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Benefits

Benefit Grids
Prior Authorization
Prior Auth. Lookup Tool
Services that Require Approval

Benefit Grids

The Benefit Grids include service codes, service limits, level of care and documentation requirements for service authorization requests. They also include requirements for unmanaged services.

CMS-Approved Non-Quantitative Treatment Limitations

The North Carolina Department of Health and Human Services approved Non-Quantitative Treatment Limitations that maintain compliance with the Mental Health Parity and Addiction Equity Act.

Prior Authorization

Vaya Partners Authorization Guidelines

Services Managed by Other Organizations

Some services are managed by organizations outside of Partners. Use the information below to find the right place for help.

Organization Services managed Provider information
Envolve Vision Vision services Envolve Vision
NC Medicaid Dental services NC Medicaid
Evolent Advanced imaging
Musculoskeletal surgery
Interventional pain management
Radiation oncology		 Providers may use RadMD for advanced imaging, musculoskeletal surgery and interventional pain management requests.

Radiation oncology requests are submitted through Evolent’s CarePro portal.

Evolent lists CarePro and RadMD through its provider portal.
EviCore Genetic testing Providers may use EviCore’s Provider’s Hub for prior authorization resources.


Pharmacy prior authorizations
Visit the Pharmacy/Medication Prior Authorization page for more information.

Non-participating/out-of-network providers must submit Prior Authorization for all services.

Prior Authorization Lookup Tool

Partners’ Prior Authorization (PA) Lookup Tool provides authorization requirements by service code. We have made every attempt to ensure the most current information is included in the PA Lookup Tool. However, use of this tool does not guarantee payment. It is the provider’s responsibility to ensure proper eligibility, coverage benefits, provider contracts, correct coding and billing practices are followed. You may also refer to the Partners Benefit Grids and enter an authorization request into ProAuth if prior authorization is indicated.

Search for all codes that require approval.

Enter the base code of the service you would like to check, and then select a mod:

Authorization Required
Yes
Authorization
0100 - ICF/IID All Inclusive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0100 - ICF/IID All Inclusive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0101 All-inclusive room and board Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0101 All-inclusive room and board Med Direct B Pre-authorization is required for all providers.
Con
Authorization
110 ROOM-BOARD/PVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0110 General Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0110 General Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0111 Medical/surgical/GYN Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0111 Medical/surgical/GYN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
112 OB/PVT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0113 Pediatric Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0113 Pediatric Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0114 Psychiatric Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0114 Psychiatric Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
115 HOSPICE/PVT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0116 Detoxification Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0116 Detoxification Med Direct B Pre-authorization is required for all providers.
Con
Authorization
117 ONCOLOGY/PVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
118 REHAB/PVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
119 OTHER/PVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0120 General Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0120 General Med Direct B Pre-authorization is required for all providers.
Con
Authorization
121 MED-SUR-GY/SEMI Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
122 OB/SEMI-PVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
123 PEDS/SEMI-PVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0124 Psychiatric Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0124 Psychiatric Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
125 HOSPICE/SEMI-PVT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0126 Detoxification Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0126 Detoxification Med Direct B Pre-authorization is required for all providers.
Con
Authorization
127 ONCOLOGY/SEMI Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
128 REHAB/SEMI-PVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
129 OTHER/SEMI-PVT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
130 ROOM-BOARD/3AND4BED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
131 MED-SUR-GY/3AND4BED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
132 OB/3AND4BED Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
133 PEDS/3AND4BED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
134 PSYCH/3AND4BED Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
135 HOSPICE/3AND4BED Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
136 DETOX/3AND4BED Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
137 ONCOLOGY/3AND4BED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
138 REHAB/3AND4BED Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
139 OTHER/3AND4BED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
140 ROOM-BOARD/DLX PVT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
141 MED-SUR-GY/DLXPVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
142 OB/DLXPVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
143 PEDS/DLX PVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
145 HOSPICE/DLXPVT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
146 DETOX/DLXPVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
147 ONCOLOGY/DLXPVT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
148 REHAB/DLXPVT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
149 OTHER/DLXPVT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
150 ROOM-BOARD/WARD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
151 MED-SUR-GY/WARD Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
152 OB/WARD Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
153 PEDS/WARD Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
154 PSYCH/WARD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
155 HOSPICE/WARD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
156 DETOX/WARD Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
157 ONCOLOGY/WARD Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
158 REHAB/WARD Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
159 OTHER/WARD Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0160 - IMD-All Inclusive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0160 - IMD-All Inclusive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
161 ROOM AND BOARD OTHER-HOSPITAL AT HOME Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
164 RANDB/STERILE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
167 RANDB/SELF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
169 RANDB/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
170 NURSERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
171 NURSERY/LEVEL I Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
172 NURSERY/LEVEL II Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
173 NURSERY/LEVEL III Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
174 NURSERY/LEVEL IV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
179 NURSERY-OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
180 LEAVE OF ABSENCE OR LOA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
182 LOA/PT CONV Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
185 LOA/NURS HOME Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
189 LOA/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
190 SUBACUTE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
191 SUBACUTE/LEVEL I Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
192 SUBACUTE/LEVEL II Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
193 SUBACUTE/LEVEL III Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
194 SUBACUTE/LEVEL IV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
199 SUBACUTE/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
200 INTENSIVE CARE (ICU) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
201 ICU/SURGICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
202 ICU/MEDICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
203 ICU/ PEDS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
204 ICU/PSYCH Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
206 ICU/INTERMEDIATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
207 ICU/BURN CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
208 ICU/TRAUMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
209 ICU/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
210 CORONARY CARE (CCU) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
211 CCU/MYO INFARC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
212 CCU/PULMONARY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
213 CCU/TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
214 CCU/INTERMEDIATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
219 NECK/CHEST SURGERY PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
220 SPECIAL CHARGES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
221 ADMIT CHARGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
222 TECH SUPPORT CHG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
223 UR CHARGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
224 LATE DISCH/MED NEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
229 OTHER SPEC CHG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
230 NURSING INCREM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
231 NUR INCR/NURSERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
232 NUR INCR/OB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
233 NUR INCR/ICU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
234 NUR INCR/CCU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
235 NUR INCR/HOSPICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
239 NUR INCR/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
240 ALL INCL ANCIL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
241 ALL INCL BASIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
242 ALL INCL COMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
243 ALL INCL SPECIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
249 ALL INCL ANCIL/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
250 PHARMACY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
251 DRUGS/GENERIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
252 DRUGS/NONGENERIC Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
253 DRUGS/TAKEHOME Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
254 DRUGS/INCIDENT ODX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
255 DRUGS/INCIDENT RAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
256 DRUGS/EXPERIMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
257 DRGS/NONPSCRPT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
258 IV SOLUTIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
259 DRGS/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
260 IV THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
261 IV THER/INFSN PUMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
262 IV THER/PHARM SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
263 IV THER/DRUG/SUPPLY DELV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
264 IV THER/SUPPLIES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
269 IV THERAPY/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
270 MED-SUR SUPPLIES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
271 NON-STER SUPPLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
272 STERILE SUPPLY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
273 TAKE HOME SUPPLY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
274 PROSTH/ORTH DEV Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
275 PACEMAKER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
276 INTRA OC LENS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
277 O2/TAKEHOME Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
278 SUPPLY/IMPLANTS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
279 SUPPLY/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
280 ONCOLOGY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
289 ONCOLOGY OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
290 DME - GENERAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
291 DME-RENTAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
292 DME-NEW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
293 DME-USED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
294 DME-SUPPLIES/DRUGS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
299 DME-OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
300 LAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
301 CHEMISTRY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
302 IMMUNOLOGY TESTS /TRANSFUSION - CIRCULATORY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
303 RENAL-HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
304 NON-RTNE DIALYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
305 HEMATOLOGY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
306 BACT AND MICRO TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
307 UROLOGY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
309 OTHER LAB TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
310 PATHOLOGY LAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
311 CYTOLOGY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
312 HISTOLOGY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
314 BIOPSY TESTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
319 PATH LAB OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
320 DX X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
321 DX X-RAY/ANGIO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
322 DX X-RAY/ARTHO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
323 DX X-RAY/ARTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
324 DX X-RAY/CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
329 DX X-RAY/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
330 RADIOLOGY THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
331 RAD-CHEMO-INJECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
332 RAD-CHEMO-ORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
333 RAD-RADIATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
335 RAD-CHEMO-IV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
339 RADIOLOGY OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
340 NUCLEAR MEDICINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
341 NUC MED/DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
342 NUC MED/RX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
343 NUC MED/DX RADIOPHARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
344 NUC MED/RX RADIOPHARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
349 NUC MED/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
360 OR SERVICES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
361 OR/MINOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
362 OR/ORGAN TRANS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
367 OR/KIDNEY TRANS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
369 OR/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
374 ANESTHE/ACUPUNC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
380 BLOOD AND BLOOD COMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
381 BLOOD/PKD RED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
382 BLOOD/WHOLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
383 BLOOD/PLASMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
384 BLOOD/PLATELETS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
385 BLOOD/LEUCOCYTES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
386 BLOOD/COMPONENTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
387 BLOOD/DERIVATIVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
389 BLOOD/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
390 BLOOD/ADMIN/STOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
391 BLOOD/ADMIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
392 BLOOD/STORAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
399 BLOOD/ADMIN/STOR/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
400 IMAGING SERVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
401 DIAG MAMMOGRAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
402 ULTRASOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
403 SCRN MAMMOGRAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
409 OTHER IMAGE SVCS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
410 RESPIRATORY SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
412 INHALATION SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
413 HYPERBARIC O2 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
419 OTHER RESPIR SVS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
420 PHYSICAL THERP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
421 PHYS THERP/VISIT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
422 PHYS THERP/HOUR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
423 PHYS THERP/GROUP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
424 PHYS THERP/EVAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
429 OTHER PHYS THERP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
430 OCCUPATIONAL THER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
431 OCCUP THERP/VISIT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
432 OCCUP THERP/HOUR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
433 OCCUP THERP/GROUP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
434 OCCUP THERP/EVAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
439 OCCUP THERP/OTHER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
440 SPEECH THERAPY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
441 SPEECH THERP/VISIT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
442 SPEECH THERP/HOUR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
443 SPEECH THERP/GROUP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
444 SPEECH THERP/EVAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
449 OTHER SPEECH THERAPY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
450 EMERG ROOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
451 ER/EMTALA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
452 ER/BEYOND EMTALA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
456 ER/URGENT CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
459 OTHER EMER ROOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
460 PULMONARY FUNC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
469 OTHER PULMONARY FUNC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
470 AUDIOLOGY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
471 AUDIOLOGY/DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
472 AUDIOLOGY/RX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
479 OTHER AUDIOL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
480 CARDIOLOGY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
481 CARDIAC CATH LAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
482 STRESS TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
489 OTHER CARDIOL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
490 AMBULTRY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
499 OTHER AMBL SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
500 OUTPATIENT SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
509 OTHER-O/P SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
510 CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
511 CHRONIC PAIN CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
512 DENTAL CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
514 OB-GYN CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
515 PEDIATRIC CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
516 URGENT CARE CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
517 FAMILY CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
519 OTHER CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
520 FREESTAND CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
521 FS-RURAL/CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
522 FS-RURAL/HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
523 FS-FAMILY PRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
524 FR/STD FAMILY CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
525 RHC/FQHC/SNF/NONCOVERED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
526 FR/STD URGENT CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
527 RHC/FQHC/HOME/VIS NURSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
528 RHC/FQHC/OTHER SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
529 OTHER FS-CLINIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
530 OSTEOPATH SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
531 OSTEOPATH RX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
539 OTHER OSTEOPATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
540 AMBULANCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
541 AMBUL/SUPPLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
542 AMBUL/MED TRANS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
543 AMBUL/HEART MOB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
544 AMBUL/OXYGEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
545 AIR AMBULANCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
546 AMBUL/NEONAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
547 AMBUL/PHARMAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
548 AMBUL/EKG TRANS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
549 AMBUL/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
550 SKILLED NURSING-HH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
551 SKILLED NURS-VISIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
552 SKILLED NURS-HOUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
559 SKILLED NURS/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
560 MED SOCIAL-HH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
561 HOME HEALTH (HH)-MEDICAL SOCIAL SERVICES-VISIT CHARGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
562 MED SOC SERVS-HOUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
569 MED SOC SERVS-OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
570 HH AIDE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
571 HH AIDE-VISIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
572 HH AIDE-HOUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
579 HH AIDE-OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
580 HH-OTH VIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
581 HH-OTH VIS/VISIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
582 HH-OTH VIS/HOUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
583 HH-OTH VIS/ASSESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
589 HH-OTH VIS/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
590 HH-SVCS/UNIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
599 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
600 O2/HOME HEALTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
601 O2/STAT EQUIP/SUPPL/CONT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
602 O2/STAT EQP/SUPPL<1 LPM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
603 O2/STAT EQP/SUPPL>4 LPM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
604 O2/PORTABLE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
609 O2/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
613 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
621 MED-SUR SUPL-INCDNT RAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
622 MED-SUR SUPL-INCDNT ODX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
623 SURG DRESSING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
624 FDA INVESTIGATIONAL DEVICES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
630 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
631 DRUG/SNGLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
632 DRUG/MULTIPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
633 DRUG/RESTRICT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
634 DRUG/EPO<10,000 UNITS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
635 DRUG/EPO >= 10,000 UNITS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
636 DRUGS/DETAIL CODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
637 DRUGS/SELF ADMIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
640 IV THERAPY SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
641 NON RT NURSING/CENTRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
642 IV SITE CARE/CENTRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
643 IV STRT/CHNG/PERIPHAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
644 NONRT NURSING/PERIPHRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
645 TRNG PT/CAREGVR/CENTRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
646 TRNG DSBLPT/CENTRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
647 TRNG/PT/CARGVR/PERIPHRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
648 TRNG/DSBLPAT/PERIPHRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
649 OTHER IV THERAPY SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
650 HOSPICE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
651 HOSPICE/RTN HOME Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
652 HOSPICE/CTNS HOME Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
653 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
654 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
655 HOSPICE/IP RESPITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
656 HOSPICE/IP NON-RESPITE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
657 HOSPICE/PHYSICIAN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
658 HOSPICE SERVICE-HOSPICE ROOM AND BOARD-NURSING FACILITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
659 HOSPICE/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
660 RESPITE CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
661 RESPITE/NURSING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
662 RESPITE/AIDE/HMEMKR/COMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
663 RESPITE/DAILY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
669 RESPITE/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
670 OP SPEC RES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
671 OP SPEC RES/HOSP OWNED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
672 OP SPEC RES/CONTRACTED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
679 OP SPEC RES/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
680 NOT USED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
681 TRAUMA LEVEL I Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
682 TRAUMA LEVEL II Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
683 TRAUMA LEVEL III Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
684 TRAUMA LEVEL IV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
689 TRAUMA OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
690 PREHOSPICE/PALLIATIVE CARE-GENERAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
691 PRE-HOSPICE/PALLIATIVE CARE-VISIT CHARGE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
692 PRE-HOSPICE/PALLIATIVE CARE-HOURLY CHRG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
693 PRE-HOSPICE/PALLIATIVE CARE-EVALUATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
694 PREHOSPICE/PALLIATIVE CARE-CONSULT AND ED Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
695 PRE-HOSPICE/PALLIATIVE CARE-IP CARE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
696 PRE-HOSPICE/PALLIATIVE -PHYSICIAN SVCS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
699 PRE-HOSPICE/PALLIATIVE CARE-OTHER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
700 CAST ROOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
710 RECOVERY ROOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
720 DELIVERY ROOM/LABOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
721 LABOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
722 DELIVERY ROOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
723 CIRCUMCISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
724 BIRTHING CENTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
729 OTHER/DELIV-LABOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
730 EKG/ECG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
731 HOLTER MONT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
732 TELEMETRY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
739 OTHER EKG/ECG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
740 EEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
750 GASTR-INST SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
760 SPECIALTY SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
761 TREATMENT RM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
762 OBSERVATION HOURS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
769 OTHER SPECIALTY SVC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
770 PREVENTIVE CARE SERVICES-GENERAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
771 VACCINE ADMINISTRATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
779 RESERVED BY NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
780 TELEMEDICINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
781 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
782 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
783 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
784 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
785 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
786 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
787 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
788 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
789 RESERVED BY THE NUBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
790 EXTRA-CORPOREAL SHOCK WAVE THRPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
800 RENAL DIALYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
801 DIALY/INPATIENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
802 DIALY/IP/PER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
803 DIALY/IP/CAPD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
804 DIALY/IP/CCPD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
809 DIALY/IP/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
810 ORGAN ACQUISIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
811 LIVING DONOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
812 CADAVER DONOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
813 UNKNOWN DONOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
814 UNSUCCESSFUL SEARCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
815 STEM CELL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
819 OTHER DONOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
820 HEMO/OP OR HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
821 HEMO/COMPOSITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
822 HEMO/HOME/SUPPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
823 HEMO/HOME/EQUIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
824 HEMO/HOME/100 PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
825 HEMO/HOME/SUPSERV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
829 HEMO-OTHER OP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
830 PERITONEAL/OP OR HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
831 PERTNL/COMPOSITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
832 PERTNL/HOME/SUPPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
833 PERTNL/HOME/EQUIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
834 PERTNL/HOME/100 PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
835 PERTNL/HOME/SUPSERV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
839 PERTNL/HOME/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
840 CAPD/OP OR HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
841 CAPD/COMPOSITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
842 CAPD/HOME/SUPPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
843 CAPD/HOME/EQUIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
844 CAPD/HOME/100 PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
845 CAPD/HOME/SUPSERV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
849 CAPD/HOME/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
850 CCPD/OP OR HOME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
851 CCPD/COMPOSITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
852 CCPD/HOME/SUPPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
853 CCPD/HOME/EQUIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
854 CCPD/HOME/100 PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
855 CCPD/HOME/SUPSERV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
859 CAPD/HOME/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
860 MAGNETOENCEPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
861 MEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
870 CELL - GENE THERAPY - GENERAL CLASSIFICATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
871 CELL COLLECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
872 SPECIAL BIOLOGIC PROCESSING AND STORAGE - PRIOR TO TRANSPORT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
873 STORAGE AND PROCESSING AFTER RECEIPT OF CELLS FROM THE MANUFACTURER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
874 INFUSION OF MODIFIED CELLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
875 INJECTION OF MODIFIED CELLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
880 DIALY/MISC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
881 DIALY/ULTRAFILT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
882 HOME DIALYSIS AID VISIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
889 DIALY/MISC/OTHER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
891 DRUGS/CELL THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0901 HA - Electroshock Therapy Child/Adolescent Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0901 HA - Electroshock Therapy Child/Adolescent Med Direct B Pre-authorization is required for all providers.
Con
Authorization
901 BH/ELECTRO SHOCK Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0902 - Milieu Therapy Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0902 - Milieu Therapy Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
904 BH/ACTIVITY THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
0911 AD - PRTF LEAP Program Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0911 AD - PRTF LEAP Program State Pre-authorization is required for all providers.
Yes
Authorization
0911 AD - PRTF LEAP Program Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0911 GT AD - PRTF LEAP Program Telemedicine State Pre-authorization is required for all providers.
Yes
Authorization
0911 GT AD - PRTF LEAP Program Telemedicine Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0911 GT AD - PRTF LEAP Program Telemedicine Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0911 GT - Psychiatric Residential Treatment Facility Telemedicine Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0911 GT - Psychiatric Residential Treatment Facility Telemedicine Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0911 GT - Psychiatric Residential Treatment Facility Telemedicine State Pre-authorization is required for all providers.
Yes
Authorization
0911 - Psychiatric Residential Treatment Facility State Pre-authorization is required for all providers.
Yes
Authorization
0911 - Psychiatric Residential Treatment Facility Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0911 - Psychiatric Residential Treatment Facility Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0912 - Partial Hospitalization, Less Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0912 - Partial Hospitalization, Less Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0912 GT - Partial Hospitalization, Less Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0912 GT - Partial Hospitalization, Less Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0912 KX- Partial Hospitalization, Less Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0912 KX- Partial Hospitalization, Less Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0913 GT - Partial hospitalization-Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0913 GT - Partial hospitalization-Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0913 KX - Partial hospitalization-Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0913 KX - Partial hospitalization-Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0913 Partial hospitalization-Intensive Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0913 Partial hospitalization-Intensive Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
0919 - Other Behavioral Health Treatment Services Med Direct B Pre-authorization is required for all providers.
Yes
Authorization
0919 - Other Behavioral Health Treatment Services Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
920 OTHER DX SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
921 PERI VASCUL LAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
922 EMG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
923 PAP SMEAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
924 ALLERGY TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
925 PREG TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
