circumstance (PDF) prior to claim submission, or how to appeal a claim that has been administratively denied.

Inpatient admissions

See below for chemical dependency and mental health admissions.

Hospital admissions

  • Notification of a hospital admissions or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Notification of hospital admission and discharge required within 24 hours, regardless of federal holidays or day of the week.

  • Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.

Inpatient hospice

  • Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Notification of inpatient hospice admission and discharge required within 24 hours, regardless of federal holidays or day of the week.

  • Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.

Long Term Acute Care Facility (LTAC)

  • Pre-authorization required prior to patient admission.

Acute Rehabilitation (PDF)

  • Pre-authorization required prior to patient admission.

Skilled Nursing Facility (SNF) (PDF)

  • Sometimes referred to as "sub-acute rehabilitation
  • Pre-authorization required prior to patient admission

  • SNF is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • Asuris requires the facility to notify us when ECMO is initiated on an Asuris Member. We will initiate concurrent review upon this notification.

Home health care

Pre-authorization is required for any home health services delivered 61 days or more after the initial start date, which is the beginning of the second episode of care.

Pre-authorization requests should be submitted three to five days before the subsequent episode begins. Requests should include the original Outcome and Assessment Information Set (OASIS) and the completed medication reconciliation form, both signed by the physician. Documentation of a verbal or signed order from the ordering provider is also needed to show provider is in agreement with the continued plan of care.

Note: A single full-length episode of care is defined as a period of 60 consecutive days, not by the number of individual home health visits. A second subsequent episode would start on the first day after the initial episode is completed—the 61st day after the first service was delivered—regardless of whether a service will be delivered on the 61st day. Episodes may be shorter than 60 days; for example, if a member transfers to another home health agency or is discharged and readmitted to the same home health agency.

The home health agency is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.

View the Medicare Advantage medical policy for Home Health Services (PDF) including, but not limited to the following: G0151, G0152, G0153, G0154, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0171, G0299, G0300.

Chemical dependency and mental health

Pre-authorization is required for the services listed below. Emergency inpatient services do not require pre-authorization but are subject to admission notification requirements.

  • Applied behavior analysis (ABA) therapy:
    • Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
    • Procedure codes 97151, 97152, and 0362T: Pre-authorization Is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments
    • Pre-authorization for medical necessity is not required for Medicare members under the age of 18, but Medicare-approved provider requirements still apply
  • Inpatient: Psychiatric or ASAM 4.0 detoxification - Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for substance use disorders - Request for authorization is required no later than the day of admission.

  • Intensive outpatient: Psychiatric or ASAM level 2.1 for substance use disorders - Request for authorization is required no later than the day of admission.

View our resources and forms for behavioral health facilities and our behavioral health medical policies.

Clinical trials, Investigational Device Exemption (IDE) studies, and Coverage with Evidence Development (CED) studies and registries

Clinical trial, registry or study

Contact and coverage summary

IMPORTANT NOTE: Services in the following categories that are not listed as requiring pre-authorization elsewhere on this page do not require pre-authorization. In addition, the following guidelines may apply to these services, and should be fully reviewed. We recommend confirming coverage with Medicare and/or the health plan. Providers are expected to only submit claims for medically reasonable and necessary services per Title XVIII of the Social Security Act §1862(a)(1)(A).

Category A and Category B Investigational Device Exemption (IDE) studies

Coverage for CMS-approved Category A and B IDE studies includes routine care items and services. Category B IDE devices are also reimbursable, but reimbursement for Category A devices under investigation is statutorily excluded.

View the Medicare Advantage medical policy for Category A and Category B Investigational Device Exemption (IDE) Studies (PDF)

Coverage with Evidence Development (CED) studies and registries

Medicare determines coverage requirements and restrictions for services covered under the CED provision. These services generally have a national coverage determination (NCD) available, and approved studies and registries are added to the CMS clinical trials/registry web site.

