This pre-authorization list includes services and supplies that require pre-authorization or notification for Medicare Advantage products.
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
- Learn more about submitting requests through Availity
- 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:
- Behavioral health facility submission forms. Tip: Download the form and then fill it out to avoid browser discrepancies.
- Initial Request Form (PDF) (can be added to an Availity submission)
- Concurrent Request Form (PDF)
- Stepdown Request Form (PDF)
- Discharge Notification Form (PDF)
- Applied Behavioral Analysis (ABA) Initial Request Form (PDF)
- Applied Behavioral Analysis (ABA) Concurrent Request Form (PDF)
- Transcranial Magnetic Stimulation (rTMS) Request Form (PDF) for initial and ongoing services
Type of service | Online | Phone | Fax (only if unable to submit online) |
|---|---|---|---|
Long term acute care and inpatient rehabilitation | Submit an electronic pre-authorization request through Availity Essentials | 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 |
Phone | Fax (only if unable to submit online) | |
Continued stay | 1 (855) 848-8220 | |
Admissions and/or discharge notification | 1 (800) 423-6884 | 1 (800) 453-4341 |
Online | Phone | Fax | |
Admissions and/or discharge notification Clinical records for stays | |||
Acute inpatient medical and behavioral health hospital stays require concurrent review. | |||
Medical management program | Authorization |
|---|---|
Cardiovascular/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 application on Availity Essentials. View Carelon's clinical guidelines. | Request pre-authorization from Carelon:
|
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 application on Availity Essentials. View eviCore's clinical guidelines. | Obtain or verify an authorization with eviCore healthcare (eviCore):
|
- Failure to pre-authorize services subject to pre-authorization requirements or follow concurrent review requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
- Before requesting pre-authorization and providing services, please verify member eligibility and benefits via Availity Essentials as the member contract determines the covered benefits.
- Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
- 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.
- 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. Hospital admissions are subject to concurrent review.
- 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.
- 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, on the Clinical edits tab, for additional information.
- 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.
- All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete information.
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 |
Concurrent | 24 hours - includes newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission. | 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. | ||
Failure to secure approval for services subject to pre-authorization or concurrent review 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.
There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):
- 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.
- Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
- Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
- 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.
- A surgery which requires pre-authorization occurs in an urgent or emergent situation. Services are subject to review post-service for medical necessity.
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.
See below for chemical dependency and mental health admissions.
Hospital admissions
- Pre-authorization is required for elective inpatient admissions.
- Notification of hospital admission and discharge required within 1 calendar day, 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.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Acute Rehabilitation
- Pre-authorization required prior to patient admission.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Skilled Nursing Facility (SNF)
- 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.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
We require the facility to notify us when ECMO is initiated on an Asuris Member. We will initiate concurrent review upon this notification.
Contact Carelon for:
- Concurrent review
- All visits in excess of the authorized number of visits or authorization period will require a subsequent pre-authorization request.
- Providers must include visit notes and an updated treatment plan to demonstrate the member’s status at the time of the pre-authorization request—not their status upon admission to home health services.
- The Outcome and Assessment Information Set (OASIS) is only required every 60 days.
- Initial notification submitted within 24-48 hours of the first home visit. Notification must include:
- The original OASIS and the completed medication reconciliation form, both signed by the physician
- A signed physician’s order for home health services and the plan of care; non-physician practitioner-signed documentation will be accepted where allowed by law
- G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0299, G0300, G0493, G0494, G0495, G0496
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Pre-authorization is required for the services listed below.
- Inpatient: Psychiatric, eating disorder, ASAM 4.0 or ASAM 3.7 in a hospital setting
- Pre-uthorization requests should be submitted as soon as possible and are accepted if they are within 3 business days of admission.
- Timely concurrent review will be required if additional days are requested after an initial pre-authorization is issued. Concurrent review records are due on the last covered date of a pre-authorization. Failure to follow concurrent review requirements may result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
- Partial Hospitalization & Intensive Outpatient Treatment
- Includes mental health, eating disorder and chemical dependency (ASAM 2.5, ASAM 2.1)
- Request for pre-authorization is required within 7 calendar days of start date.
- Includes mental health, eating disorder and chemical dependency (ASAM 2.5, ASAM 2.1)
- Transcranial magnetic stimulation (TMS) & applied behavior analysis (ABA)
- Request for pre-authorization is required within 7 calendar days of start date.
- ABA services require pre-authorization for all members regardless of age.
View our resources and forms for behavioral health facilities and our behavioral health medical policies.
- Behavioral Health (Psychiatric) Services
- 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
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) |
21245, 21246, 21248, 21249
Carelon Cardiovascular
We partner with Carelon to administer our cardiovascular
program.