929 OTHER DX SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
931 HALF DAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
932 FULL DAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
940 OTHER RX SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
941 RECREATION RX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
942 EDUC/TRAINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
943 CARDIAC REHAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
944 DRUG REHAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
945 ALCOHOL REHAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
946 CMPLX MED EQUIP-ROUT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
947 CMPLX MED EQUIP-ANC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
948 PULMONARY REHAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
949 ADDITIONAL RX SVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
951 ATHLETIC TRAINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
952 KINESIOTHERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
953 CHEMDEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
960 PRO FEE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
961 PRO FEE/PSYCH Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
962 PRO FEE/EYE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
963 PRO FEE/ANES MD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
964 PRO FEE/ANEST CRNA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
969 PRO FEE/OTHER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
971 PRO FEE/LAB Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
972 PRO FEE/RAD/DX Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
973 PRO FEE/RAD/RX Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
974 PRO FEE/NUC MED Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
975 PRO FEE/OR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
976 PRO FEE/RESPIR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
977 PRO FEE/PHYSI Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
978 PRO FEE/OCCUPA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
979 PRO FEE/SPEECH Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
982 PRO FEE/OUTPT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
983 PRO FEE/CLINIC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
984 PRO FEE/SOC SVC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
985 PRO FEE/EKG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
986 PRO FEE/EEG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
987 PRO FEE/HOS VIS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
988 PRO FEE/CONSULT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
989 PRO FEE/PVT NURSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
990 PT CONVENIENCE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
991 CAFETERIA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
992 LINEN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
993 TELEPHONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
994 TV/RADIO Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
995 NONPT ROOM RENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
996 LATE DISCHARGE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
997 ADM KITS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
998 BARBER/BEAUTY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
999 PT CONV/OTHER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
1005 BH/RANDB GROUP HOME Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
01999 UNLISTED ANESTH PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
10004 FINE NEEDLE ASPIRATION BX WITH O IMG GDN EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10005 FINE NEEDLE ASPIRATION BX WITH US GDN 1ST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10006 FINE NEEDLE ASPIRATION BX WITH US GDN EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10007 FINE NEEDLE ASPIRATION BX WITH FLUOR GDN 1ST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10008 FINE NEEDLE ASPIRATION BX WITH FLUOR GDN EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10009 FINE NEEDLE ASPIRATION BX WITH CT GDN 1ST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10010 FINE NEEDLE ASPIRATION BX WITH CT GDN EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10011 FINE NEEDLE ASPIRATION BX WITH MR GDN 1ST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10012 FINE NEEDLE ASPIRATION BX WITH MR GDN EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10021 FINE NEEDLE ASPIRATION BX WITH O IMG GDN 1ST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10030 GUIDE CATHET FLUID DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10035 PERQ DEV SOFT TISS 1ST IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10036 PERQ DEV SOFT TISS ADD IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10040 EXTRACTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10060 DRAINAGE OF SKIN ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10061 DRAINAGE OF SKIN ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10080 DRAINAGE OF PILONIDAL CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10081 DRAINAGE OF PILONIDAL CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10120 REMOVE FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10121 REMOVE FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10140 DRAINAGE OF HEMATOMA/FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10160 PUNCTURE DRAINAGE OF LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
10180 COMPLEX DRAINAGE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11000 DEBRIDE INFECTED SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11001 DEBRIDE INFECTED SKIN ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11004 DEBRIDE GENITALIA AND PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11005 DEBRIDE ABDOM WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11006 DEBRIDE GENIT/PER/ABDOM WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11008 REMOVE MESH FROM ABD WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11010 DEBRIDE SKIN AT FX SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11011 DEBRIDE SKIN MUSC AT FX SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11012 DEB SKIN BONE AT FX SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11042 DEB SUBQ TISSUE 20 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11043 DEB MUSC/FASCIA 20 SQ CM/< Tailored Plan Pre-authorization required after the first 12 visits per calendar year for all providers.
Con
Authorization
11044 DEB BONE 20 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11045 DEB SUBQ TISSUE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11046 DEB MUSC/FASCIA ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11047 DEB BONE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11055 TRIM SKIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11056 TRIM SKIN LESIONS 2 TO 4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11057 TRIM SKIN LESIONS OVER 4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11102 TANGENTIAL BIOPSY SKIN SINGLE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11103 TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11104 PUNCH BIOPSY SKIN SINGLE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11105 PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11106 INCISIONAL BIOPSY SKIN SINGLE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11107 INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11200 REMOVAL OF SKIN TAGS < WITH 15 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11201 REMOVE SKIN TAGS ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11300 SHAVE SKIN LESION 0.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11301 SHAVE SKIN LESION 0.6-1.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11302 SHAVE SKIN LESION 1.1-2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11303 SHAVE SKIN LESION >2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11305 SHAVE SKIN LESION 0.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11306 SHAVE SKIN LESION 0.6-1.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11307 SHAVE SKIN LESION 1.1-2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11308 SHAVE SKIN LESION >2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11310 SHAVE SKIN LESION 0.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11311 SHAVE SKIN LESION 0.6-1.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11312 SHAVE SKIN LESION 1.1-2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11313 SHAVE SKIN LESION >2.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11400 EXC TR-EXT B9PLUSMARG 0.5 CM< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11401 EXC TR-EXT B9PLUSMARG 0.6-1 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11402 EXC TR-EXT B9PLUSMARG 1.1-2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11403 EXC TR-EXT B9PLUSMARG 2.1-3CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11404 EXC TR-EXT B9PLUSMARG 3.1-4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11406 EXC TR-EXT B9PLUSMARG >4.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11420 EXC H-F-NK-SP B9PLUSMARG 0.5/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11421 EXC H-F-NK-SP B9PLUSMARG 0.6-1 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11422 EXC H-F-NK-SP B9PLUSMARG 1.1-2 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11423 EXC H-F-NK-SP B9PLUSMARG 2.1-3 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11424 EXC H-F-NK-SP B9PLUSMARG 3.1-4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11426 EXC H-F-NK-SP B9PLUSMARG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11440 EXC FACE-MM B9PLUSMARG 0.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11441 EXC FACE-MM B9PLUSMARG 0.6-1 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11442 EXC FACE-MM B9PLUSMARG 1.1-2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11443 EXC FACE-MM B9PLUSMARG 2.1-3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11444 EXC FACE-MM B9PLUSMARG 3.1-4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11446 EXC FACE-MM B9PLUSMARG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11450 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11451 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11462 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11463 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11470 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11471 REMOVAL SWEAT GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11600 EXC TR-EXT MALPLUSMARG 0.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11601 EXC TR-EXT MALPLUSMARG 0.6-1 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11602 EXC TR-EXT MALPLUSMARG 1.1-2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11603 EXC TR-EXT MALPLUSMARG 2.1-3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11604 EXC TR-EXT MALPLUSMARG 3.1-4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11606 EXC TR-EXT MALPLUSMARG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11620 EXC H-F-NK-SP MALPLUSMARG 0.5/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11621 EXC S/N/H/F/G MALPLUSMRG 0.6-1 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11622 EXC S/N/H/F/G MALPLUSMRG 1.1-2 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11623 EXC S/N/H/F/G MALPLUSMRG 2.1-3 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11624 EXC S/N/H/F/G MALPLUSMRG 3.1-4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11626 EXC S/N/H/F/G MALPLUSMRG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11640 EXC F/E/E/N/L MALPLUSMRG 0.5CM< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11641 EXC F/E/E/N/L MALPLUSMRG 0.6-1 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11642 EXC F/E/E/N/L MALPLUSMRG 1.1-2 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11643 EXC F/E/E/N/L MALPLUSMRG 2.1-3 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11644 EXC F/E/E/N/L MALPLUSMRG 3.1-4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11646 EXC F/E/E/N/L MALPLUSMRG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11719 TRIM NAIL(S) ANY NUMBER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11720 DEBRIDE NAIL 1-5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11721 DEBRIDE NAIL 6 OR MORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11730 REMOVAL OF NAIL PLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11732 REMOVE NAIL PLATE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11740 DRAIN BLOOD FROM UNDER NAIL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11750 REMOVAL OF NAIL BED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11755 BIOPSY NAIL UNIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11760 REPAIR OF NAIL BED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11762 RECONSTRUCTION OF NAIL BED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11765 EXCISION OF NAIL FOLD TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11770 REMOVE PILONIDAL CYST SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11771 REMOVE PILONIDAL CYST EXTEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11772 REMOVE PILONIDAL CYST COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11900 INJECT SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11901 INJECT SKIN LESIONS >7 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11920 CORRECT SKIN COLOR 6.0 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11921 CORECT SKIN COLOR 6.1-20.0CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11922 CORRECT SKIN COLOR EA 20.0CM Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
11950 TX CONTOUR DEFECTS 1 CC/< Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
11951 TX CONTOUR DEFECTS 1.1-5.0CC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
11952 TX CONTOUR DEFECTS 5.1-10CC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
11954 TX CONTOUR DEFECTS >10.0 CC Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
11960 INSERT TISSUE EXPANDER(S) Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Yes
Authorization
11970 REPLACEMENT TISSUE EXPANDER W/PERMANENT IMPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
11971 REMOVAL TISSUE EXPANDER W/O INSERTION IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11976 REMOVE CONTRACEPTIVE CAPSULE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11980 IMPLANT HORMONE PELLET(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11981 INSERTION DRUG DELIVERY IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11982 REMOVE DRUG IMPLANT DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
11983 REMOVE/INSERT DRUG IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12001 RPR S/N/AX/GEN/TRNK 2.5CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12002 RPR S/N/AX/GEN/TRNK2.6-7.5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12004 RPR S/N/AX/GEN/TRK7.6-12.5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12005 RPR S/N/A/GEN/TRK12.6-20.0CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12006 RPR S/N/A/GEN/TRK20.1-30.0CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12007 RPR S/N/AX/GEN/TRNK >30.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12011 RPR F/E/E/N/L/M 2.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12013 RPR F/E/E/N/L/M 2.6-5.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12014 RPR F/E/E/N/L/M 5.1-7.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12015 RPR F/E/E/N/L/M 7.6-12.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12016 RPR FE/E/EN/L/M 12.6-20.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12017 RPR FE/E/EN/L/M 20.1-30.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12018 RPR F/E/E/N/L/M >30.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12020 CLOSURE OF SPLIT WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12021 CLOSURE OF SPLIT WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12031 INTMD RPR S/A/T/EXT 2.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12032 INTMD RPR S/A/T/EXT 2.6-7.5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12034 INTMD RPR S/TR/EXT 7.6-12.5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12035 INTMD RPR S/A/T/EXT 12.6-20 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12036 INTMD RPR S/A/T/EXT 20.1-30 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12037 INTMD RPR S/TR/EXT >30.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12041 INTMD RPR N-HF/GENIT 2.5CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12042 INTMD RPR N-HF/GENIT2.6-7.5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12044 INTMD RPR N-HF/GENIT7.6-12.5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12045 INTMD RPR N-HF/GENIT12.6-20 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12046 INTMD RPR N-HF/GENIT20.1-30 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12047 INTMD RPR N-HF/GENIT >30.0CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12051 INTMD RPR FACE/MM 2.5 CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12052 INTMD RPR FACE/MM 2.6-5.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12053 INTMD RPR FACE/MM 5.1-7.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12054 INTMD RPR FACE/MM 7.6-12.5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12055 INTMD RPR FACE/MM 12.6-20 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12056 INTMD RPR FACE/MM 20.1-30.0 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
12057 INTMD RPR FACE/MM >30.0 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13100 CMPLX RPR TRUNK 1.1-2.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13101 CMPLX RPR TRUNK 2.6-7.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13102 CMPLX RPR TRUNK ADDL 5CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13120 CMPLX RPR S/A/L 1.1-2.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13121 CMPLX RPR S/A/L 2.6-7.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13122 CMPLX RPR S/A/L ADDL 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13131 CMPLX RPR F/C/C/M/N/AX/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13132 CMPLX RPR F/C/C/M/N/AX/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13133 CMPLX RPR F/C/C/M/N/AX/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13151 CMPLX RPR E/N/E/L 1.1-2.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13152 CMPLX RPR E/N/E/L 2.6-7.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13153 CMPLX RPR E/N/E/L ADDL 5CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
13160 LATE CLOSURE OF WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14000 TIS TRNFR TRUNK 10 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14001 TIS TRNFR TRUNK 10.1-30SQCM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14020 TIS TRNFR S/A/L 10 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14021 TIS TRNFR S/A/L 10.1-30 SQCM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14040 TIS TRNFR F/C/C/M/N/A/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14041 TIS TRNFR F/C/C/M/N/A/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14060 TIS TRNFR E/N/E/L 10 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14061 TIS TRNFR E/N/E/L10.1-30SQCM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14301 TIS TRNFR ANY 30.1-60 SQ CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14302 TIS TRNFR ADDL 30 SQ CM/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
14350 FILLETED FINGER/TOE FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15002 WOUND PREP TRK/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15003 WOUND PREP ADDL 100 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15004 WOUND PREP F/N/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15005 WND PREP F/N/HF/G ADDL CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15040 HARVEST CULTURED SKIN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15050 SKIN PINCH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15100 SKIN SPLT GRFT TRNK/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15101 SKIN SPLT GRFT T/A/L ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15110 EPIDRM AUTOGRFT TRNK/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15111 EPIDRM AUTOGRFT T/A/L ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15115 EPIDRM A-GRFT FACE/NCK/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15116 EPIDRM A-GRFT F/N/HF/G ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15120 SKN SPLT A-GRFT FAC/NCK/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15121 SKN SPLT A-GRFT F/N/HF/G ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15130 DERM AUTOGRAFT TRNK/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15131 DERM AUTOGRAFT T/A/L ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15135 DERM AUTOGRAFT FACE/NCK/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15136 DERM AUTOGRAFT F/N/HF/G ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15150 CULT SKIN GRFT T/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15151 CULT SKIN GRFT T/A/L ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15152 CULT SKIN GRAFT T/A/L PLUS PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15155 CULT SKIN GRAFT F/N/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15156 CULT SKIN GRFT F/N/HFG ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15157 CULT EPIDERM GRFT F/N/HFG PLUS PERCENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15200 SKIN FULL GRAFT TRUNK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15201 SKIN FULL GRAFT TRUNK ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15220 SKIN FULL GRAFT SCLP/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15221 SKIN FULL GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15240 SKIN FULL GRFT FACE/GENIT/HF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15241 SKIN FULL GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15260 SKIN FULL GRAFT EEN AND LIPS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15261 SKIN FULL GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15271 SKIN SUB GRAFT TRNK/ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15272 SKIN SUB GRAFT T/A/L ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15273 SKIN SUB GRFT T/ARM/LG CHILD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15274 SKN SUB GRFT T/A/L CHILD ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15275 SKIN SUB GRAFT FACE/NK/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15276 SKIN SUB GRAFT F/N/HF/G ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15277 SKN SUB GRFT F/N/HF/G CHILD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15278 SKN SUB GRFT F/N/HF/G CH ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15570 SKIN PEDICLE FLAP TRUNK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15572 SKIN PEDICLE FLAP ARMS/LEGS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15574 PEDCLE FH/CH/CH/M/N/AX/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15576 PEDICLE E/N/E/L/NTRORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15600 DELAY FLAP TRUNK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15610 DELAY FLAP ARMS/LEGS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15620 DELAY FLAP F/C/C/N/AX/G/H/F Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15630 DELAY FLAP EYE/NOS/EAR/LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15650 TRANSFER SKIN PEDICLE FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15730 MDFC FLAP WITH PRSRV VASC PEDCL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15731 FOREHEAD FLAP WITH VASC PEDICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15733 MUSC MYOQ/FSCQ FLP H AND N PEDCL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15734 MUSCLE-SKIN GRAFT TRUNK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15736 MUSCLE-SKIN GRAFT ARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15738 MUSCLE-SKIN GRAFT LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15740 ISLAND PEDICLE FLAP GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15750 NEUROVASCULAR PEDICLE FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15756 FREE MYO/SKIN FLAP MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15757 FREE SKIN FLAP MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15758 FREE FASCIAL FLAP MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15760 COMPOSITE SKIN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15770 DERMA-FAT-FASCIA GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15777 ACELLULAR DERM MATRIX IMPLT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15778 IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
15780 DERMABRASION TOTAL FACE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15781 DERMABRASION SEGMENTAL FACE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15782 DERMABRASION OTHER THAN FACE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15783 DERMABRASION SUPRFL ANY SITE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15786 ABRASION LESION SINGLE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15787 ABRASION LESIONS ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15788 CHEMICAL PEEL FACE EPIDERM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15789 CHEMICAL PEEL FACE DERMAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15792 CHEMICAL PEEL NONFACIAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15793 CHEMICAL PEEL NONFACIAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15820 REVISION OF LOWER EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15821 REVISION OF LOWER EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15822 REVISION OF UPPER EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15823 REVISION OF UPPER EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15830 EXC SKIN ABD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15832 EXCISE EXCESSIVE SKIN THIGH Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15833 EXCISE EXCESSIVE SKIN LEG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15834 EXCISE EXCESSIVE SKIN HIP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15835 EXCISE EXCESSIVE SKIN BUTTCK Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15836 EXCISE EXCESSIVE SKIN ARM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15837 EXCISE EXCESS SKIN ARM/HAND Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15838 EXCISE EXCESS SKIN FAT PAD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
15839 EXCISE EXCESS SKIN AND TISSUE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
15840 NERVE PALSY FASCIAL GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15841 NERVE PALSY MUSCLE GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15842 NERVE PALSY MICROSURG GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15845 SKIN AND MUSCLE REPAIR FACE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
15847 EXC SKIN ABD ADD-ON Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
15852 DRESSING CHANGE NOT FOR BURN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15860 TEST FOR BLOOD FLOW IN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15920 REMOVAL OF TAIL BONE ULCER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15922 REMOVAL OF TAIL BONE ULCER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15931 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15933 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15934 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15935 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15936 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15937 REMOVE SACRUM PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15940 REMOVE HIP PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15941 REMOVE HIP PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15944 REMOVE HIP PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15945 REMOVE HIP PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15946 REMOVE HIP PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15950 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15951 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15952 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15953 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15956 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
15958 REMOVE THIGH PRESSURE SORE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
15999 REMOVAL OF PRESSURE SORE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
16000 INITIAL TREATMENT OF BURN(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
16020 DRESS/DEBRID P-THICK BURN S Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
16025 DRESS/DEBRID P-THICK BURN M Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
16030 DRESS/DEBRID P-THICK BURN L Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
16035 INCISION OF BURN SCAB INITI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
16036 ESCHAROTOMY ADDL INCISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17000 DESTRUCT PREMALG LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17003 DESTRUCT PREMALG LES 2-14 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17004 DESTROY PREMAL LESIONS 15/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17106 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17107 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17108 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17110 DESTRUCT B9 LESION 1-14 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17111 DESTRUCT LESION 15 OR MORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17250 CHEM CAUT OF GRANLTJ TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17260 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17261 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17262 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17263 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17264 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17266 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17270 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17271 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17272 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17273 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17274 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17276 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17280 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17281 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17282 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17283 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17284 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17286 DESTRUCTION OF SKIN LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17311 MOHS 1 STAGE H/N/HF/G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17312 MOHS ADDL STAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17313 MOHS 1 STAGE T/A/L Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17314 MOHS ADDL STAGE T/A/L Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
17315 MOHS SURG ADDL BLOCK Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
17340 CRYOTHERAPY OF SKIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
17360 SKIN PEEL THERAPY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
17380 HAIR REMOVAL BY ELECTROLYSIS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
17999 SKIN TISSUE PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
19000 DRAINAGE OF BREAST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19001 DRAIN BREAST LESION ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19020 INCISION OF BREAST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19030 INJECTION FOR BREAST X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19081 BX BREAST 1ST LESION STRTCTC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19082 BX BREAST ADD LESION STRTCTC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19083 BX BREAST 1ST LESION US IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19084 BX BREAST ADD LESION US IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19085 BX BREAST 1ST LESION MR IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19086 BX BREAST ADD LESION MR IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19100 BX BREAST PERCUT WITH O IMAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19101 BIOPSY OF BREAST OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19105 CRYOSURG ABLATE FA EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19110 NIPPLE EXPLORATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19112 EXCISE BREAST DUCT FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19120 REMOVAL OF BREAST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19125 EXCISION BREAST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19126 EXCISION ADDL BREAST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19281 PERQ DEVICE BREAST 1ST IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19282 PERQ DEVICE BREAST EA IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19283 PERQ DEV BREAST 1ST STRTCTC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19284 PERQ DEV BREAST ADD STRTCTC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19285 PERQ DEV BREAST 1ST US IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19286 PERQ DEV BREAST ADD US IMAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19287 PERQ DEV BREAST 1ST MR GUIDE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19288 PERQ DEV BREAST ADD MR GUIDE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19294 PREP TUM CAV IORT PRTL MAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19296 PLACE PO BREAST CATH FOR RAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19297 PLACE BREAST CATH FOR RAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19298 PLACE BREAST RAD TUBE/CATHS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19300 REMOVAL OF BREAST TISSUE Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19301 PARTIAL MASTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19302 P-MASTECTOMY WITH LN REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19303 MAST SIMPLE COMPLETE Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
19305 MAST RADICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19306 MAST RAD URBAN TYPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19307 MAST MOD RAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19316 SUSPENSION OF BREAST Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19318 BREAST REDUCTION Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19325 BREAST AUGMENTATION WITH IMPLANT Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19328 REMOVAL INTACT BREAST IMPLANT Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19330 RMVL RUPTURED BREAST IMPLANT W/IMPLANT CONTENTS Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19340 INSERTION BREAST IMPLANT SAME DAY OF MASTECTOMY Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19342 INSJ/RPLCMT BREAST IMPLANT SEP DAY MASTECTOMY Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19350 BREAST RECONSTRUCTION Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19355 CORRECT INVERTED NIPPLE(S) Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19357 TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19361 BREAST RECONSTRUCTION W/LATISSIMUS DORSI FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19364 BREAST RECONSTRUCTION W/FREE FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19367 BREAST RECONSTRUCTION SINGLE PEDICLED TRAM FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19368 BREAST RECONSTRUCTION 1PEDICLED TRAM FLAP ANAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19369 BREAST RECONSTRUCTION BIPEDICLED TRAM FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19370 REVISION PERI-IMPLANT CAPSULE BREAST Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19371 PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