View the Medicare Advantage medical policy for Coverage with Evidence Development (CED) Studies and Registries (PDF)

Clinical trials or registries (not otherwise specified)

Medicare determines coverage for clinical trials, including for Medicare Advantage beneficiaries. We recommend providers call Medicare directly at 1-800-MEDICARE to determine Medicare approval status of the requested clinical trial/registry.

View the Medicare Advantage medical policy for Clinical Trials/Registries (PDF)

Allied health

Dental Services (PDF)

  • 21245, 21246, 21248, 21249

Durable medical equipment

Bone Growth Stimulators (Osteogenic Stimulation) (PDF)

  • 20979, E0747, E0760

Commode Chairs with Seat Lift Mechanism (PDF)

  • E0170, E0171

Electrical Stimulation and Electromagnetic Therapy Devices (PDF)

  • 0278T, A4560, E0731, E0745, E0761, E0764, E0770, G0329

Multi-Positional Patient Transfer System (PDF)

  • E0636, E1035, E1036

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

  • L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L8701, L8702

Definitive Lower Limb Prostheses (PDF)

  • L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987

  • Effective October 1, 2023: L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5968

Negative Pressure Wound Therapy in the Outpatient Setting (PDF)

  • 97605, 97606, 97607, 97608, A6550, A7000, E2402, K0743

  • The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466

Pneumatic Compression Devices (PDF)

  • E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673

Power Wheelchairs - Group 2 and Group 3 (PDF)

  • E2300, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Powered Exoskeleton for Ambulation (PDF)

  • K1007

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle Foot Orthoses (PDF)

  • K1014, L2006, L5859, L5973 L5856, L5857, L5858

Sleep Medicine

  • View the Sleep Medicine Program for notification or authorization requirements

  • Review the codes requiring authorization or notification in the sleep medicine section on this list.

Tumor Treatment Field Therapy (TTFT) (PDF)

  • E0766

Genetic testing

Genetic and Molecular Diagnostics - Single Gene or Variant Testing (PDF)

  • 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, G9143, 0009U, 0016U, 0017U, 0023U, 0027U, 0031U, 0032U, 0046U, 0049U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0080U, 0154U, 0155U, 0156U, 0177U, 0218U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0338U, 0355U

Genetic and Molecular Diagnostics - Next Generation Sequencing and Genetic Panel Testing and Biomarker Testing (PDF)

  • 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81460, 81465, 81470, 81471, 81493, 81504, 81507, 81513, 81514, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 0011M, 0017M, 0005U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0033U, 0034U, 0037U, 0045U, 0047U, 0048U, 0068U, 0086U, 0089U, 0090U, 0101U, 0109U, 0111U, 0112U, 0118U, 0129U, 0131U, 0133U, 0134U, 0140U, 0141U, 0142U, 0169U, 0171U, 0172U, 0179U, 0202U, 0223U, 0225U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0250U, 0288U, 0306U, 0307U, 0311U, 0323U, 0326U, 0327U, 0329U, 0330U, 0331U, 0334U, 0340U, 0343U, 0345U, 0352U, 0356U, 0362U, 0364U, 0371U, 0372U, 0375U, 0376U, 0377U, 0378U, 0379U, 0380U, 0386U, 0387U, 0388U, 0389U, 0391U, 0393U, 0395U, 0397U, 0398U, 0399U, G0327

Medicine

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions (PDF)

  • 0232T, G0460, G0465, P9020

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)

  • A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A6460, A6461, C9356, C9358, C9360, C9363, C9364, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4130, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284

Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting (PDF)

  • 0607T, 0608T, 33289, 93264, 93701 C2624

Cell Therapy for Peripheral Arterial Disease (PDF)

  • 0263T, 0264T, 0265T

Charged-Particle (Proton) Radiotherapy (PDF)

  • 77301, 77338, 77520, 77522, 77523, 77525

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions (PDF)

  • 28890, 0101T, 0102T

Gender Affirming Interventions for Gender Dysphoria (PDF)

  • 15775, 15776, 17380, 55970, 55980
  • Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
  • 15771, 15773, 17999, 19303, 19316, 19318, 19325, 19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, C1813, C2622, L8600
  • Use code 17999 to request laser hair removal.

  • Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to:

    • Abdominoplasty - 15830
    • Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast - 15771
    • Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
    • Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
    • Chin Implants - 21120, 21121, 21122, 21123, 21209
    • Collagen Injections - 11950, 11951, 11952, 11954
    • Cosmetic and Reconstructive Procedures - 15771, 15773
    • Panniculectomy - 15830
    • Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants - 15771
    • Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450

Hyperoxemic Reperfusion Therapy (PDF)

  • 0659T

Intensity Modulated Radiation Therapy (IMRT) (PDF)

Submit the IMRT Pre-authorization Request Supplemental Form (PDF) when requesting pre-authorization for these services. This form will help determine what specific clinical documentation is required.

  • 77301, 77338 G6015, G6016

In Vivo Analysis of Colorectal Lesions (PDF)

  • 88375

Laser Interstitial Thermal Therapy (PDF)

  • 61736, 61737

Low-Level Laser Therapy (PDF)

  • 0552T

Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders (PDF)

  • 83987

Myocardial Strain Imaging (PDF)

  • C9762, C9763

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

  • 38206, 38232, 38241, 0565T, 0566T, C9782

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF)

  • 38205, 38206, 38240, 38241

Quantitative Sensory Testing (PDF)

  • 0106T, 0107T, 0108T, 0109T, 0110T

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE) (PDF)

  • 37243, 79445 C2616

Signal-Averaged Electrocardiography (SAECG) (PDF)

  • 93278

Skin Lesion Imaging and Spectroscopy (PDF)

  • 0658T, 96931, 96932, 96933, 96934, 96935, 96936

Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF)

  • 96002, 96004

Sleep Medicine

  • View the Sleep Medicine Program for notification or authorization requirements

  • Review the codes requiring authorization or notification in the Sleep medicine section.

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF)

Vestibular Evoked Myogenic Potential Testing (PDF)

  • 92517, 92518, 92519

Physical Medicine

We partner with eviCore healthcare (eviCore) to administer our Physical Medicine program.

  1. Review this entire page for similar services that require pre-authorization
  2. Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
  3. Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials

  4. Obtain or verify an authorization with eviCore:

Physical therapy, speech therapy, occupational therapy (PT,ST,OT); complementary and alternative medicine

  • Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials.
  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF) for enrolled dependents aged 17 and younger.
  • Rehabilitative care (PT, OT, ST) ordered by home health and performed during home health care visits does not require review by eviCore, but does require pre-authorization from Asuris.

  • We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 95851, 95852, 96105, 97012, 97016, 97018, 97022, 97024, 97028, 97032, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97129, 97130, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, S9152

Pain management

  • Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials

  • We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685, 63688, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72285, 72295, G0259, G0260

Joint management

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
  • We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916

Joint management site-of-service

  • We require authorization from eviCore for these codes: 20520, 20525, 20670, 20680, 20693, 20694, 23000, 23020, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27130, 27332, 27333, 27334, 27335, 27403, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086. 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29834, 29837, 29838, 29844, 29846, 29848, 29860, 29861, 29862, 29863, 29866, 29867, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29914, 29915, 29916

  • Note: Site-of-service pre-authorization is not required when procedures performed in an ambulatory surgery center, physician office, or emergency facility for urgent services

Spine

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
  • We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749

Radiology

Contact Asuris for pre-authorization for the following codes:

Carelon Medical Benefits Management (Carelon)

We partner with Carelon to administer our radiology program which has two components: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Please note, ASO groups who do not participate in the Advanced Imaging component may require an order number through the RQI component. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

To determine whether your patient's plan participates in this program, use the electronic authorization tool on the Availity Portal.