- Sign in to Carelon's Provider Portal
- Phone 1 (877) 291-0509
- View workarounds for Carelon system outages
- Contact Carelon to request pre-authorization for the following codes: 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33270, 33271, 33274, 33285, 36901, 36902, 36903, 36904, 36905, 36906, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37241, 37242, 37243, 37244, 92920, 92924, 92928, 92933, 92937, 92943, 93228, 93229, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93642, 93644, 93650, 93653, 93654, 93656, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 0823T, 0825T, 0913T, C1721, C1722, C1764, C1777, C1785, C1786, C1882, C1895, C1896, C1899, C2619, C2620, C2621, C7513, C7514, C7515, C7530, E0616, G0448
- Effective July 1, 2025: Pre-authorization will be required for codes: C7557, C7558
- Procedures performed in an inpatient setting or on an emergent basis do not require pre-authorization from Carelon. Inpatient stays are subject to review by Regence for determining the appropriate length of stay.
- Retrospective review is not allowed for cardiac rhythm monitors (93228 and 33285). Retrospective review is allowed for cardiac ablation and wearable and cardioverter defibrillators if records are received within 10 business days of the date of service.
Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment (PDF)
E0767
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, 0882T, 0883T, 0906T, 0907T, A4542, A4544, A4560, A4596, E0731, E0732, E0733, E0734, E0743, E0745, E0761, E0764, E0770, G0329
Lower Extremity Sensory Prostheses (PDF)
- L8720, L8721
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)
L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5783, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987
Negative Pressure Wound Therapy in the Outpatient Setting (PDF)
97605, 97606, 97607, 97608, A6550, A7000, E2402, K0743
Noninvasive Ventilators in the Home Setting (PDF)
E0466, E0468
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)
- E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E2298, 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)
E0739, K1007
L2006, L5615, L5859, L5973 L5856, L5857, L5858
Sleep Medicine
- View the Sleep Medicine Program for notification or pre-authorization requirements
Review the codes requiring pre-authorization or notification in the sleep medicine section on this list.
Tumor Treatment Field Therapy (TTFT) (PDF)
- E0766
Upper Extremity Rehabilitation System with Brain-Computer Interface (PDF)
- E0738
- 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0039U, 0068U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0086U, 0105U, 0109U, 0112U, 0115U, 0118U, 0140U, 0141U, 0142U, 0156U, 0169U, 0202U, 0218U, 0223U, 0225U, 0230U, 0231U, 0232U, 0233U, 0234U, 0236U, 0237U, 0311U, 0323U, 0327U, 0330U, 0345U, 0355U, 0371U, 0372U, 0377U, 0378U, 0389U, 0393U, 0399U, 0402U, 0407U, 0411U, 0419U, 0423U, 0441U, 0442U, 0446U, 0447U, 0455U, 0456U, 0457U, 0480U, 0483U, 0484U, 0493U, 0500U, 0502U, 0504U, 0505U, 0508U, 0509U, 0516U, 0527U, 0528U, 0531U, 0533U, 0540U, 0542U, 0544U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81161, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81204, 81205, 81209, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81234, 81238, 81239, 81242, 81243, 81244, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81265, 81266, 81267, 81268, 81269, 81271, 81274, 81283, 81284, 81285, 81286, 81289, 81290, 81302, 81303, 81304, 81306, 81312, 81324, 81325, 81326, 81328, 81329, 81330, 81331, 81332, 81333, 81335, 81336, 81337, 81343, 81344, 81349, 81350, 81355, 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, 81434, 81439, 81440, 81441, 81442, 81443, 81448, 81460, 81465, 81470, 81471, 81493, 81507, 81513, 81514, 81554, 87523, G9143
- 0011M, 0017M, 0020M, 0005U, 0009U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0037U, 0045U, 0046U, 0047U, 0048U, 0049U, 0069U, 0080U, 0089U, 0090U, 0111U, 0154U, 0155U, 0171U, 0172U, 0177U, 0179U, 0229U, 0239U, 0242U, 0244U, 0245U, 0250U, 0288U, 0306U, 0307U, 0314U, 0326U, 0329U, 0331U, 0334U, 0338U, 0339U, 0340U, 0343U, 0356U, 0360U, 0362U, 0364U, 0375U, 0376U, 0379U, 0387U, 0388U, 0391U, 0395U, 0398U, 0403U, 0404U, 0405U, 0406U, 0409U, 0410U, 0413U, 0414U, 0418U, 0420U, 0422U, 0424U, 0433U, 0436U, 0444U, 0450U, 0451U, 0467U, 0470U, 0471U, 0473U, 0478U, 0481U, 0485U, 0486U, 0487U, 0490U, 0491U, 0492U, 0495U, 0497U, 0498U, 0499U, 0502U, 0506U, 0507U, 0510U, 0512U, 0513U, 0523U, 0530U, 0537U, 0538U, 0539U, 0543U, 0549U, 0550U, 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81175, 81176, 81191, 81192, 81193, 81194, 81206, 81207, 81208, 81210, 81212, 81216, 81218, 81219, 81233, 81235, 81236, 81237, 81245, 81246, 81261, 81262, 81263, 81264, 81270, 81272, 81273, 81275, 81276, 81277, 81278, 81279, 81287, 81301, 81305, 81309, 81310, 81311, 81313, 81314, 81315, 81316, 81320, 81327, 81334, 81338, 81339, 81340, 81341, 81342, 81345, 81347, 81348, 81351, 81352, 81357, 81360, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81462, 81463, 81464, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, G0327