19380 REVISION OF RECONSTRUCTED BREAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19396 DESIGN CUSTOM BREAST IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
19499 BREAST SURGERY PROCEDURE Tailored Plan No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.
Con
Authorization
20100 EXPLORE WOUND NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20101 EXPLORE WOUND CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20102 EXPLORE WOUND ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20103 EXPLORE WOUND EXTREMITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20150 EXCISE EPIPHYSEAL BAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20200 MUSCLE BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20205 DEEP MUSCLE BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20206 NEEDLE BIOPSY MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20220 BONE BIOPSY TROCAR/NEEDLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20225 BONE BIOPSY TROCAR/NEEDLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20240 BONE BIOPSY OPEN SUPERFICIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20245 BONE BIOPSY OPEN DEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20250 OPEN BONE BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20251 OPEN BONE BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20500 INJECTION OF SINUS TRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20501 INJECT SINUS TRACT FOR X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20520 REMOVAL OF FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20525 REMOVAL OF FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20526 THER INJECTION CARP TUNNEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20527 INJ DUPUYTREN CORD WITH ENZYME Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20550 INJ TENDON SHEATH/LIGAMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20551 INJ TENDON ORIGIN/INSERTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20552 INJ TRIGGER POINT 1/2 MUSCL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
20553 INJECT TRIGGER POINTS 3/> Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
20555 PLACE NDL MUSC/TIS FOR RT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20600 DRAIN/INJECT JOINT/BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20604 DRAIN/INJ JOINT/BURSA WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20605 DRAIN/INJECT JOINT/BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20606 DRAIN/INJ JOINT/BURSA WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20610 DRAIN/INJECT JOINT/BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20611 DRAIN/INJ JOINT/BURSA WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20612 ASPIRATE/INJ GANGLION CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20615 TREATMENT OF BONE CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20650 INSERT AND REMOVE BONE PIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20660 APPLY REM FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20661 APPLICATION OF HEAD BRACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20662 APPLICATION OF PELVIS BRACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20663 APPLICATION OF THIGH BRACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20664 APPLICATION OF HALO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20665 REMOVAL OF FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20670 REMOVAL OF SUPPORT IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20680 REMOVAL OF SUPPORT IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20690 APPLY BONE FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20692 APPLY BONE FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20693 ADJUST BONE FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20694 REMOVE BONE FIXATION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20696 COMP MULTIPLANE EXT FIXATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20697 COMP EXT FIXATE STRUT CHANGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20700 MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20701 REMOVAL DEEP DRUG DELIVERY DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20702 MANUAL PREP AND INSJ INTRAMEDULLARY DRUG DLVR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20703 REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20704 MANUAL PREP AND INSJ I-ARTIC DRUG DELIVERY DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20705 REMOVAL INTRA-ARTICULAR DRUG DELIVERY DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20802 REPLANTATION ARM COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20805 REPLANT FOREARM COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20808 REPLANTATION HAND COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20816 REPLANTATION DIGIT COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20822 REPLANTATION DIGIT COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20824 REPLANTATION THUMB COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20827 REPLANTATION THUMB COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20838 REPLANTATION FOOT COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20900 REMOVAL OF BONE FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20902 REMOVAL OF BONE FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20910 REMOVE CARTILAGE FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20912 REMOVE CARTILAGE FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20920 REMOVAL OF FASCIA FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20922 REMOVAL OF FASCIA FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20924 REMOVAL OF TENDON FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20932 OSTEOARTICULAR ALLOGRAFT WITH ARTICULAR SURF AND BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20933 HEMICORTICAL INTERCALARY ALLOGRAFT PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20934 INTERCALARY ALLOGRAFT COMPLETE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20950 FLUID PRESSURE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20955 FIBULA BONE GRAFT MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20956 ILIAC BONE GRAFT MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20957 MT BONE GRAFT MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20962 OTHER BONE GRAFT MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20969 BONE/SKIN GRAFT MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20970 BONE/SKIN GRAFT ILIAC CREST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20972 BONE/SKIN GRAFT METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20973 BONE/SKIN GRAFT GREAT TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20974 ELECTRICAL BONE STIMULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20975 ELECTRICAL BONE STIMULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20979 US BONE STIMULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20982 ABLATE BONE TUMOR(S) PERQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20983 ABLATE BONE TUMOR(S) PERQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
20985 CPTR-ASST DIR MS PX Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
20999 MUSCULOSKELETAL SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21010 INCISION OF JAW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21011 EXC FACE LES SC <2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21012 EXC FACE LES SBQ 2 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21013 EXC FACE TUM DEEP < 2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21014 EXC FACE TUM DEEP 2 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21015 RESECT FACE/SCALP TUM < 2 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21016 RESECT FACE/SCALP TUM 2 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21025 EXCISION OF BONE LOWER JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21026 EXCISION OF FACIAL BONE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21029 CONTOUR OF FACE BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21030 EXCISE MAX/ZYGOMA B9 TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21031 REMOVE EXOSTOSIS MANDIBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21032 REMOVE EXOSTOSIS MAXILLA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21034 EXCISE MAX/ZYGOMA MAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21040 EXCISE MANDIBLE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21044 REMOVAL OF JAW BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21045 EXTENSIVE JAW SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21046 REMOVE MANDIBLE CYST COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21047 EXCISE LWR JAW CYST WITH REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21048 REMOVE MAXILLA CYST COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21049 EXCIS UPPR JAW CYST WITH REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21050 REMOVAL OF JAW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21060 REMOVE JAW JOINT CARTILAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21070 REMOVE CORONOID PROCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21076 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21077 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21079 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21080 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21081 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21082 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21083 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21084 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21085 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21086 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21087 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21088 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21089 PREPARE FACE/ORAL PROSTHESIS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21100 MAXILLOFACIAL FIXATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21110 INTERDENTAL FIXATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21116 INJECTION JAW JOINT X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21120 RECONSTRUCTION OF CHIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21121 RECONSTRUCTION OF CHIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21122 RECONSTRUCTION OF CHIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21123 RECONSTRUCTION OF CHIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21125 AUGMENTATION LOWER JAW BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21127 AUGMENTATION LOWER JAW BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21137 REDUCTION OF FOREHEAD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21138 REDUCTION OF FOREHEAD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21139 REDUCTION OF FOREHEAD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21141 LEFORT I-1 PIECE WITH O GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21142 LEFORT I-2 PIECE WITH O GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21143 LEFORT I-3/> PIECE WITH O GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21145 LEFORT I-1 PIECE WITH GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21146 LEFORT I-2 PIECE WITH GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21147 LEFORT I-3/> PIECE WITH GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21150 LEFORT II ANTERIOR INTRUSION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21151 LEFORT II WITH BONE GRAFTS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21154 LEFORT III WITH O LEFORT I Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21155 LEFORT III WITH LEFORT I Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21159 LEFORT III WITH FHD WITH O LEFORT I Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21160 LEFORT III WITH FHD WITH LEFORT I Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21172 RECONSTRUCT ORBIT/FOREHEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21175 RECONSTRUCT ORBIT/FOREHEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21179 RECONSTRUCT ENTIRE FOREHEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21180 RECONSTRUCT ENTIRE FOREHEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21181 CONTOUR CRANIAL BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21182 RECONSTRUCT CRANIAL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21183 RECONSTRUCT CRANIAL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21184 RECONSTRUCT CRANIAL BONE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21188 RECONSTRUCTION OF MIDFACE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21193 RECONST LWR JAW WITH O GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21194 RECONST LWR JAW WITH GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21195 RECONST LWR JAW WITH O FIXATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21196 RECONST LWR JAW WITH FIXATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21198 RECONSTR LWR JAW SEGMENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21199 RECONSTR LWR JAW WITH ADVANCE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21206 RECONSTRUCT UPPER JAW BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21208 AUGMENTATION OF FACIAL BONES Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21209 REDUCTION OF FACIAL BONES Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21210 FACE BONE GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21215 LOWER JAW BONE GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21230 RIB CARTILAGE GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21235 EAR CARTILAGE GRAFT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21240 RECONSTRUCTION OF JAW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21242 RECONSTRUCTION OF JAW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21243 RECONSTRUCTION OF JAW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21244 RECONSTRUCTION OF LOWER JAW Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21247 RECONSTRUCT LOWER JAW BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21255 RECONSTRUCT LOWER JAW BONE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21256 RECONSTRUCTION OF ORBIT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21260 REVISE EYE SOCKETS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21261 REVISE EYE SOCKETS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21263 REVISE EYE SOCKETS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21267 REVISE EYE SOCKETS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21268 REVISE EYE SOCKETS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21270 AUGMENTATION CHEEK BONE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21275 REVISION ORBITOFACIAL BONES Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21280 REVISION OF EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21282 REVISION OF EYELID Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21295 REVISION OF JAW MUSCLE/BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21296 REVISION OF JAW MUSCLE/BONE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
21299 CRANIO/MAXILLOFACIAL SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21315 CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21320 CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21325 OPEN TX NOSE FX UNCOMPLICATD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21330 OPEN TX NOSE FX WITH SKELE FIXJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21335 OPEN TX NOSE AND SEPTAL FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21336 OPEN TX SEPTAL FX WITH WO STABJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21337 CLOSED TX SEPTALANDNOSE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21338 OPEN NASOETHMOID FX WITH O FIXJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21339 OPEN NASOETHMOID FX WITH FIXJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21340 PERQ TX NASOETHMOID FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21343 OPEN TX DPRSD FRONT SINUS FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21344 OPEN TX COMPL FRONT SINUS FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21345 CLOSED TX NOSE/JAW FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21346 OPN TX NASOMAX FX WITH FIXJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21347 OPN TX NASOMAX FX MULTPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21348 OPN TX NASOMAX FX WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21355 PERQ TX MALAR FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21356 OPN TX DPRSD ZYGOMATIC ARCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21360 OPN TX DPRSD MALAR FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21365 OPN TX COMPLX MALAR FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21366 OPN TX COMPLX MALAR WITH GRFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21385 OPN TX ORBIT FX TRANSANTRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21386 OPN TX ORBIT FX PERIORBITAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21387 OPN TX ORBIT FX COMBINED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21390 OPN TX ORBIT PERIORBTL IMPLT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21395 OPN TX ORBIT PERIORBT WITH GRFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21400 CLOSED TX ORBIT WITH O MANIPULJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21401 CLOSED TX ORBIT WITH MANIPULJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21406 OPN TX ORBIT FX WITH O IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21407 OPN TX ORBIT FX WITH IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21408 OPN TX ORBIT FX WITH BONE GRFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21421 TREAT MOUTH ROOF FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21422 TREAT MOUTH ROOF FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21423 TREAT MOUTH ROOF FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21431 TREAT CRANIOFACIAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21432 TREAT CRANIOFACIAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21433 TREAT CRANIOFACIAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21435 TREAT CRANIOFACIAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21436 TREAT CRANIOFACIAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21440 TREAT DENTAL RIDGE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21445 TREAT DENTAL RIDGE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21450 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21451 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21452 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21453 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21454 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21461 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21462 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21465 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21470 TREAT LOWER JAW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21480 RESET DISLOCATED JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21485 RESET DISLOCATED JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21490 REPAIR DISLOCATED JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21497 INTERDENTAL WIRING Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21499 HEAD SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21501 DRAIN NECK/CHEST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21502 DRAIN CHEST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21510 DRAINAGE OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21550 BIOPSY OF NECK/CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21552 EXC NECK LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21554 EXC NECK TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21555 EXC NECK LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21556 EXC NECK TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21557 RESECT NECK THORAX TUMOR<5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21558 RESECT NECK TUMOR 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21600 PARTIAL REMOVAL OF RIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21601 EXCISION CHEST WALL TUMOR INCLUDING RIBS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21602 EXCISION CH WAL TUM W/RIB W/O MEDSTNL LYMPHADEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21603 EXCISION CH WAL TUM W/RIB W/MEDSTNL LYMPHADEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21610 PARTIAL REMOVAL OF RIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21615 REMOVAL OF RIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21616 REMOVAL OF RIB AND NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21620 PARTIAL REMOVAL OF STERNUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21627 STERNAL DEBRIDEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21630 RADICAL RESECTION STERNUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21685 HYOID MYOTOMY AND SUSPENSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21700 REVISION OF NECK MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21705 REVISION OF NECK MUSCLE/RIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21720 REVISION OF NECK MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21725 REVISION OF NECK MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21740 RECONSTRUCTION OF STERNUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21742 REPAIR STERN/NUSS WITH O SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21743 REPAIR STERNUM/NUSS WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21750 REPAIR OF STERNUM SEPARATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21811 TREATMENT OF RIB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21812 OPTX OF RIB FX WITH FIXJ SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21813 TREATMENT OF RIB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21820 TREATMENT OF RIB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21825 TREAT STERNUM FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
21899 TREAT STERNUM FRACTURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
21920 BIOPSY SOFT TISSUE OF BACK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21925 BIOPSY SOFT TISSUE OF BACK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21930 EXC BACK LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21931 EXC BACK LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21932 EXC BACK TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21933 EXC BACK TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21935 RESECT BACK TUM < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
21936 RESECT BACK TUM 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22010 I AND D P-SPINE C/T/CERV-THOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22015 I AND D ABSCESS P-SPINE L/S/LS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22100 REMOVE PART OF NECK VERTEBRA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
22101 REMOVE PART THORAX VERTEBRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22102 REMOVE PART LUMBAR VERTEBRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22103 REMOVE EXTRA SPINE SEGMENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22110 REMOVE PART OF NECK VERTEBRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22112 REMOVE PART THORAX VERTEBRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22114 REMOVE PART LUMBAR VERTEBRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22116 REMOVE EXTRA SPINE SEGMENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22206 INCIS SPINE 3 COLUMN THORAC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22207 INCIS SPINE 3 COLUMN LUMBAR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22208 INCIS SPINE 3 COLUMN ADL SEG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22210 INCIS 1 VERTEBRAL SEG CERV Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22212 INCIS 1 VERTEBRAL SEG THORAC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22214 INCIS 1 VERTEBRAL SEG LUMBAR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22216 INCIS ADDL SPINE SEGMENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22220 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM CRV Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22222 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22224 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM LUMBAR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22226 OSTEOTOMY SPINE W/DSC ANT APPR 1 VRT SGM EA ADDL Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
22310 CLOSED TX VERT FX WITH O MANJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22315 CLOSED TX VERT FX WITH MANJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22318 TREAT ODONTOID FX WITH O GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22319 TREAT ODONTOID FX WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22325 TREAT SPINE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22326 TREAT NECK SPINE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22327 TREAT THORAX SPINE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22328 TREAT EACH ADD SPINE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22505 MANIPULATION OF SPINE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
22510 PERQ CERVICOTHORACIC INJECT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22511 PERQ LUMBOSACRAL INJECTION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22512 VERTEBROPLASTY ADDL INJECT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22513 PERQ VERTEBRAL AUGMENTATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22514 PERQ VERTEBRAL AUGMENTATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22515 PERQ VERTEBRAL AUGMENTATION Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
22526 IDET SINGLE LEVEL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
22527 IDET 1 OR MORE LEVELS Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Yes
Authorization
22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22556 ARTHRD ANT INTERBODY MIN DSC THORACIC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22586 ARTHRODESIS PRESACRAL NTRBDY DSC W/INSTRMJ L5-S1 Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22610 ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC THORACIC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22800 ARTHRODESIS POSTERIOR SPINAL DFRM <6 VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13+ VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22812 ARTHRODESIS ANTERIOR SPINAL DFRM 8+ VRT SGM Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22818 KYPHECTOMY 1-2 SEGMENTS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22819 KYPHECTOMY 3 OR MORE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22830 EXPLORATION OF SPINAL FUSION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22847 INSERT SPINE FIXATION DEVICE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22848 INSERT PELV FIXATION DEVICE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22849 REINSERT SPINAL FIXATION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22850 REMOVE SPINE FIXATION DEVICE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22852 REMOVE SPINE FIXATION DEVICE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22853 INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC WITH ARTHRD Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22855 REMOVE SPINE FIXATION DEVICE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
22899 SPINE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
22900 EXC ABDL TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22901 EXC ABDL TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22902 EXC ABD LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22903 EXC ABD LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22904 RADICAL RESECT ABD TUMOR<5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
22905 RAD RESECT ABD TUMOR 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
22999 ABDOMEN SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
23000 REMOVAL OF CALCIUM DEPOSITS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23020 RELEASE SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23030 DRAIN SHOULDER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23031 DRAIN SHOULDER BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23035 DRAIN SHOULDER BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23040 EXPLORATORY SHOULDER SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23044 EXPLORATORY SHOULDER SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23065 BIOPSY SHOULDER TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23066 BIOPSY SHOULDER TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23071 EXC SHOULDER LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23073 EXC SHOULDER TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23075 EXC SHOULDER LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23076 EXC SHOULDER TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23077 RESECT SHOULDER TUMOR < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23078 RESECT SHOULDER TUMOR 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23100 BIOPSY OF SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23101 SHOULDER JOINT SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23105 REMOVE SHOULDER JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23106 INCISION OF COLLARBONE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23107 EXPLORE TREAT SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23140 REMOVAL OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23145 REMOVAL OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23146 REMOVAL OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23150 REMOVAL OF HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23155 REMOVAL OF HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23156 REMOVAL OF HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23170 REMOVE COLLAR BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23172 REMOVE SHOULDER BLADE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23174 REMOVE HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23180 REMOVE COLLAR BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23182 REMOVE SHOULDER BLADE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23184 REMOVE HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23190 PARTIAL REMOVAL OF SCAPULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23195 REMOVAL OF HEAD OF HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23200 RESECT CLAVICLE TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23210 RESECT SCAPULA TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23220 RESECT PROX HUMERUS TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23330 REMOVE SHOULDER FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23333 REMOVE SHOULDER FB DEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23334 SHOULDER PROSTHESIS REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23335 SHOULDER PROSTHESIS REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23350 INJECTION FOR SHOULDER X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23395 MUSCLE TRANSFER SHOULDER/ARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23397 MUSCLE TRANSFERS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23400 FIXATION OF SHOULDER BLADE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23406 INCISE TENDON(S) AND MUSCLE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23440 REMOVE/TRANSPLANT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23480 REVISION OF COLLAR BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23485 REVISION OF COLLAR BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23490 REINFORCE CLAVICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23491 REINFORCE SHOULDER BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23500 TREAT CLAVICLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23505 TREAT CLAVICLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23515 TREAT CLAVICLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23520 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23525 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23530 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23532 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23540 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23545 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23550 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23552 TREAT CLAVICLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23570 TREAT SHOULDER BLADE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23575 TREAT SHOULDER BLADE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23585 TREAT SCAPULA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23600 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23605 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23615 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23616 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23620 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23625 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23630 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23650 TREAT SHOULDER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23655 TREAT SHOULDER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23660 TREAT SHOULDER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23665 TREAT DISLOCATION/FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23670 TREAT DISLOCATION/FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23675 TREAT DISLOCATION/FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23680 TREAT DISLOCATION/FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23800 FUSION OF SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23802 FUSION OF SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23900 AMPUTATION OF ARM AND GIRDLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23920 AMPUTATION AT SHOULDER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23921 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
23929 SHOULDER SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
23930 DRAINAGE OF ARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23931 DRAINAGE OF ARM BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