Contact Carelon to request pre-authorization for the following codes:

  • 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0501T, 0502T, 0503T, 0504T, 0648T, 0649T
  • Effective November 1, 2023, contact Carelon to request pre-authorization for the following codes: 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78102, 78103, 78104, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78445, 78456, 78457, 78458, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78830, 78831, 78832

Sleep Medicine

We partner with Carelon to administer our Sleep Medicine program.

Contact Carelon to obtain an order number for the following codes:

  • 95782, 95783, 95805, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601

Cardiology

We partner with Carelon to administer our cardiology program.

Contact Carelon to obtain an order number for the following codes: 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 92920, 92924, 92928, 92933, 92937, 92943, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931

Surgery

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)

  • 15769, 15771, 15772, 19380

  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19380 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, not medically necessary.
    • Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.

Automated Percutaneous and Percutaneous Endoscopic Discectomy (PDF)

  • 62287, 62380, C2614

Balloon Dilation of the Eustachian Tube (PDF)

  • 69705, 69706

Balloon Ostial Dilation for Treatment of Sinusitis (PDF)

  • 31295, 31296, 31297, 31298

Baroreflex Stimulation Devices (PDF)

  • 0266T, 0267T, 0268T, 0272T, 0273T, C1825

Blepharoplasty, Eyelid Surgery, and Brow Lift (PDF)

  • 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950

Cosmetic and Reconstructive Procedures (PDF)

  • 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15830, 15847, 15876, 15877, 15878, 15879, 17106, 17107, 17108, 17360, 19300, 19355, 21244, 21245, 21246, 21248, 21249, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 41510, 49250, 54360, G0429, J0591, Q2026, Q2028

    • Codes 11950, 11951, 11952, 11954, 15769, 15771 and 15772 always require pre-authorization (see other sections of this pre-authorization list, including the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section).
    • Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast
    • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
    • Codes 21245, 21246, 21248 and 21249 are also found in the Medicare Dental Services Medical Policy.

Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) (PDF)

  • 62287, 62292

Deep Brain Stimulation (PDF)

  • 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • Please see the Inpatient Admission section for further information.

Focal Laser Ablation of Prostate Cancer (PDF)

  • 0655T

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, 64595, C1767, C1778, C1883, C1897

  • E0765

Gastroesophageal Reflux Surgery (PDF)

  • 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337

Hypoglossal Nerve Stimulation (PDF)

  • 64568, 64582, 64583, C1767

Image-Guided Minimally Invasive Decompression (IG-MSD) for Spinal Stenosis (PDF)

  • 0274T

Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) (PDF)

  • 22867, 22868, 22869, 22870, C1821

Intracardiac Ischemia Monitoring (PDF)

  • 0525T, 0526T, 0527T, 0528T, 0529T

Lung Volume Reduction Surgery (LVRS, or Reduction Pneumoplasty) (PDF)

  • 32491, 32672, G0302, G0303, G0304, G0305

Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) (PDF)

  • 43284, 43285

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)

  • 55880, C9734, 0398T, 0071T, 0072T

Occipital Nerve Stimulation (ONS) (PDF)

  • 61885, 61886, 64553, 64555, 64568, 64569, 64575, 64585, 64590, 64595

Orthognathic Surgery (PDF)

  • 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21230, 21215, 21295, 21296

  • Codes 21145, 21196, 21198 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Pacemakers; Leadless Pacemakers (PDF)

  • 33274, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T

Percutaneous Axial Lumbosacral Interbody Fusion (LIF) (PDF)

  • 22586

Percutaneous Transluminal Angioplasty (PTA) and Stenting (PDF)

  • 37215, 37217, 37238, 37239, 37246, 37247, 37248, 37249, 61635

Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) (PDF)

  • 64555, 64575, 64585, 64590, 64595, C1778

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

  • 0424T, 0425T, 0426T, 0427T, 0431T, 0432T, 0433T, 0434T, 0435T, 0436T, C1823

Plugs for Enteric and Anorectal Fistula Repair (PDF)

  • 46707

Posterior Tibial Nerve Stimulation (PTNS) (PDF)