Genetic and Molecular Diagnostics - Testing for Inherited Cancer Risk (PDF)
- 0101U, 0129U, 0130U, 0131U, 0133U, 0134U, 0162U, 0235U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81165, 81166, 81167, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81307, 81308, 81317, 81318, 81319, 81321, 81322, 81323, 81351, 81352, 81353, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81432, 81435, 81437
Allergy and Sensitivity Tests of Uncertain Efficacy (PDF)
86001, 86343, 95065
Biochemical and Cellular Markers of Alzheimer’s Disease (PDF)
0206U, 0207U, 0358U, 0412U, 0445U, 0459U, 0479U, 0503U, 0551U, 82233, 82234, 84393, 84394
Chemoresistance and Chemosensitivity Assays (PDF)
81535, 81536, 0083U
0202U, 0223U, 0225U
81232, 81346
Measurement of Serum Antibodies to Selected Biologic Agents (PDF)
80145, 80230, 80280
81596, 0002M, 0003M, 0014M, 0166U, 81517
Multimarker and Proteomics-based Testing Related to Ovarian Cancer (PDF)
- 81500, 81503
0232T, G0460, G0465, P9020
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)
15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2029, A6460, A6461, C8002, 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, 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, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4285, Q4286, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353
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
Coverage with Evidence Development (CED) Studies and Registries (PDF)
- J0174, J0175
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder (PDF)
- G0552, G0553, G0554
Digital Therapeutic Products for Chronic Low Back Pain
- E1905, G0552, G0553, G0554
Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder (PDF)
- G0552, G0553, G0554
Digital Therapeutic Products for Substance Use Disorders (PDF)
- G0552, G0553, G0554
Electromagnetic Navigation Bronchoscopy (PDF)
- Effective July 1, 2025: Pre-authorization will be required for codes: 31626, 31627, C7509, C7510, C7511, C9751
Extracorporeal Shock Wave Therapy (ESWT) (PDF)
28890, 0101T, 0102T, 0512T, 0513T
Gender Affirming Interventions for Gender Dysphoria (PDF)
- 11920, 11921, 11950, 15769, 15771, 15772, 15773, 15774, 15775, 15776, 15825, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 17380, 17999, 19303, 19316, 19318, 19325, 19350, 21125, 21127, 21137, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, C1813, C2622, L8600
- Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
- 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
Immunological Cellular Therapies and Gene Therapies (PDF)
- 36511
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer (PDF)
77301, 77338, G6015, G6016
- 77301, 77338, G6015, G6016
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities (PDF)
- 77301, 77338, G6015, G6016
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk (PDF)
77301, 77338, G6015, G6016
- 0888T, 0893T, 0898T
In Vivo Analysis of Colorectal Lesions (PDF)
88375
Laser Interstitial Thermal Therapy (PDF)
61736, 61737
0552T, 97037
83987
Myocardial Strain Imaging (PDF)
C9762, C9763
38206, 38232, 38241, 0565T, 0566T, C9782
Periurethral Transperineal Adjustable Balloon Continence Device (PDF)
- 53451, 53452, 53453, 53454
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
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
- View the Sleep Medicine Program for notification or pre-authorization requirements
Review the codes requiring pre-authorization or notification in the Sleep medicine section.
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF)
- 0858T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869
Submit the Transcranial Magnetic Stimulation (rTMS) Request Form (PDF) for initial and ongoing services
Transcutaneous Electrical Nerve Stimulator, Stimulates Nerves in the Auricular Region (PDF)
- E0721
Vestibular Evoked Myogenic Potential Testing (PDF)
- 92517, 92518, 92519
We partner with eviCore healthcare (eviCore) to administer our Physical Medicine program.
- Review this entire page for similar services that require pre-authorization
- Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials
Obtain or verify an authorization with eviCore:
- Login to eviCore's portal
- Phone (855) 252-1115
- Fax (855) 774-1319
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.