23935 DRAIN ARM/ELBOW BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24000 EXPLORATORY ELBOW SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24006 RELEASE ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24065 BIOPSY ARM/ELBOW SOFT TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24066 BIOPSY ARM/ELBOW SOFT TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24071 EXC ARM/ELBOW LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24073 EX ARM/ELBOW TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24075 EXC ARM/ELBOW LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24076 EX ARM/ELBOW TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24077 RESECT ARM/ELBOW TUM < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24079 RESECT ARM/ELBOW TUM 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24100 BIOPSY ELBOW JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24101 EXPLORE/TREAT ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24102 REMOVE ELBOW JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24105 REMOVAL OF ELBOW BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24110 REMOVE HUMERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24115 REMOVE/GRAFT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24116 REMOVE/GRAFT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24120 REMOVE ELBOW LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24125 REMOVE/GRAFT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24126 REMOVE/GRAFT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24130 REMOVAL OF HEAD OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24134 REMOVAL OF ARM BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24136 REMOVE RADIUS BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24138 REMOVE ELBOW BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24140 PARTIAL REMOVAL OF ARM BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24145 PARTIAL REMOVAL OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24147 PARTIAL REMOVAL OF ELBOW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24149 RADICAL RESECTION OF ELBOW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24150 RESECT DISTAL HUMERUS TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24152 RESECT RADIUS TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24155 REMOVAL OF ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24160 REMOVE ELBOW JOINT IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24164 REMOVE RADIUS HEAD IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24200 REMOVAL OF ARM FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24201 REMOVAL OF ARM FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24220 INJECTION FOR ELBOW X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24301 MUSCLE/TENDON TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24305 ARM TENDON LENGTHENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24310 REVISION OF ARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24320 REPAIR OF ARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24330 REVISION OF ARM MUSCLES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24331 REVISION OF ARM MUSCLES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24332 TENOLYSIS TRICEPS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24340 REPAIR OF BICEPS TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24341 REPAIR ARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24342 REPAIR OF RUPTURED TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24343 REPR ELBOW LAT LIGMNT WITH TISS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24344 RECONSTRUCT ELBOW LAT LIGMNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24345 REPR ELBW MED LIGMNT WITH TISSU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24346 RECONSTRUCT ELBOW MED LIGMNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24357 REPAIR ELBOW PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24358 REPAIR ELBOW WITH DEB OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24359 REPAIR ELBOW DEB/ATTCH OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
24360 RECONSTRUCT ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
24361 RECONSTRUCT ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
24362 RECONSTRUCT ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
24363 REPLACE ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
24365 RECONSTRUCT HEAD OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
24366 RECONSTRUCT HEAD OF RADIUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
24370 REVISE RECONST ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
24371 REVISE RECONST ELBOW JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
24400 REVISION OF HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24410 REVISION OF HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24420 REVISION OF HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24430 REPAIR OF HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24435 REPAIR HUMERUS WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24470 REVISION OF ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24495 DECOMPRESSION OF FOREARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24498 REINFORCE HUMERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24500 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24505 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24515 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24516 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24530 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24535 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24538 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24545 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24546 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24560 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24565 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24566 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24575 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24576 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24577 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24579 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24582 TREAT HUMERUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24586 TREAT ELBOW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24587 TREAT ELBOW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24600 TREAT ELBOW DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24605 TREAT ELBOW DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24615 TREAT ELBOW DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24620 TREAT ELBOW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24635 TREAT ELBOW FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24640 TREAT ELBOW DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24650 TREAT RADIUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24655 TREAT RADIUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24665 TREAT RADIUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24666 TREAT RADIUS FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24670 TREAT ULNAR FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24675 TREAT ULNAR FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24685 TREAT ULNAR FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24800 FUSION OF ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24802 FUSION/GRAFT OF ELBOW JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24900 AMPUTATION OF UPPER ARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24920 AMPUTATION OF UPPER ARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24925 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24930 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24931 AMPUTATE UPPER ARM AND IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24935 REVISION OF AMPUTATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
24940 REVISION OF UPPER ARM Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
24999 UPPER ARM/ELBOW SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
25000 INCISION OF TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25001 INCISE FLEXOR CARPI RADIALIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25020 DECOMPRESS FOREARM 1 SPACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25023 DECOMPRESS FOREARM 1 SPACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25024 DECOMPRESS FOREARM 2 SPACES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25025 DECOMPRESS FOREARM 2 SPACES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25028 DRAINAGE OF FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25031 DRAINAGE OF FOREARM BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25035 TREAT FOREARM BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25040 EXPLORE/TREAT WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25065 BIOPSY FOREARM SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25066 BIOPSY FOREARM SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25071 EXC FOREARM LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25073 EXC FOREARM TUM DEEP 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25075 EXC FOREARM LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25076 EXC FOREARM TUM DEEP < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25077 RESECT FOREARM/WRIST TUM<3CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25078 RESECT FORARM/WRIST TUM 3CM> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25085 INCISION OF WRIST CAPSULE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25100 BIOPSY OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25101 EXPLORE/TREAT WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25105 REMOVE WRIST JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25107 REMOVE WRIST JOINT CARTILAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25109 EXCISE TENDON FOREARM/WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25110 REMOVE WRIST TENDON LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25111 REMOVE WRIST TENDON LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25112 REREMOVE WRIST TENDON LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25115 REMOVE WRIST/FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25116 REMOVE WRIST/FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25118 EXCISE WRIST TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25119 PARTIAL REMOVAL OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25120 REMOVAL OF FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25125 REMOVE/GRAFT FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25126 REMOVE/GRAFT FOREARM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25130 REMOVAL OF WRIST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25135 REMOVE AND GRAFT WRIST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25136 REMOVE AND GRAFT WRIST LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25145 REMOVE FOREARM BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25150 PARTIAL REMOVAL OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25151 PARTIAL REMOVAL OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25170 RESECT RADIUS/ULNAR TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25210 REMOVAL OF WRIST BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25215 REMOVAL OF WRIST BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25230 PARTIAL REMOVAL OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25240 PARTIAL REMOVAL OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25246 INJECTION FOR WRIST X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25248 REMOVE FOREARM FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25250 REMOVAL OF WRIST PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25251 REMOVAL OF WRIST PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25260 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25263 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25265 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25270 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25272 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25274 REPAIR FOREARM TENDON/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25275 REPAIR FOREARM TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25280 REVISE WRIST/FOREARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25290 INCISE WRIST/FOREARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25295 RELEASE WRIST/FOREARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25300 FUSION OF TENDONS AT WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25301 FUSION OF TENDONS AT WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25310 TRANSPLANT FOREARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25312 TRANSPLANT FOREARM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25315 REVISE PALSY HAND TENDON(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25316 REVISE PALSY HAND TENDON(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25320 REPAIR/REVISE WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
25332 REVISE WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
25335 REALIGNMENT OF HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25337 RECONSTRUCT ULNA/RADIOULNAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25350 REVISION OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25355 REVISION OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25360 REVISION OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25365 REVISE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25370 REVISE RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25375 REVISE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25390 SHORTEN RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25391 LENGTHEN RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25392 SHORTEN RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25393 LENGTHEN RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25394 REPAIR CARPAL BONE SHORTEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25400 REPAIR RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25405 REPAIR/GRAFT RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25415 REPAIR RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25420 REPAIR/GRAFT RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25425 REPAIR/GRAFT RADIUS OR ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25426 REPAIR/GRAFT RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25430 VASC GRAFT INTO CARPAL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25431 REPAIR NONUNION CARPAL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25440 REPAIR/GRAFT WRIST BONE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
25441 RECONSTRUCT WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25442 RECONSTRUCT WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25443 RECONSTRUCT WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25444 RECONSTRUCT WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25445 RECONSTRUCT WRIST JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25446 WRIST REPLACEMENT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
25447 ARTHRP INTERCARPAL/CARP/MTCRPL JT INTERPOSITION Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
25448 ARTHRP INTERCARPAL/CARP/MTCRPL JT SUSPENSION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
25449 REMOVE WRIST JOINT IMPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
25450 REVISION OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25455 REVISION OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25490 REINFORCE RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25491 REINFORCE ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25492 REINFORCE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25500 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25505 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25515 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25520 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25525 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25526 TREAT FRACTURE OF RADIUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25530 TREAT FRACTURE OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25535 TREAT FRACTURE OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25545 TREAT FRACTURE OF ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25560 TREAT FRACTURE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25565 TREAT FRACTURE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25574 TREAT FRACTURE RADIUS AND ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25575 TREAT FRACTURE RADIUS/ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25600 TREAT FRACTURE RADIUS/ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25605 TREAT FRACTURE RADIUS/ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25606 TREAT FX DISTAL RADIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25607 TREAT FX RAD EXTRA-ARTICUL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25608 TREAT FX RAD INTRA-ARTICUL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25609 TREAT FX RADIAL 3PLUS FRAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25622 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25624 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25628 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25630 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25635 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25645 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25650 TREAT WRIST BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25651 PIN ULNAR STYLOID FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25652 TREAT FRACTURE ULNAR STYLOID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25660 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25670 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25671 PIN RADIOULNAR DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25675 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25676 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25680 TREAT WRIST FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25685 TREAT WRIST FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25690 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25695 TREAT WRIST DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25800 FUSION OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25805 FUSION/GRAFT OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25810 FUSION/GRAFT OF WRIST JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25820 FUSION OF HAND BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25825 FUSE HAND BONES WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25830 FUSION RADIOULNAR JNT/ULNA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25900 AMPUTATION OF FOREARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25905 AMPUTATION OF FOREARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25907 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25909 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25915 AMPUTATION OF FOREARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25920 AMPUTATE HAND AT WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25922 AMPUTATE HAND AT WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25924 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25927 AMPUTATION OF HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25929 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
25931 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
25999 FOREARM OR WRIST SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
26010 DRAINAGE OF FINGER ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26011 DRAINAGE OF FINGER ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26020 DRAIN HAND TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26025 DRAINAGE OF PALM BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26030 DRAINAGE OF PALM BURSAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26034 TREAT HAND BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26035 DECOMPRESS FINGERS/HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26037 DECOMPRESS FINGERS/HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26040 RELEASE PALM CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26045 RELEASE PALM CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26055 INCISE FINGER TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26060 INCISION OF FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26070 EXPLORE/TREAT HAND JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26075 EXPLORE/TREAT FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26080 EXPLORE/TREAT FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26100 BIOPSY HAND JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26105 BIOPSY FINGER JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26110 BIOPSY FINGER JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26111 EXC HAND LES SC 1.5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26113 EXC HAND TUM DEEP 1.5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26115 EXC HAND LES SC < 1.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26116 EXC HAND TUM DEEP < 1.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26117 RAD RESECT HAND TUMOR < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26118 RAD RESECT HAND TUMOR 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26121 RELEASE PALM CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26123 RELEASE PALM CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26125 RELEASE PALM CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26130 REMOVE WRIST JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26135 REVISE FINGER JOINT EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26140 REVISE FINGER JOINT EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26145 TENDON EXCISION PALM/FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26160 REMOVE TENDON SHEATH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26170 REMOVAL OF PALM TENDON EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26180 REMOVAL OF FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26185 REMOVE FINGER BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26200 REMOVE HAND BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26205 REMOVE/GRAFT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26210 REMOVAL OF FINGER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26215 REMOVE/GRAFT FINGER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26230 PARTIAL REMOVAL OF HAND BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26235 PARTIAL REMOVAL FINGER BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26236 PARTIAL REMOVAL FINGER BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26250 EXTENSIVE HAND SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26260 RESECT PROX FINGER TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26262 RESECT DISTAL FINGER TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26320 REMOVAL OF IMPLANT FROM HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26341 MANIPULAT PALM CORD POST INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26350 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26352 REPAIR/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26356 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26357 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26358 REPAIR/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26370 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26372 REPAIR/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26373 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26390 REVISE HAND/FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26392 REPAIR/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26410 REPAIR HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26412 REPAIR/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26415 EXCISION HAND/FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26416 GRAFT HAND OR FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26418 REPAIR FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26420 REPAIR/GRAFT FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26426 REPAIR FINGER/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26428 REPAIR/GRAFT FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26432 REPAIR FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26433 REPAIR FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26434 REPAIR/GRAFT FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26437 REALIGNMENT OF TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26440 RELEASE PALM/FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26442 RELEASE PALM AND FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26445 RELEASE HAND/FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26449 RELEASE FOREARM/HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26450 INCISION OF PALM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26455 INCISION OF FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26460 INCISE HAND/FINGER TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26471 FUSION OF FINGER TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26474 FUSION OF FINGER TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26476 TENDON LENGTHENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26477 TENDON SHORTENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26478 LENGTHENING OF HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26479 SHORTENING OF HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26480 TRANSPLANT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26483 TRANSPLANT/GRAFT HAND TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26485 TRANSPLANT PALM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26489 TRANSPLANT/GRAFT PALM TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26490 REVISE THUMB TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26492 TENDON TRANSFER WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26494 HAND TENDON/MUSCLE TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26496 REVISE THUMB TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26497 FINGER TENDON TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26498 FINGER TENDON TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26499 REVISION OF FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26500 HAND TENDON RECONSTRUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26502 HAND TENDON RECONSTRUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26508 RELEASE THUMB CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26510 THUMB TENDON TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26516 FUSION OF KNUCKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26517 FUSION OF KNUCKLE JOINTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26518 FUSION OF KNUCKLE JOINTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26520 RELEASE KNUCKLE CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26525 RELEASE FINGER CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
26530 REVISE KNUCKLE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
26531 REVISE KNUCKLE WITH IMPLANT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
26535 REVISE FINGER JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
26536 REVISE/IMPLANT FINGER JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
26540 REPAIR HAND JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26541 REPAIR HAND JOINT WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26542 REPAIR HAND JOINT WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26545 RECONSTRUCT FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26546 REPAIR NONUNION HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26548 RECONSTRUCT FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26550 CONSTRUCT THUMB REPLACEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26551 GREAT TOE-HAND TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26553 SINGLE TRANSFER TOE-HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26554 DOUBLE TRANSFER TOE-HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26555 POSITIONAL CHANGE OF FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26556 TOE JOINT TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26560 REPAIR OF WEB FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26561 REPAIR OF WEB FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26562 REPAIR OF WEB FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26565 CORRECT METACARPAL FLAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26567 CORRECT FINGER DEFORMITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26568 LENGTHEN METACARPAL/FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26580 REPAIR HAND DEFORMITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26587 RECONSTRUCT EXTRA FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26590 REPAIR FINGER DEFORMITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26591 REPAIR MUSCLES OF HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26593 RELEASE MUSCLES OF HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26596 EXCISION CONSTRICTING TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26600 TREAT METACARPAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26605 TREAT METACARPAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26607 TREAT METACARPAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26608 TREAT METACARPAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26615 TREAT METACARPAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26641 TREAT THUMB DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26645 TREAT THUMB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26650 TREAT THUMB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26665 TREAT THUMB FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26670 TREAT HAND DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26675 TREAT HAND DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26676 PIN HAND DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26685 TREAT HAND DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26686 TREAT HAND DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26700 TREAT KNUCKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26705 TREAT KNUCKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26706 PIN KNUCKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26715 TREAT KNUCKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26720 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26725 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26727 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26735 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26740 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26742 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26746 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26750 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26755 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26756 PIN FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26765 TREAT FINGER FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26770 TREAT FINGER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26775 TREAT FINGER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26776 PIN FINGER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26785 TREAT FINGER DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26820 THUMB FUSION WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26841 FUSION OF THUMB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26842 THUMB FUSION WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26843 FUSION OF HAND JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26844 FUSION/GRAFT OF HAND JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26850 FUSION OF KNUCKLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26852 FUSION OF KNUCKLE WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26860 FUSION OF FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26861 FUSION OF FINGER JNT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26862 FUSION/GRAFT OF FINGER JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26863 FUSE/GRAFT ADDED JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26910 AMPUTATE METACARPAL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26951 AMPUTATION OF FINGER/THUMB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26952 AMPUTATION OF FINGER/THUMB Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
26989 HAND/FINGER SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
26990 DRAINAGE OF PELVIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26991 DRAINAGE OF PELVIS BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