  • 64566, 0587T, 0588T, 0589T, 0590T

Pressure Ulcer Treatment by Musculocutaneous or Free Flap (PDF)

  • 15734, 15738, 15756, 15757, 15758

Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)

  • 20982, 31641, 32998, 50542, 50592

Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (PDF)

  • 11920, 11921, 19316, 15769, 15771, 15772, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600
  • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

  • Notes:

    • Codes 11950, 11951, 11952, 11954,15769, 15771, 15772 and 19380 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, not medically necessary
    • Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Reduction Mammaplasty (Mammoplasty) (PDF)

  • 15877, 19318

  • Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

Responsive Neurostimulation (PDF)

  • 61850, 61860, 61863, 61864, 61885, 61886

Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction (PDF)

  • 64561, 64581, 64585, 64590, 64595, C1767

Sacroiliac Joint Fusion (PDF)

  • 27279, 27280, 0775T, 0809T

Subtalar Arthroereisis (PDF)

  • 0335T, 0510T, 0511T

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)

  • 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 41512, 41530, 42140, 42145, 42160

  • Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Surgical Site of Service - Hospital Outpatient (PDF)

  • NOTE: Pre-authorization is not required when procedures performed in an ambulatory surgery center, physician office, or emergency facility for urgent services
  • Submit the Surgical Site of Service Additional Information Form (PDF) if faxing a pre-authorization request for these services.
  • 11755, 14040, 14060, 15851, 17311, 17313, 30130, 30140, 30520, 30802, 31200, 31205 31525, 31574, 31591, 32408, 32555, 32557, 38221, 38222, 42821, 42826, 42831, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43254, 43260, 43261, 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 46505, 46607, 49082, 49422, 50430, 51715, 52001, 52235, 52287, 52450, 53445, 54150, 54161, 54162, 54163, 54164, 54300, 54450, 54840, 55040, 55041, 55700, 56810, 57283, 58263, 62270, 63661, 64418, 64425, 64530, 64610, 64642, 64644, 64646, 64702, 64718, 64719, 64721 64774, 64795, 64831, 65756, 65779, 65780, 65855, 66183, 66761, 66840, 66850, 67028, 67218, 68320

Surgical Treatments for Lymphedema and Lipedema (PDF)

  • 15876, 15877, 15878, 15879

Surgical Ventricular Restoration (PDF)

  • 33548, 0643T

Total Facet Arthroplasty (PDF)

  • 0202T

Transcatheter Heart Valve Procedure (PDF)

  • 0484T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 33419, 0345T

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)

  • 43192, 43201, 43236, 43257

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate (PDF)

  • 53854, 0421T, C2596

Vagus Nerve Stimulation (VNS) (PDF)

  • 61885, 61886, 64553, 64568, 64569, K1020

Varicose Vein Treatment (PDF)

  • 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 0524T

  • Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment

Physical Medicine Program

  • View Physical Medicine Program for notification or authorization requirements through eviCore
  • Review the codes requiring authorization or notification in the Physical medicine section.

Transplants and ventricular assist devices

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, L8698

Heart Transplants (PDF)

  • 33945

Heart-Lung Transplants (PDF)

  • 33935

Intestinal and Multi-Visceral Transplants (PDF)

  • 44132, 44133, 44135, 44136, 44715, 44720, 44721, 47135, 48554

Islet Cell Transplantation (PDF)

  • 0584T, 0585T, 0586T, G0343, G0341, G0342

Liver Transplants (PDF)

  • 47135

Lung Transplants (PDF)

  • 32851, 32852, 32853, 32854

Pancreas Transplants (PDF)

  • 48554

Stem Cell and Bone Marrow Transplantation (PDF)

  • 38205, 38206, 38232, 38240, 38241, 38242, C9782

Utilization management

Air Ambulance Transport (PDF)

  • A0430, A0435
  • Pre-authorization is required prior to elective fixed wing air ambulance transport.
  • Emergency air ambulance transports may be reviewed retrospectively for medical necessity.