We require pre-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 pre-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
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
We require pre-authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27132, 27134, 27137, 27138, 27130, 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
Spine
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
- We require pre-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
- Cone Beam Computed Tomography of the Breast (PDF)
- 0633T, 0634T, 0635T, 0636T, 0637T, 0638T
- Magnetic Resonance Spectroscopy
- 0609T, 0610T, 0611T, 0612T, 76390
- Opto-acoustic Imaging of the Breast
- 0857T
- 93895
We partner with Carelon to administer our Radiology Program.
Note: The Radiology Quality Initiative (RQI) component of this program was phased out in 2023.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
- 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, 75580, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 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, 78429, 78430, 78431, 78432, 78433, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0648T, 0649T
- Procedures performed in an inpatient setting or on an emergent basis do not require pre-authorization from Carelon. Inpatient stays are subject to review by Asuris for determining the appropriate length of stay.
Carelon Sleep Medicine
We partner with Carelon to administer our Sleep Medicine program.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
- View workarounds for Carelon system outages
Contact Carelon to request pre-authorization for the following codes: 95782, 95783, 95805, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601
Ablation of Peripheral Nerves to Treat Pain (PDF)
- 64624, 64640, C9808, C9809, 0440T, 0441T, 0442T
Ablation for the Treatment of Chronic Rhinitis (PDF)
- 31242, 31243
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
Benign Prostatic Hyperplasia Surgical Treatments (PDF)
- 53854, 0421T, 0867T, C2596
Blepharoplasty, Eyelid Surgery, and Brow Lift (PDF)
15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Coronary Intravascular Lithotripsy (PDF)
- 92972, C1761
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, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 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, 67950, G0429
- 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.
62287, 62292
61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886
Dual Chamber Leadless Cardiac Pacemakers (PDF)
- 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T
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
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve (PDF)
- 64628, 64629
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
- 51721, 55880, 55881, 55882, 61715, C9734, 0071T, 0072T, 0947T
Micro-Invasive Glaucoma Surgery (MIGS) and Laser Trabeculectomy and Trabeculostomy (PDF)
- 0449T, 66989, 66991
Minimally Invasive Treatments of Nasal Valve Collapse (PDF)
- 30469
Occipital Nerve Stimulation (ONS) (PDF)
61885, 61886, 64553, 64555, 64568, 64569, 64575, 64585, 64590, 64595, 64596, 64597, 64598
- 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 diagnosis 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
Percutaneous Axial Lumbosacral Interbody Fusion (LIF) (PDF)
22586
Percutaneous Transluminal Angioplasty (PTA) and Stenting (PDF)
37215, 37217, 37238, 37239, 37246, 37247, 37248, 37249, 61635, C7563
Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) (PDF)
64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598, C1778
Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)
33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 93150, 93151, 93152, 93153, C1823
Plugs for Enteric and Anorectal Fistula Repair (PDF)
46707
Pressure Ulcer Treatment by Musculocutaneous or Free Flap (PDF)
15734, 15738, 15756, 15757, 15758
- 0338T, 0339T, 0935T, C1735, C1736
Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)
- 20982, 31641, 32998, 50542, 50592, 58580, 60660, 60661
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. 61889, 61891
Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction (PDF)
- 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, 64596, 64597, 64598, C1767, C1778, C1883
- 27278, 27279, 27280, C1737
Subacromial Balloon Placement (PDF)
- C9781
Subcutaneous Tibial Nerve Stimulation (PDF)
- 0816T, 0817T, 0818T, 0819T
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 diagnosis 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 Treatments for Lymphedema and Lipedema (PDF)
15876, 15877, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15878, 15879
Surgical Ventricular Restoration (PDF)
33548, 0643T
- 52284, 53865, 53866, 0941T, 0942T, 0943T
Total Facet Arthroplasty (PDF)
0202T
Transcatheter Heart Valve Procedure (PDF)
0483T, 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
Vagus Nerve Stimulation (VNS) (PDF)
0908T, 0909T, 0911T, 0912T, 61885, 61886, 64553, 64568, 64569, E0735
- 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
Vertebral Body Tethering and Stapling (PDF)
- 0790T, 22836, 22837, 22838
Physical Medicine Program
- View Physical Medicine Program for notification or pre-authorization requirements through eviCore
- Review the codes requiring pre-authorization or notification in the Physical medicine section.
Ventricular Assist Devices and Total Artificial Hearts (PDF)
33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, L8698
33945
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
47135
32851, 32852, 32853, 32854
48554
Stem Cell and Bone Marrow Transplantation (PDF)
38205, 38206, 38232, 38240, 38241, 38242, C9782
- 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T
- 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.
- Effective July 1, 2025: HCPCS codes A0431and A0436 will be reviewed post- service.