26992 DRAINAGE OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27000 INCISION OF HIP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27001 INCISION OF HIP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27003 INCISION OF HIP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27005 INCISION OF HIP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27006 INCISION OF HIP TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27025 INCISION OF HIP/THIGH FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27027 BUTTOCK FASCIOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27030 DRAINAGE OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27033 EXPLORATION OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27035 DENERVATION OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27036 EXCISION OF HIP JOINT/MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27040 BIOPSY OF SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27041 BIOPSY OF SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27043 EXC HIP PELVIS LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27045 EXC HIP/PELV TUM DEEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27047 EXC HIP/PELVIS LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27048 EXC HIP/PELV TUM DEEP < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27049 RESECT HIP/PELV TUM < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27050 BIOPSY OF SACROILIAC JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27052 BIOPSY OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27054 REMOVAL OF HIP JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27057 BUTTOCK FASCIOTOMY WITH DBRDMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27059 RESECT HIP/PELV TUM 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27060 REMOVAL OF ISCHIAL BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27062 REMOVE FEMUR LESION/BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27065 REMOVE HIP BONE LES SUPER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27066 REMOVE HIP BONE LES DEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27067 REMOVE/GRAFT HIP BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27070 PART REMOVE HIP BONE SUPER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27071 PART REMOVAL HIP BONE DEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27075 RESECT HIP TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27076 RESECT HIP TUM INCL ACETABUL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27077 RESECT HIP TUM WITH INNOM BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27078 RSECT HIP TUM INCL FEMUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27080 REMOVAL OF TAIL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27086 REMOVE HIP FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27087 REMOVE HIP FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27090 REMOVAL OF HIP PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27091 REMOVAL OF HIP PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27093 INJECTION FOR HIP X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27095 INJECTION FOR HIP X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27097 REVISION OF HIP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27098 TRANSFER TENDON TO PELVIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27100 TRANSFER OF ABDOMINAL MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27105 TRANSFER OF SPINAL MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27110 TRANSFER OF ILIOPSOAS MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27111 TRANSFER OF ILIOPSOAS MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27120 RECONSTRUCTION OF HIP SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27122 RECONSTRUCTION OF HIP SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27125 PARTIAL HIP REPLACEMENT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27140 TRANSPLANT FEMUR RIDGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27146 INCISION OF HIP BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27147 REVISION OF HIP BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27151 INCISION OF HIP BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27156 REVISION OF HIP BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27158 REVISION OF PELVIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27161 INCISION OF NECK OF FEMUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27165 INCISION/FIXATION OF FEMUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27170 REPAIR/GRAFT FEMUR HEAD/NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27175 TREAT SLIPPED EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27176 TREAT SLIPPED EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27177 TREAT SLIPPED EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27178 TREAT SLIPPED EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27179 REVISE HEAD/NECK OF FEMUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27181 TREAT SLIPPED EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27185 REVISION OF FEMUR EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27187 REINFORCE HIP BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27197 CLSD TX PELVIC RING FX WITH O MANIPULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27200 TREAT TAIL BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27202 TREAT TAIL BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27215 TREAT PELVIC FRACTURE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27216 TREAT PELVIC RING FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27217 TREAT PELVIC RING FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27218 TREAT PELVIC RING FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27220 TREAT HIP SOCKET FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27222 TREAT HIP SOCKET FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27226 TREAT HIP WALL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27227 TREAT HIP FRACTURE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27228 TREAT HIP FRACTURE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27230 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27232 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27235 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27236 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27238 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27240 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27244 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27245 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27246 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27248 TREAT THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27250 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27252 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27253 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27254 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27256 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27257 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27258 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27259 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27265 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27266 TREAT HIP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27267 CLTX THIGH FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27268 CLTX THIGH FX WITH MNPJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27269 OPTX THIGH FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27275 MANIPULATION OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27282 FUSION OF PUBIC BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27284 FUSION OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27286 FUSION OF HIP JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27290 AMPUTATION OF LEG AT HIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27295 AMPUTATION OF LEG AT HIP Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27299 PELVIS/HIP JOINT SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27301 DRAIN THIGH/KNEE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27303 DRAINAGE OF BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27305 INCISE THIGH TENDON AND FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27306 INCISION OF THIGH TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27307 INCISION OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27310 EXPLORATION OF KNEE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27323 BIOPSY THIGH SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27324 BIOPSY THIGH SOFT TISSUES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27325 NEURECTOMY HAMSTRING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27326 NEURECTOMY POPLITEAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27327 EXC THIGH/KNEE LES SC < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27328 EXC THIGH/KNEE TUM DEEP <5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27329 RESECT THIGH/KNEE TUM < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27330 BIOPSY KNEE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27331 EXPLORE/TREAT KNEE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27334 REMOVE KNEE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27335 REMOVE KNEE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27337 EXC THIGH/KNEE LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27339 EXC THIGH/KNEE TUM DEP 5CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27340 REMOVAL OF KNEECAP BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27345 REMOVAL OF KNEE CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27347 REMOVE KNEE CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27350 REMOVAL OF KNEECAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27355 REMOVE FEMUR LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27356 REMOVE FEMUR LESION/GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27357 REMOVE FEMUR LESION/GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27358 REMOVE FEMUR LESION/FIXATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27360 PARTIAL REMOVAL LEG BONE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27364 RESECT THIGH/KNEE TUM 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27365 RESECT FEMUR/KNEE TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27369 NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27372 REMOVAL OF FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27380 REPAIR OF KNEECAP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27381 REPAIR/GRAFT KNEECAP TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27385 REPAIR OF THIGH MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27386 REPAIR/GRAFT OF THIGH MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27390 INCISION OF THIGH TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27391 INCISION OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27392 INCISION OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27393 LENGTHENING OF THIGH TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27394 LENGTHENING OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27395 LENGTHENING OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27396 TRANSPLANT OF THIGH TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27397 TRANSPLANTS OF THIGH TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27400 REVISE THIGH MUSCLES/TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27430 REVISION OF THIGH MUSCLES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27435 INCISION OF KNEE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27437 REVISE KNEECAP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27440 REVISION OF KNEE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27441 REVISION OF KNEE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27442 REVISION OF KNEE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27443 REVISION OF KNEE JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27448 INCISION OF THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27450 INCISION OF THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27454 REALIGNMENT OF THIGH BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27455 REALIGNMENT OF KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27457 REALIGNMENT OF KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27458 OSTEOT FEMUR UNI INSJ XTRNL CTRLD IMED LNGTH DEV Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27465 SHORTENING OF THIGH BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27466 LENGTHENING OF THIGH BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27470 REPAIR OF THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27472 REPAIR/GRAFT OF THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27475 SURGERY TO STOP LEG GROWTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27477 SURGERY TO STOP LEG GROWTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27479 SURGERY TO STOP LEG GROWTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27485 SURGERY TO STOP LEG GROWTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27488 REMOVAL OF KNEE PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27495 REINFORCE THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27496 DECOMPRESSION OF THIGH/KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27497 DECOMPRESSION OF THIGH/KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27498 DECOMPRESSION OF THIGH/KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27499 DECOMPRESSION OF THIGH/KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27500 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27501 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27502 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27503 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27506 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27507 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27508 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27509 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27510 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27511 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27513 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27514 TREATMENT OF THIGH FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27516 TREAT THIGH FX GROWTH PLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27517 TREAT THIGH FX GROWTH PLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27519 TREAT THIGH FX GROWTH PLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27520 TREAT KNEECAP FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27524 TREAT KNEECAP FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27530 TREAT KNEE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27532 TREAT KNEE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27535 TREAT KNEE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27536 TREAT KNEE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27538 TREAT KNEE FRACTURE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27540 TREAT KNEE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27550 TREAT KNEE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27552 TREAT KNEE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27556 TREAT KNEE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27557 TREAT KNEE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27558 TREAT KNEE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27560 TREAT KNEECAP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27562 TREAT KNEECAP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27566 TREAT KNEECAP DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27580 FUSION OF KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27590 AMPUTATE LEG AT THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27591 AMPUTATE LEG AT THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27592 AMPUTATE LEG AT THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27594 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27596 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27598 AMPUTATE LOWER LEG AT KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27599 LEG SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27600 DECOMPRESSION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27601 DECOMPRESSION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27602 DECOMPRESSION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27603 DRAIN LOWER LEG LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27604 DRAIN LOWER LEG BURSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27605 INCISION OF ACHILLES TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27606 INCISION OF ACHILLES TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27607 TREAT LOWER LEG BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27610 EXPLORE/TREAT ANKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27612 EXPLORATION OF ANKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27613 BIOPSY LOWER LEG SOFT TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27614 BIOPSY LOWER LEG SOFT TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27615 RESECT LEG/ANKLE TUM < 5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27616 RESECT LEG/ANKLE TUM 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27618 EXC LEG/ANKLE TUM < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27619 EXC LEG/ANKLE TUM DEEP <5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27620 EXPLORE/TREAT ANKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27625 REMOVE ANKLE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27626 REMOVE ANKLE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27630 REMOVAL OF TENDON LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27632 EXC LEG/ANKLE LES SC 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27634 EXC LEG/ANKLE TUM DEP 5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27635 REMOVE LOWER LEG BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27637 REMOVE/GRAFT LEG BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27638 REMOVE/GRAFT LEG BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27640 PARTIAL REMOVAL OF TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27641 PARTIAL REMOVAL OF FIBULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27645 RESECT TIBIA TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27646 RESECT FIBULA TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27647 RESECT TALUS/CALCANEUS TUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27648 INJECTION FOR ANKLE X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27650 REPAIR ACHILLES TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27652 REPAIR/GRAFT ACHILLES TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27654 REPAIR OF ACHILLES TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27656 REPAIR LEG FASCIA DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27658 REPAIR OF LEG TENDON EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27659 REPAIR OF LEG TENDON EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27664 REPAIR OF LEG TENDON EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27665 REPAIR OF LEG TENDON EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27675 REPAIR LOWER LEG TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27676 REPAIR LOWER LEG TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27680 RELEASE OF LOWER LEG TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27681 RELEASE OF LOWER LEG TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27685 REVISION OF LOWER LEG TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27686 REVISE LOWER LEG TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27687 REVISION OF CALF TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27690 REVISE LOWER LEG TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27691 REVISE LOWER LEG TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27692 REVISE ADDITIONAL LEG TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27695 REPAIR OF ANKLE LIGAMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27696 REPAIR OF ANKLE LIGAMENTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27698 REPAIR OF ANKLE LIGAMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27700 REVISION OF ANKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27702 RECONSTRUCT ANKLE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27703 RECONSTRUCTION ANKLE JOINT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
27704 REMOVAL OF ANKLE IMPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27705 INCISION OF TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27707 INCISION OF FIBULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27709 INCISION OF TIBIA AND FIBULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27712 REALIGNMENT OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27713 OSTEOT TIBIA UNI INSJ XTRNL CTRLD IMED LNGTH DEV Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
27715 REVISION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27720 REPAIR OF TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27722 REPAIR/GRAFT OF TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27724 REPAIR/GRAFT OF TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27725 REPAIR OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27726 REPAIR FIBULA NONUNION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27727 REPAIR OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27730 REPAIR OF TIBIA EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27732 REPAIR OF FIBULA EPIPHYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27734 REPAIR LOWER LEG EPIPHYSES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27740 REPAIR OF LEG EPIPHYSES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27742 REPAIR OF LEG EPIPHYSES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27745 REINFORCE TIBIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27750 TREATMENT OF TIBIA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27752 TREATMENT OF TIBIA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27756 TREATMENT OF TIBIA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27758 TREATMENT OF TIBIA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27759 TREATMENT OF TIBIA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27760 CLTX MEDIAL ANKLE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27762 CLTX MED ANKLE FX WITH MNPJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27766 OPTX MEDIAL ANKLE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27767 CLTX POST ANKLE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27768 CLTX POST ANKLE FX WITH MNPJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27769 OPTX POST ANKLE FX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27780 TREATMENT OF FIBULA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27781 TREATMENT OF FIBULA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27784 TREATMENT OF FIBULA FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27786 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27788 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27792 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27808 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27810 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27814 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27816 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27818 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27822 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27823 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27824 TREAT LOWER LEG FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27825 TREAT LOWER LEG FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27826 TREAT LOWER LEG FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27827 TREAT LOWER LEG FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27828 TREAT LOWER LEG FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27829 TREAT LOWER LEG JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27830 TREAT LOWER LEG DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27831 TREAT LOWER LEG DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27832 TREAT LOWER LEG DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27840 TREAT ANKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27842 TREAT ANKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27846 TREAT ANKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27848 TREAT ANKLE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27860 FIXATION OF ANKLE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27870 FUSION OF ANKLE JOINT OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27871 FUSION OF TIBIOFIBULAR JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27880 AMPUTATION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27881 AMPUTATION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27882 AMPUTATION OF LOWER LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27884 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27886 AMPUTATION FOLLOW-UP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27888 AMPUTATION OF FOOT AT ANKLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27889 AMPUTATION OF FOOT AT ANKLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27892 DECOMPRESSION OF LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27893 DECOMPRESSION OF LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
27894 DECOMPRESSION OF LEG Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
27899 LEG/ANKLE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
28001 DRAINAGE OF BURSA OF FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28002 TREATMENT OF FOOT INFECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28003 TREATMENT OF FOOT INFECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28005 TREAT FOOT BONE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28008 INCISION OF FOOT FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28010 INCISION OF TOE TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28011 INCISION OF TOE TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28020 EXPLORATION OF FOOT JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28022 EXPLORATION OF FOOT JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28024 EXPLORATION OF TOE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28035 DECOMPRESSION OF TIBIA NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28039 EXC FOOT/TOE TUM SC 1.5 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28041 EXC FOOT/TOE TUM DEP 1.5CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28043 EXC FOOT/TOE TUM SC < 1.5 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28045 EXC FOOT/TOE TUM DEEP <1.5CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28046 RESECT FOOT/TOE TUMOR < 3 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28047 RESECT FOOT/TOE TUMOR 3 CM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28050 BIOPSY OF FOOT JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28052 BIOPSY OF FOOT JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28054 BIOPSY OF TOE JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28055 NEURECTOMY FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28060 PARTIAL REMOVAL FOOT FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28062 REMOVAL OF FOOT FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28070 REMOVAL OF FOOT JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28072 REMOVAL OF FOOT JOINT LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28080 REMOVAL OF FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28086 EXCISE FOOT TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28088 EXCISE FOOT TENDON SHEATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28090 REMOVAL OF FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28092 REMOVAL OF TOE LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28100 REMOVAL OF ANKLE/HEEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28102 REMOVE/GRAFT FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28103 REMOVE/GRAFT FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28104 REMOVAL OF FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28106 REMOVE/GRAFT FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28107 REMOVE/GRAFT FOOT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28108 REMOVAL OF TOE LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28110 PART REMOVAL OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28111 PART REMOVAL OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28112 PART REMOVAL OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28113 PART REMOVAL OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28114 REMOVAL OF METATARSAL HEADS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28116 REVISION OF FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28118 REMOVAL OF HEEL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28119 REMOVAL OF HEEL SPUR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28120 PART REMOVAL OF ANKLE/HEEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28122 PARTIAL REMOVAL OF FOOT BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28124 PARTIAL REMOVAL OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28126 PARTIAL REMOVAL OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28130 REMOVAL OF ANKLE BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28140 REMOVAL OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28150 REMOVAL OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28153 PARTIAL REMOVAL OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28160 PARTIAL REMOVAL OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28171 RESECT TARSAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28173 RESECT METATARSAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28175 RESECT PHALANX OF TOE TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28190 REMOVAL OF FOOT FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28192 REMOVAL OF FOOT FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28193 REMOVAL OF FOOT FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28200 REPAIR OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28202 REPAIR/GRAFT OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28208 REPAIR OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28210 REPAIR/GRAFT OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28220 RELEASE OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28222 RELEASE OF FOOT TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28225 RELEASE OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28226 RELEASE OF FOOT TENDONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28230 INCISION OF FOOT TENDON(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28232 INCISION OF TOE TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28234 INCISION OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28238 REVISION OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28240 RELEASE OF BIG TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28250 REVISION OF FOOT FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28260 RELEASE OF MIDFOOT JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28261 REVISION OF FOOT TENDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28262 REVISION OF FOOT AND ANKLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28264 RELEASE OF MIDFOOT JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28270 RELEASE OF FOOT CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28272 RELEASE OF TOE JOINT EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28280 FUSION OF TOES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28285 REPAIR OF HAMMERTOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28286 REPAIR OF HAMMERTOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28288 PARTIAL REMOVAL OF FOOT BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28289 CORRJ HALUX RIGDUS WITH O IMPLT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28291 HALLUX RIGIDUS WITH CHEILECTOMY 1ST MP JT WITH IMPLT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28292 CORRJ HLX VLGS BNCTY SESMDC RESCJ PROX PHLX BASE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28295 CORRJ HLX VLGS BNCTY SESMDC PROX METAR OSTEOT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
28296 CORRJ HLX VLGS BNCTY SESMDC DSTL METAR OSTEOT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
28297 CORRJ HLX VLGS BNCTY SESMDC JOINT ARTHRODESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28298 CORRJ HLX VLGS BNCTY SESMDC PROX PHLX OSTEOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28299 CORRJ HLX VLGS BNCTY SESMDC W/DOUBLE OSTEOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28300 INCISION OF HEEL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28302 INCISION OF ANKLE BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28304 INCISION OF MIDFOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28305 INCISE/GRAFT MIDFOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28306 INCISION OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28307 INCISION OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28308 INCISION OF METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28309 INCISION OF METATARSALS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28310 REVISION OF BIG TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28312 REVISION OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28313 REPAIR DEFORMITY OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28315 REMOVAL OF SESAMOID BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28320 REPAIR OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28322 REPAIR OF METATARSALS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28340 RESECT ENLARGED TOE TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28341 RESECT ENLARGED TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28344 REPAIR EXTRA TOE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28345 REPAIR WEBBED TOE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28360 RECONSTRUCT CLEFT FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28400 TREATMENT OF HEEL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28405 TREATMENT OF HEEL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28406 TREATMENT OF HEEL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28415 TREAT HEEL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28420 TREAT/GRAFT HEEL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28430 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28435 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28436 TREATMENT OF ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28445 TREAT ANKLE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28446 OSTEOCHONDRAL TALUS AUTOGRFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28450 TREAT MIDFOOT FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28455 TREAT MIDFOOT FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28456 TREAT MIDFOOT FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28465 TREAT MIDFOOT FRACTURE EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28470 TREAT METATARSAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28475 TREAT METATARSAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28476 TREAT METATARSAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28485 TREAT METATARSAL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28490 TREAT BIG TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28495 TREAT BIG TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28496 TREAT BIG TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28505 TREAT BIG TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28510 TREATMENT OF TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28515 TREATMENT OF TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28525 TREAT TOE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28530 TREAT SESAMOID BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28531 TREAT SESAMOID BONE FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28540 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28545 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28546 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28555 REPAIR FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28570 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28575 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28576 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28585 REPAIR FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28600 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28605 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28606 TREAT FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28615 REPAIR FOOT DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28630 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28635 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28636 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28645 REPAIR TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28660 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28665 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28666 TREAT TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28675 REPAIR OF TOE DISLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28705 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28715 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28725 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28730 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28735 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28737 REVISION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28740 FUSION OF FOOT BONES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28750 FUSION OF BIG TOE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28755 FUSION OF BIG TOE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28760 FUSION OF BIG TOE JOINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28800 AMPUTATION OF MIDFOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28805 AMPUTATION THRU METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28810 AMPUTATION TOE AND METATARSAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28820 AMPUTATION OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28825 PARTIAL AMPUTATION OF TOE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
28890 HI ENRGY ESWT PLANTAR FASCIA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
28899 FOOT/TOES SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
29000 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29010 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29015 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29035 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29040 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29044 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29046 APPLICATION OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29049 APPLICATION OF FIGURE EIGHT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29055 APPLICATION OF SHOULDER CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29058 APPLICATION OF SHOULDER CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29065 APPLICATION OF LONG ARM CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29075 APPLICATION OF FOREARM CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29085 APPLY HAND/WRIST CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29086 APPLY FINGER CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29105 APPLY LONG ARM SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29125 APPLY FOREARM SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29126 APPLY FOREARM SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29130 APPLICATION OF FINGER SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29131 APPLICATION OF FINGER SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29200 STRAPPING OF CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29240 STRAPPING OF SHOULDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29260 STRAPPING OF ELBOW OR WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29280 STRAPPING OF HAND OR FINGER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29305 APPLICATION OF HIP CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29325 APPLICATION OF HIP CASTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29345 APPLICATION OF LONG LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29355 APPLICATION OF LONG LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29358 APPLY LONG LEG CAST BRACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29365 APPLICATION OF LONG LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29405 APPLY SHORT LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29425 APPLY SHORT LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29435 APPLY SHORT LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29440 ADDITION OF WALKER TO CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29445 APPLY RIGID LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29450 APPLICATION OF LEG CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29505 APPLICATION LONG LEG SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29515 APPLICATION LOWER LEG SPLINT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29520 STRAPPING OF HIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29530 STRAPPING OF KNEE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29540 STRAPPING OF ANKLE AND/OR FT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29550 STRAPPING OF TOES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29580 APPLICATION OF PASTE BOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29581 APPLY MULTLAY COMPRS LWR LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29584 APPL MULTLAY COMPRS ARM/HAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29700 REMOVAL/REVISION OF CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29705 REMOVAL/REVISION OF CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29710 REMOVAL/REVISION OF CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29720 REPAIR OF BODY CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29730 WINDOWING OF CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29740 WEDGING OF CAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29750 WEDGING OF CLUBFOOT CAST Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
29799 CASTING/STRAPPING PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
29800 JAW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29804 JAW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29830 ELBOW ARTHROSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29834 ELBOW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29835 ELBOW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29836 ELBOW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29837 ELBOW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29838 ELBOW ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29840 WRIST ARTHROSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29843 WRIST ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29844 WRIST ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29845 WRIST ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29846 WRIST ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29847 WRIST ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29848 WRIST ENDOSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29850 KNEE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29851 KNEE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29855 TIBIAL ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29856 TIBIAL ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29871 KNEE ARTHROSCOPY/DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29891 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29892 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29893 SCOPE PLANTAR FASCIOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29894 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29895 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29897 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29898 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29899 ANKLE ARTHROSCOPY/SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29900 MCP JOINT ARTHROSCOPY DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29901 MCP JOINT ARTHROSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29902 MCP JOINT ARTHROSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29904 SUBTALAR ARTHRO WITH FB RMVL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29905 SUBTALAR ARTHRO WITH EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29906 SUBTALAR ARTHRO WITH DEB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
29907 SUBTALAR ARTHRO WITH FUSION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
29999 ARTHROSCOPY OF JOINT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
30000 DRAINAGE OF NOSE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30020 DRAINAGE OF NOSE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30100 INTRANASAL BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30110 REMOVAL OF NOSE POLYP(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30115 REMOVAL OF NOSE POLYP(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30117 REMOVAL OF INTRANASAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30118 REMOVAL OF INTRANASAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
30120 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
30124 REMOVAL OF NOSE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30125 REMOVAL OF NOSE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
30130 EXCISE INFERIOR TURBINATE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30140 RESECT INFERIOR TURBINATE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
30150 PARTIAL REMOVAL OF NOSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30160 REMOVAL OF NOSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30200 INJECTION TREATMENT OF NOSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30210 NASAL SINUS THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30220 INSERT NASAL SEPTAL BUTTON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30300 REMOVE NASAL FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30310 REMOVE NASAL FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30320 REMOVE NASAL FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
30400 RECONSTRUCTION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30410 RECONSTRUCTION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30420 RECONSTRUCTION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30430 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30435 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30450 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30460 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30462 REVISION OF NOSE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30465 REPAIR NASAL STENOSIS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30468 RPR NSL VLV COLLAPSE SUBQ/SBMCSL LAT WALL IMPLT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30469 RPR NSL VLV COLLAPSE LW NRG SUBQ/SBMCSL RMDLG Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
30520 REPAIR OF NASAL SEPTUM Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
30540 REPAIR NASAL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30545 REPAIR NASAL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30560 RELEASE OF NASAL ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30580 REPAIR UPPER JAW FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30600 REPAIR MOUTH/NOSE FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
30620 INTRANASAL RECONSTRUCTION Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
30630 REPAIR NASAL SEPTUM DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30801 ABLATE INF TURBINATE SUPERF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30802 ABLATE INF TURBINATE SUBMUC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30901 CONTROL OF NOSEBLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30903 CONTROL OF NOSEBLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30905 CONTROL OF NOSEBLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30906 REPEAT CONTROL OF NOSEBLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30915 LIGATION NASAL SINUS ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30920 LIGATION UPPER JAW ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
30930 THER FX NASAL INF TURBINATE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
30999 NASAL SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
31000 IRRIGATION MAXILLARY SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31002 IRRIGATION SPHENOID SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31020 EXPLORATION MAXILLARY SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31030 EXPLORATION MAXILLARY SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31032 EXPLORE SINUS REMOVE POLYPS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31040 EXPLORATION BEHIND UPPER JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31050 EXPLORATION SPHENOID SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31051 SPHENOID SINUS SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31070 EXPLORATION OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31075 EXPLORATION OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31080 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31081 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31084 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31085 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31086 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31087 REMOVAL OF FRONTAL SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31090 EXPLORATION OF SINUSES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31200 REMOVAL OF ETHMOID SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31201 REMOVAL OF ETHMOID SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31205 REMOVAL OF ETHMOID SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31225 REMOVAL OF UPPER JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31230 REMOVAL OF UPPER JAW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31231 NASAL ENDOSCOPY DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31233 NASAL/SINUS ENDOSCOPY DX MAXILLARY SINUSOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31235 NASAL/SINUS ENDOSCOPY DX SPHENOID SINUSOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31237 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31238 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31239 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31240 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31241 NSL/SINS NDSC WITH ARTERY LIG Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
31253 NSL/SINS NDSC TOTAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31254 NSL/SINS NDSC WITH PRTL ETHMDCT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31255 NSL/SINS NDSC WITH TOT ETHMDCT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31256 EXPLORATION MAXILLARY SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31257 NSL/SINS NDSC TOT WITH SPHENDT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31259 NSL/SINS NDSC SPHN TISS RMVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31267 ENDOSCOPY MAXILLARY SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31276 NSL/SINS NDSC FRNT TISS RMVL Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
31287 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31288 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31290 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31291 NASAL/SINUS ENDOSCOPY SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31292 NASAL/SINUS NDSC SURG MEDIAL/INF ORB WALL DCMPRN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31293 NASAL/SINUS NDSC SURG MEDIAL AND INF ORB WALL DCMPRN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31294 NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
31295 NASAL/SINUS NDSC SURG W/DILATION MAXILLARY SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31296 NASAL/SINUS NDSC SURG W/DILATION FRONTAL SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31297 NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31298 NASAL/SINUS NDSC SURG W/DILATION FRNT AND SPHN SINUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
31299 SINUS SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
31300 REMOVAL OF LARYNX LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31360 REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31365 REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31367 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31368 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31370 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31375 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31380 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31382 PARTIAL REMOVAL OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31390 REMOVAL OF LARYNX AND PHARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31395 RECONSTRUCT LARYNX AND PHARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31400 REVISION OF LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31420 REMOVAL OF EPIGLOTTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31500 INSERT EMERGENCY AIRWAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31502 CHANGE OF WINDPIPE AIRWAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31505 DIAGNOSTIC LARYNGOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31510 LARYNGOSCOPY WITH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31511 REMOVE FOREIGN BODY LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31512 REMOVAL OF LARYNX LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31513 INJECTION INTO VOCAL CORD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31515 LARYNGOSCOPY FOR ASPIRATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31520 DX LARYNGOSCOPY NEWBORN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31525 DX LARYNGOSCOPY EXCL NB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31526 DX LARYNGOSCOPY WITH OPER SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31527 LARYNGOSCOPY FOR TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31528 LARYNGOSCOPY AND DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31529 LARYNGOSCOPY AND DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31530 LARYNGOSCOPY WITH FB REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31531 LARYNGOSCOPY WITH FB AND OP SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31535 LARYNGOSCOPY WITH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31536 LARYNGOSCOPY WITH BX AND OP SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31540 LARYNGOSCOPY WITH EXC OF TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31541 LARYNSCOP WITH TUMR EXC PLUS SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31545 REMOVE VC LESION WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31546 REMOVE VC LESION SCOPE/GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31551 LARYNGOPLASTY LARYNGEAL STEN WITH O STENT < 12 YRS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31552 LARYNGOPLASTY LARYNGEAL STEN WITH O STENT 12 YRS > Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31553 LARYNGOPLASTY LARYNGEAL STEN WITH STENT < 12 YRS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31554 LARYNGOPLASTY LARYNGEAL STEN WITH STENT 12 YRS > Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31560 LARYNGOSCOP WITH ARYTENOIDECTOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31561 LARYNSCOP REMVE CART PLUS SCOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31570 LARYNGOSCOPE WITH VC INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31571 LARYNGOSCOP WITH VC INJ PLUS SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31572 LARYNGOSCOPY FLEXIBLE ABLATJ DESTJ LESION(S) UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31573 LARYNGOSCOPY FLEXIBLE THERAPEUTIC INJECTION UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31574 LARYNGOSCOPY FLEXIBLE WITH INJECTION AGMNTJ UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31575 DIAGNOSTIC LARYNGOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31576 LARYNGOSCOPY WITH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31577 LARGSC WITH RMVL FOREIGN BDY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31578 LARGSC WITH REMOVAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31579 LARYNGOSCOPY TELESCOPIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31580 LARYNGOPLASTY LARYNGEAL WEB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31584 LARYNGOPLASTY FX RDCTJ FIXJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31587 LARYNGOPLASTY CRICOID SPLIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31590 REINNERVATE LARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31591 LARYNGOPLASTY MEDIALIZATION UNLIATERAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31592 CRICOTRACHEAL RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
31599 LARYNX SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
31600 INCISION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31601 INCISION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31603 INCISION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31605 INCISION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31610 INCISION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31611 SURGERY/SPEECH PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31612 PUNCTURE/CLEAR WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31613 REPAIR WINDPIPE OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31614 REPAIR WINDPIPE OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31615 VISUALIZATION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31622 DX BRONCHOSCOPE/WASH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31623 DX BRONCHOSCOPE/BRUSH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31624 DX BRONCHOSCOPE/LAVAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31625 BRONCHOSCOPY WITH BIOPSY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31626 BRONCHOSCOPY WITH MARKERS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31627 NAVIGATIONAL BRONCHOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31628 BRONCHOSCOPY/LUNG BX EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31629 BRONCHOSCOPY/NEEDLE BX EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31630 BRONCHOSCOPY DILATE/FX REPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31631 BRONCHOSCOPY DILATE WITH STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31632 BRONCHOSCOPY/LUNG BX ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31633 BRONCHOSCOPY/NEEDLE BX ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31634 BRONCH WITH BALLOON OCCLUSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31635 BRONCHOSCOPY WITH FB REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31636 BRONCHOSCOPY BRONCH STENTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31637 BRONCHOSCOPY STENT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31638 BRONCHOSCOPY REVISE STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31640 BRONCHOSCOPY WITH TUMOR EXCISE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31641 BRONCHOSCOPY TREAT BLOCKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31643 DIAG BRONCHOSCOPE/CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31645 BRNCHSC WITH THER ASPIR 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31646 BRNCHSC WITH THER ASPIR SBSQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31647 BRONCHIAL VALVE INIT INSERT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31648 BRONCHIAL VALVE REMOV INIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31649 BRONCHIAL VALVE REMOV ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31651 BRNCHSC OCCLUSION AND INSERT BRONCH VALVE ADDL LOBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31652 BRONCH EBUS SAMPLNG 1/2 NODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31653 BRONCH EBUS SAMPLNG 3/> NODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31654 BRONCH EBUS IVNTJ PERPH LES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31660 BRONCH THERMOPLSTY 1 LOBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31661 BRONCH THERMOPLSTY 2/> LOBES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31717 BRONCHIAL BRUSH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31720 CLEARANCE OF AIRWAYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31725 CLEARANCE OF AIRWAYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31730 INTRO WINDPIPE WIRE/TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31750 REPAIR OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31755 REPAIR OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31760 REPAIR OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31766 RECONSTRUCTION OF WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31770 REPAIR/GRAFT OF BRONCHUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31775 RECONSTRUCT BRONCHUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31780 RECONSTRUCT WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31781 RECONSTRUCT WINDPIPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31785 REMOVE WINDPIPE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31786 REMOVE WINDPIPE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31800 REPAIR OF WINDPIPE INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31805 REPAIR OF WINDPIPE INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31820 CLOSURE OF WINDPIPE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31825 REPAIR OF WINDPIPE DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
31830 REVISE WINDPIPE SCAR Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
31899 AIRWAYS SURGICAL PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
32035 THORACOSTOMY WITH RIB RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32036 THORACOSTOMY WITH FLAP DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32096 OPEN WEDGE/BX LUNG INFILTR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32097 OPEN WEDGE/BX LUNG NODULE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32098 OPEN BIOPSY OF LUNG PLEURA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32100 EXPLORATION OF CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32110 EXPLORE/REPAIR CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32120 RE-EXPLORATION OF CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32124 EXPLORE CHEST FREE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32140 REMOVAL OF LUNG LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32141 REMOVE/TREAT LUNG LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32150 REMOVAL OF LUNG LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32151 REMOVE LUNG FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32160 OPEN CHEST HEART MASSAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32200 DRAIN OPEN LUNG LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32215 TREAT CHEST LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32220 RELEASE OF LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32225 PARTIAL RELEASE OF LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32310 REMOVAL OF CHEST LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32320 FREE/REMOVE CHEST LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32400 NEEDLE BIOPSY CHEST LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32408 CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32440 REMOVE LUNG PNEUMONECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32442 SLEEVE PNEUMONECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32445 REMOVAL OF LUNG EXTRAPLEURAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32480 PARTIAL REMOVAL OF LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32482 BILOBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32484 SEGMENTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32486 SLEEVE LOBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32488 COMPLETION PNEUMONECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
32491 LUNG VOLUME REDUCTION Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
32501 REPAIR BRONCHUS ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32503 RESECT APICAL LUNG TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32504 RESECT APICAL LUNG TUM/CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32505 WEDGE RESECT OF LUNG INITIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32506 WEDGE RESECT OF LUNG ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32507 WEDGE RESECT OF LUNG DIAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32540 REMOVAL OF LUNG LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32550 INSERT PLEURAL CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32551 INSERTION OF CHEST TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32552 REMOVE LUNG CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32553 INS MARK THOR FOR RT PERQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32554 ASPIRATE PLEURA WITH O IMAGING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32555 ASPIRATE PLEURA WITH IMAGING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32556 INSERT CATH PLEURA WITH O IMAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32557 INSERT CATH PLEURA WITH IMAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32560 TREAT PLEURODESIS WITH AGENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32561 LYSE CHEST FIBRIN INIT DAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32562 LYSE CHEST FIBRIN SUBQ DAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32601 THORACOSCOPY DIAGNOSTIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32604 THORACOSCOPY WBX SAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32606 THORACOSCOPY WITH BX MED SPACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32607 THORACOSCOPY WITH BX INFILTRATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32608 THORACOSCOPY WITH BX NODULE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32609 THORACOSCOPY WITH BX PLEURA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32650 THORACOSCOPY WITH PLEURODESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32651 THORACOSCOPY REMOVE CORTEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32652 THORACOSCOPY REM TOTL CORTEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32653 THORACOSCOPY REMOV FB/FIBRIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32654 THORACOSCOPY CONTRL BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32655 THORACOSCOPY RESECT BULLAE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32656 THORACOSCOPY WITH PLEURECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32658 THORACOSCOPY WITH SAC FB REMOVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32659 THORACOSCOPY WITH SAC DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32661 THORACOSCOPY WITH PERICARD EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32662 THORACOSCOPY WITH MEDIAST EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32663 THORACOSCOPY WITH LOBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32664 THORACOSCOPY WITH TH NRV EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32665 THORACOSCOP WITH ESOPH MUSC EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32666 THORACOSCOPY WITH WEDGE RESECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32667 THORACOSCOPY WITH W RESECT ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32668 THORACOSCOPY WITH W RESECT DIAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32669 THORACOSCOPY REMOVE SEGMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32670 THORACOSCOPY BILOBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32671 THORACOSCOPY PNEUMONECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32672 THORACOSCOPY FOR LVRS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32673 THORACOSCOPY WITH THYMUS RESECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32674 THORACOSCOPY LYMPH NODE EXC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32701 THORAX STEREO RAD TARGET WITH TX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32800 REPAIR LUNG HERNIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32810 CLOSE CHEST AFTER DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32815 CLOSE BRONCHIAL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32820 RECONSTRUCT INJURED CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
32850 DONOR PNEUMONECTOMY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
32851 LUNG TRANSPLANT SINGLE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
32852 LUNG TRANSPLANT WITH BYPASS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
32853 LUNG TRANSPLANT DOUBLE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
32854 LUNG TRANSPLANT WITH BYPASS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
32855 PREPARE DONOR LUNG SINGLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32856 PREPARE DONOR LUNG DOUBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32900 REMOVAL OF RIB(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32905 REVISE AND REPAIR CHEST WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32906 REVISE AND REPAIR CHEST WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32940 REVISION OF LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32960 THERAPEUTIC PNEUMOTHORAX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32994 ABLATE PULM TUMOR PERQ CRYBL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32997 TOTAL LUNG LAVAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
32998 ABLATE PULM TUMOR PERQ RF Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
32999 CHEST SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
33016 PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33017 PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33018 PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33019 PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33020 INCISION OF HEART SAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33025 INCISION OF HEART SAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33030 PARTIAL REMOVAL OF HEART SAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33031 PARTIAL REMOVAL OF HEART SAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33050 RESECT HEART SAC LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33120 REMOVAL OF HEART LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33130 REMOVAL OF HEART LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33140 HEART REVASCULARIZE (TMR) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33141 HEART TMR WITH OTHER PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33202 INSERT EPICARD ELTRD OPEN Tailored Plan Services administered by TurningPoint
Con
Authorization
33203 INSERT EPICARD ELTRD ENDO Tailored Plan Services administered by TurningPoint
Con
Authorization
33206 INSERT HEART PM ATRIAL Tailored Plan Services administered by TurningPoint
Con
Authorization
33207 INSERT HEART PM VENTRICULAR Tailored Plan Services administered by TurningPoint
Con
Authorization
33208 INSRT HEART PM ATRIAL AND VENT Tailored Plan Services administered by TurningPoint
Con
Authorization
33210 INSERT ELECTRD/PM CATH SNGL Tailored Plan Services administered by TurningPoint
Con
Authorization
33211 INSERT CARD ELECTRODES DUAL Tailored Plan Services administered by TurningPoint
Con
Authorization
33212 INSERT PULSE GEN SNGL LEAD Tailored Plan Services administered by TurningPoint
Con
Authorization
33213 INSERT PULSE GEN DUAL LEADS Tailored Plan Services administered by TurningPoint
Con
Authorization
33214 UPGRADE OF PACEMAKER SYSTEM Tailored Plan Services administered by TurningPoint
Con
Authorization
33215 REPOSITION PACING-DEFIB LEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33216 INSERT 1 ELECTRODE PM-DEFIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33217 INSERT 2 ELECTRODE PM-DEFIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33218 REPAIR LEAD PACE-DEFIB ONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33220 REPAIR LEAD PACE-DEFIB DUAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33221 INSERT PULSE GEN MULT LEADS Tailored Plan Services administered by TurningPoint
Con
Authorization
33222 RELOCATION POCKET PACEMAKER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33223 RELOCATE POCKET FOR DEFIB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33224 INSERT PACING LEAD AND CONNECT Tailored Plan Services administered by TurningPoint
Con
Authorization
33225 L VENTRIC PACING LEAD ADD-ON Tailored Plan Services administered by TurningPoint
Con
Authorization
33226 REPOSITION L VENTRIC LEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33227 REMOVEANDREPLACE PM GEN SINGL Tailored Plan Services administered by TurningPoint
Con
Authorization
33228 REMVANDREPLC PM GEN DUAL LEAD Tailored Plan Services administered by TurningPoint
Con
Authorization
33229 REMVANDREPLC PM GEN MULT LEADS Tailored Plan Services administered by TurningPoint
Con
Authorization
33230 INSRT PULSE GEN WITH DUAL LEADS Tailored Plan Services administered by TurningPoint
Con
Authorization
33231 INSRT PULSE GEN WITH MULT LEADS Tailored Plan Services administered by TurningPoint
Con
Authorization
33233 REMOVAL OF PM GENERATOR Tailored Plan Services administered by TurningPoint
Con
Authorization
33234 REMOVAL OF PACEMAKER SYSTEM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33235 REMOVAL PACEMAKER ELECTRODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33236 REMOVE ELECTRODE/THORACOTOMY Tailored Plan Services administered by TurningPoint
Con
Authorization
33237 REMOVE ELECTRODE/THORACOTOMY Tailored Plan Services administered by TurningPoint
Con
Authorization
33238 REMOVE ELECTRODE/THORACOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33240 INSRT PULSE GEN WITH SINGL LEAD Tailored Plan Services administered by TurningPoint
Con
Authorization
33241 REMOVE PULSE GENERATOR Tailored Plan Services administered by TurningPoint
Con
Authorization
33243 REMOVE ELTRD/THORACOTOMY Tailored Plan Services administered by TurningPoint
Con
Authorization
33244 REMOVE ELCTRD TRANSVENOUSLY Tailored Plan Services administered by TurningPoint
Con
Authorization
33249 INSJ/RPLCMT DEFIB WITH LEAD(S) Tailored Plan Services administered by TurningPoint
Con
Authorization
33250 ABLATE HEART DYSRHYTHM FOCUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33251 ABLATE HEART DYSRHYTHM FOCUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33254 ABLATE ATRIA LMTD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33255 ABLATE ATRIA WITH O BYPASS EXT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33256 ABLATE ATRIA WITH BYPASS EXTEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33257 ABLATE ATRIA LMTD ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33258 ABLATE ATRIA X10SV ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33259 ABLATE ATRIA WITH BYPASS ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33261 ABLATE HEART DYSRHYTHM FOCUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33262 RMVLAND REPLC PULSE GEN 1 LEAD Tailored Plan Services administered by TurningPoint
Con
Authorization
33263 RMVL AND RPLCMT DFB GEN 2 LEAD Tailored Plan Services administered by TurningPoint
Con
Authorization
33264 RMVL AND RPLCMT DFB GEN MLT LD Tailored Plan Services administered by TurningPoint
Con
Authorization
33265 ABLATE ATRIA LMTD ENDO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33266 ABLATE ATRIA X10SV ENDO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33270 INS/REP SUBQ DEFIBRILLATOR Tailored Plan Services administered by TurningPoint
Con
Authorization
33271 INSJ SUBQ IMPLTBL DFB ELCTRD Tailored Plan Services administered by TurningPoint
Con
Authorization
33272 RMVL OF SUBQ DEFIBRILLATOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33273 REPOS PREV IMPLTBL SUBQ DFB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33274 TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV WITH IMG Tailored Plan Services administered by TurningPoint
Con
Authorization
33275 TCAT REMOVAL PERM LEADLESS PM RIGHT VENTR W/IMG Tailored Plan Services administered by TurningPoint
Con
Authorization
33276 INSERTION PHRENIC NERVE STIMULATOR SYSTEM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33277 INSJ PHRENIC NRV STIMULATOR TRANSVNS SENSING LD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33278 REMOVAL PHRENIC NERVE STIMULATOR SYSTEM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33279 RMVL PHRNC NRV STIMULATOR TRANSVNS STIMJ/SNSG LD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33280 RMVL PHRENIC NRV STIMULATOR PULSE GENERATOR ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33281 REPOSITIONING PHRENIC NRV STIMULATOR TRANSVNS LD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33285 INSERTION SUBQ CARDIAC RHYTHM MONITOR WITH PRGRMG Tailored Plan Services administered by TurningPoint
Con
Authorization
33286 REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR Tailored Plan Services administered by TurningPoint
Con
Authorization
33287 RMVL AND RPLCMT PHRENIC NRV STIMULATOR PLS GENERATOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33288 RMVL AND RPLCMT PHRNC NRV STIM TRNSVNS STIMJ/SNSG LD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33289 TCAT IMPL WRLS P-ART PRS SNR L-T HEMODYN MNTR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33300 REPAIR OF HEART WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33305 REPAIR OF HEART WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33310 EXPLORATORY HEART SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33315 EXPLORATORY HEART SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33320 REPAIR MAJOR BLOOD VESSEL(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33321 REPAIR MAJOR VESSEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33322 REPAIR MAJOR BLOOD VESSEL(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33330 INSERT MAJOR VESSEL GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33335 INSERT MAJOR VESSEL GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33340 PERQ CLSR TCAT L ATR APNDGE WITH ENDOCARDIAL IMPLNT Tailored Plan Services administered by TurningPoint
Con
Authorization
33361 REPLACE AORTIC VALVE PERQ Tailored Plan Services administered by TurningPoint
Con
Authorization
33362 REPLACE AORTIC VALVE OPEN Tailored Plan Services administered by TurningPoint
Con
Authorization
33363 REPLACE AORTIC VALVE OPEN Tailored Plan Services administered by TurningPoint
Con
Authorization
33364 REPLACE AORTIC VALVE OPEN Tailored Plan Services administered by TurningPoint
Con
Authorization
33365 REPLACE AORTIC VALVE OPEN Tailored Plan Services administered by TurningPoint
Con
Authorization
33366 TRCATH REPLACE AORTIC VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33367 REPLACE AORTIC VALVE WITH BYP Tailored Plan Services administered by TurningPoint
Con
Authorization
33368 REPLACE AORTIC VALVE WITH BYP Tailored Plan Services administered by TurningPoint
Con
Authorization
33369 REPLACE AORTIC VALVE WITH BYP Tailored Plan Services administered by TurningPoint
Con
Authorization
33390 VALVULOPLASTY AORTIC VALVE OPEN CARD BYP SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33391 VALVULOPLASTY AORTIC VALVE OPEN CARD BYP COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33404 PREPARE HEART-AORTA CONDUIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33405 REPLACEMENT AORTIC VALVE OPN Tailored Plan Services administered by TurningPoint
Con
Authorization
33406 REPLACEMENT AORTIC VALVE OPN Tailored Plan Services administered by TurningPoint
Con
Authorization
33410 REPLACEMENT AORTIC VALVE OPN Tailored Plan Services administered by TurningPoint
Con
Authorization
33411 REPLACEMENT OF AORTIC VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33412 REPLACEMENT OF AORTIC VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33413 REPLACEMENT OF AORTIC VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33414 REPAIR OF AORTIC VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33415 REVISION SUBVALVULAR TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33416 REVISE VENTRICLE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33417 REPAIR OF AORTIC VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33418 REPAIR TCAT MITRAL VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33419 REPAIR TCAT MITRAL VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33420 REVISION OF MITRAL VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33422 REVISION OF MITRAL VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33425 REPAIR OF MITRAL VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33426 REPAIR OF MITRAL VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33427 REPAIR OF MITRAL VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33430 REPLACEMENT OF MITRAL VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33440 RPLCMT AORTIC VALVE BY TLCJ AUTOL PULM VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33460 REVISION OF TRICUSPID VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33463 VALVULOPLASTY TRICUSPID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33464 VALVULOPLASTY TRICUSPID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33465 REPLACE TRICUSPID VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33468 REVISION OF TRICUSPID VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33474 REVISION OF PULMONARY VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33475 REPLACEMENT PULMONARY VALVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33476 REVISION OF HEART CHAMBER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33477 IMPLANT TCAT PULM VLV PERQ Tailored Plan Services administered by TurningPoint
Con
Authorization
33478 REVISION OF HEART CHAMBER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33496 REPAIR PROSTH VALVE CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33500 REPAIR HEART VESSEL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33501 REPAIR HEART VESSEL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33502 CORONARY ARTERY CORRECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33503 CORONARY ARTERY GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33504 CORONARY ARTERY GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33505 REPAIR ARTERY WITH TUNNEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33506 REPAIR ARTERY TRANSLOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33507 REPAIR ART INTRAMURAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33508 ENDOSCOPIC VEIN HARVEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33509 ENDOSCOPIC HARVEST UXTR ARTERY 1 SEGMENT CAB PX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33510 CABG VEIN SINGLE Tailored Plan Services administered by TurningPoint
Con
Authorization
33511 CABG VEIN TWO Tailored Plan Services administered by TurningPoint
Con
Authorization
33512 CABG VEIN THREE Tailored Plan Services administered by TurningPoint
Con
Authorization
33513 CABG VEIN FOUR Tailored Plan Services administered by TurningPoint
Con
Authorization
33514 CABG VEIN FIVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33516 CABG VEIN SIX OR MORE Tailored Plan Services administered by TurningPoint
Con
Authorization
33517 CABG ARTERY-VEIN SINGLE Tailored Plan Services administered by TurningPoint
Con
Authorization
33518 CABG ARTERY-VEIN TWO Tailored Plan Services administered by TurningPoint
Con
Authorization
33519 CABG ARTERY-VEIN THREE Tailored Plan Services administered by TurningPoint
Con
Authorization
33521 CABG ARTERY-VEIN FOUR Tailored Plan Services administered by TurningPoint
Con
Authorization
33522 CABG ARTERY-VEIN FIVE Tailored Plan Services administered by TurningPoint
Con
Authorization
33523 CABG ART-VEIN SIX OR MORE Tailored Plan Services administered by TurningPoint
Con
Authorization
33530 CORONARY ARTERY BYPASS/REOP Tailored Plan Services administered by TurningPoint
Con
Authorization
33533 CABG ARTERIAL SINGLE Tailored Plan Services administered by TurningPoint
Con
Authorization
33534 CABG ARTERIAL TWO Tailored Plan Services administered by TurningPoint
Con
Authorization
33535 CABG ARTERIAL THREE Tailored Plan Services administered by TurningPoint
Con
Authorization
33536 CABG ARTERIAL FOUR OR MORE Tailored Plan Services administered by TurningPoint
Con
Authorization
33542 REMOVAL OF HEART LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33545 REPAIR OF HEART DAMAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33572 OPEN CORONARY ENDARTERECTOMY Tailored Plan Services administered by TurningPoint
Con
Authorization
33600 CLOSURE OF VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33602 CLOSURE OF VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33606 ANASTOMOSIS/ARTERY-AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33608 REPAIR ANOMALY WITH CONDUIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33610 REPAIR BY ENLARGEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33611 REPAIR DOUBLE VENTRICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33612 REPAIR DOUBLE VENTRICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33615 REPAIR MODIFIED FONTAN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33617 REPAIR SINGLE VENTRICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33619 REPAIR SINGLE VENTRICLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33620 APPLY RANDL PULM ART BANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33621 TRANSTHOR CATH FOR STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33622 REDO COMPL CARDIAC ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33641 REPAIR HEART SEPTUM DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33645 REVISION OF HEART VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33647 REPAIR HEART SEPTUM DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33660 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33665 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33670 REPAIR OF HEART CHAMBERS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33675 CLOSE MULT VSD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33676 CLOSE MULT VSD WITH RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33677 CL MULT VSD WITH REM PUL BAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33681 REPAIR HEART SEPTUM DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33684 REPAIR HEART SEPTUM DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33688 REPAIR HEART SEPTUM DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33690 REINFORCE PULMONARY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33692 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33694 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33697 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33702 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33710 REPAIR OF HEART DEFECTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33720 REPAIR OF HEART DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33724 REPAIR VENOUS ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33726 REPAIR PUL VENOUS STENOSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33730 REPAIR HEART-VEIN DEFECT(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33732 REPAIR HEART-VEIN DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33735 REVISION OF HEART CHAMBER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33736 REVISION OF HEART CHAMBER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33741 TAS CONGENITAL CARDIAC ANOMALIES ANY METHOD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33745 TIS CRTJ ST CONGENITAL CARDIAC ANOMAL 1ST SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33746 TIS CRTJ ST CONGENITAL CARDIAC ANOMAL EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33750 MAJOR VESSEL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33755 MAJOR VESSEL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33762 MAJOR VESSEL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33764 MAJOR VESSEL SHUNT AND GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33766 MAJOR VESSEL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33767 MAJOR VESSEL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33768 CAVOPULMONARY SHUNTING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33770 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33771 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33774 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33775 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33776 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33777 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33778 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33779 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33780 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33781 REPAIR GREAT VESSELS DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33782 NIKAIDOH PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33783 NIKAIDOH PROC WITH OSTIA IMPLT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33786 REPAIR ARTERIAL TRUNK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33788 REVISION OF PULMONARY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33800 AORTIC SUSPENSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33802 REPAIR VESSEL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33803 REPAIR VESSEL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33814 OBLTRJ AORTOPULMONARY SEPTAL DFCT W/CARD BYPASS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33820 REVISE MAJOR VESSEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33822 REVISE MAJOR VESSEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33824 REVISE MAJOR VESSEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33840 REMOVE AORTA CONSTRICTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33845 REMOVE AORTA CONSTRICTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33851 REMOVE AORTA CONSTRICTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33852 REPAIR SEPTAL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33853 REPAIR SEPTAL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33858 AS-AORT GRF W/CARD BYP F/AORTIC DISSECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33859 AS-AORT GRF W/CARD BYP F/AORTIC DS OTH/THN DSJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33863 ASCENDING AORTIC GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33864 ASCENDING AORTIC GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33866 AORTIC HEMIARCH GRAFT WITH ISOL AND CTRL ARCH VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33871 TRANSVRS A-ARCH GRF W/CARD BYP PRFD HYPOTHERMIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33875 THORACIC AORTIC GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33877 THORACOABDOMINAL GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33880 EVASC RPR TA DPLMNT AORT-ARTC TUBE NDGFT COV LSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33881 EVASC RPR TA DPLMNT AORT-ARTC TUB NDGFT XCOV LSA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33882 EVASC RPR TA DPLMNT BRNCHD NDGFT MULTIPIECE SYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33883 DLYD PLMT PROX XTN PROSTH NOT COV LSA ORIGIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33886 DLYD PLMT DSTL XTN PROSTH LVL LSA TO CELIAC ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33894 EVASC ST RPR COARCJ THRC/AA ACRS MAJ SIDE BRNCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33895 EVASC ST RPR COARCJ THRC/AA XCRSG MAJ SIDE BRNCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33897 PERQ TRANSLUMINAL ANGIOPLASTY NATIVE/RECR COA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33900 PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33901 PERQ P-ART REVSC ST 1ST NML NATIVE CONNJ BI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33902 PERQ P-ART REVSC ST 1ST ABNOR CONNJ UNILATERAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33903 PERQ P-ART REVSC ST 1ST ABNORMAL CONNJ BILATERAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33904 PERQ P-ART REVSC ST EA ADDL VSL/SEP LES NM/ABNL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33910 REMOVE LUNG ARTERY EMBOLI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33915 REMOVE LUNG ARTERY EMBOLI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33916 SURGERY OF GREAT VESSEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33917 REPAIR PULMONARY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33920 REPAIR PULMONARY ATRESIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33922 TRANSECT PULMONARY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33924 REMOVE PULMONARY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33925 RPR PUL ART UNIFOCAL WITH O CPB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33926 REPR PUL ART UNIFOCAL WITH CPB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33927 IMPLTJ TOT RPLCMT HRT SYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33928 RMVL AND RPLCMT TOT HRT SYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33929 RMVL RPLCMT HRT SYS F/TRNSPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33930 REMOVAL OF DONOR HEART/LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33933 PREPARE DONOR HEART/LUNG Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
33935 TRANSPLANTATION HEART/LUNG Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
33940 REMOVAL OF DONOR HEART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33944 PREPARE DONOR HEART Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
33945 TRANSPLANTATION OF HEART Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
33946 ECMO/ECLS INITIATION VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33947 ECMO/ECLS INITIATION ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33948 ECMO/ECLS DAILY MGMT-VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33949 ECMO/ECLS DAILY MGMT ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33951 ECMO/ECLS INSJ PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33952 ECMO/ECLS INSJ PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33953 ECMO/ECLS INSJ PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33954 ECMO/ECLS INSJ PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33955 ECMO/ECLS INSJ CTR CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33956 ECMO/ECLS INSJ CTR CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33957 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33958 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33959 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33962 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33963 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33964 ECMO/ECLS REPOS PERPH CNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33965 ECMO/ECLS RMVL PERPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33966 ECMO/ECLS RMVL PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33967 INSERT I-AORT PERCUT DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33968 REMOVE AORTIC ASSIST DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33969 ECMO/ECLS RMVL PERPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33970 AORTIC CIRCULATION ASSIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33971 AORTIC CIRCULATION ASSIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33973 INSERT BALLOON DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33974 REMOVE INTRA-AORTIC BALLOON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33975 IMPLANT VENTRICULAR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33976 IMPLANT VENTRICULAR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33977 REMOVE VENTRICULAR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33978 REMOVE VENTRICULAR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33979 INSERT INTRACORPOREAL DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33980 REMOVE INTRACORPOREAL DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33981 REPLACE VAD PUMP EXT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33982 REPLACE VAD INTRA WITH O BP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33983 REPLACE VAD INTRA WITH BP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33984 ECMO/ECLS RMVL PRPH CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33985 ECMO/ECLS RMVL CTR CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33986 ECMO/ECLS RMVL CTR CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33987 ARTERY EXPOS/GRAFT ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33988 INSERTION OF LEFT HEART VENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33989 REMOVAL OF LEFT HEART VENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33990 INSJ PERQ VAD W/RS AND I L HRT ARTERIAL ACCESS ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33991 INSJ PERQ VAD W/RS AND I L HRT ARTERIAL AND VEN ACCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33992 REMOVAL PERQ LEFT HRT VAD ARTL/ARTL AND VEN SEP INSJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33993 REPOSITIONING PERQ R/L VAD W/IMG GDN SEP INSJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33995 INSJ PERQ VAD W/RS AND I R HEART VENOUS ACCESS ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
33997 REMOVAL PERQ R HEART VAD VENOUS CANNULA SEP INSJ Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
33999 CARDIAC SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
34001 REMOVAL OF ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34051 REMOVAL OF ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34101 REMOVAL OF ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34111 REMOVAL OF ARM ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34151 REMOVAL OF ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34201 REMOVAL OF ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34203 REMOVAL OF LEG ARTERY CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34401 REMOVAL OF VEIN CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34421 REMOVAL OF VEIN CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34451 REMOVAL OF VEIN CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34471 REMOVAL OF VEIN CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34490 REMOVAL OF VEIN CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34501 REPAIR VALVE FEMORAL VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34502 RECONSTRUCT VENA CAVA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34510 TRANSPOSITION OF VEIN VALVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34520 CROSS-OVER VEIN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34530 LEG VEIN FUSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34701 EVASC RPR A-AO NDGFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34702 EVASC RPR A-AO NDGFT RPT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34703 EVASC RPR A-UNILAC NDGFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34704 EVASC RPR A-UNILAC NDGFT RPT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34705 EVAC RPR A-BIILIAC NDGFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34706 EVASC RPR A-BIILIAC RPT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34707 EVASC RPR ILIO-ILIAC NDGFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34708 EVASC RPR ILIO-ILIAC RPT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34709 PLMT XTN PROSTH EVASC RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34710 DLYD PLMT XTN PROSTH 1ST VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34711 DLYD PLMT XTN PROSTH EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34712 TCAT DLVR ENHNCD FIXJ DEV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34713 PERQ ACCESS AND CLSR FEM ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34714 OPN FEM ART EXPOS CNDT CRTJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34715 OPN AX/SUBCLA ART EXPOS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34716 OPN AX/SUBCLA ART EXPOS CNDT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34717 EVASC RPR ILIAC ART TM OF A-ILIAC ART NDGFT UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34718 EVASC RPR ILIAC ART N/A A-ILIAC ART NDGFT UNI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34808 ENDOVAS ILIAC A DEVICE ADDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34812 OPN FEM ART EXPOS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34813 FEMORAL ENDOVAS GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34820 OPN ILIAC ART EXPOS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34830 OPEN AORTIC TUBE PROSTH REPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34831 OPEN AORTOILIAC PROSTH REPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34832 OPEN AORTOFEMOR PROSTH REPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34833 OPN ILAC ART EXPOS CNDT CRTJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34834 OPN BRACH ART EXPOS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34839 PLNNING PT SPEC FENEST GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34841 ENDOVASC VISC AORTA 1 GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34842 ENDOVASC VISC AORTA 2 GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34843 ENDOVASC VISC AORTA 3 GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34844 ENDOVASC VISC AORTA 4 GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34845 VISC AND INFRAREN ABD 1 PROSTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34846 VISC AND INFRAREN ABD 2 PROSTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34847 VISC AND INFRAREN ABD 3 PROSTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
34848 VISC AND INFRAREN ABD 4PLUS PROST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35001 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35002 REPAIR ARTERY RUPTURE NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35005 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35011 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35013 REPAIR ARTERY RUPTURE ARM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35021 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35022 REPAIR ARTERY RUPTURE CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35045 REPAIR DEFECT OF ARM ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35081 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35082 REPAIR ARTERY RUPTURE AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35091 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35092 REPAIR ARTERY RUPTURE AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35102 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35103 REPAIR ARTERY RUPTURE AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35111 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35112 REPAIR ARTERY RUPTURE SPLEEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35121 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35122 REPAIR ARTERY RUPTURE BELLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35131 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35132 REPAIR ARTERY RUPTURE GROIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35141 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35142 REPAIR ARTERY RUPTURE THIGH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35151 REPAIR DEFECT OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35152 REPAIR RUPTD POPLITEAL ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35180 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35182 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35184 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35188 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35189 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35190 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35201 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35206 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35207 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35211 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35216 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35221 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35226 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35231 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35236 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35241 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35246 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35251 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35256 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35261 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35266 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35271 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35276 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35281 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35286 REPAIR BLOOD VESSEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35301 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35302 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35303 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35304 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35305 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35306 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35311 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35321 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35331 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35341 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35351 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35355 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35361 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35363 RECHANNELING OF ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35371 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35372 RECHANNELING OF ARTERY Tailored Plan Services administered by TurningPoint
Con
Authorization
35390 REOPERATION CAROTID ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35400 ANGIOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35500 HARVEST VEIN FOR BYPASS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35501 ART BYP GRFT IPSILAT CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35506 ART BYP GRFT SUBCLAV-CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35508 ART BYP GRFT CAROTID-VERTBRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35509 ART BYP GRFT CONTRAL CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35510 ART BYP GRFT CAROTID-BRCHIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35511 ART BYP GRFT SUBCLAV-SUBCLAV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35512 ART BYP GRFT SUBCLAV-BRCHIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35515 ART BYP GRFT SUBCLAV-VERTBRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35516 ART BYP GRFT SUBCLAV-AXILARY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35518 ART BYP GRFT AXILLARY-AXILRY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35521 ART BYP GRFT AXILL-FEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35522 ART BYP GRFT AXILL-BRACHIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35523 ART BYP GRFT BRCHL-ULNR-RDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35525 ART BYP GRFT BRACHIAL-BRCHL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35526 ART BYP GRFT AOR/CAROT/INNOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35531 ART BYP GRFT AORCEL/AORMESEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35533 ART BYP GRFT AXILL/FEM/FEM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35535 ART BYP GRFT HEPATORENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35536 ART BYP GRFT SPLENORENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35537 ART BYP GRFT AORTOILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35538 ART BYP GRFT AORTOBI-ILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35539 ART BYP GRFT AORTOFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35540 ART BYP GRFT AORTBIFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35556 ART BYP GRFT FEM-POPLITEAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35558 ART BYP GRFT FEM-FEMORAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35560 ART BYP GRFT AORTORENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35563 ART BYP GRFT ILIOILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35565 ART BYP GRFT ILIOFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35566 ART BYP FEM-ANT-POST TIB/PRL Tailored Plan Services administered by TurningPoint
Con
Authorization
35570 ART BYP TIBIAL-TIB/PERONEAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35571 ART BYP POP-TIBL-PRL-OTHER Tailored Plan Services administered by TurningPoint
Con
Authorization
35572 HARVEST FEMOROPOPLITEAL VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35583 VEIN BYP GRFT FEM-POPLITEAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35585 VEIN BYP FEM-TIBIAL PERONEAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35587 VEIN BYP POP-TIBL PERONEAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35600 OPEN HARVEST UPPER EXTREMITY ART 1 SEGMENT CAB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35601 ART BYP COMMON IPSI CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35602 BPG OTH/THN VEIN CAROTID-CONTRALATERAL CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35606 ART BYP CAROTID-SUBCLAVIAN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35612 ART BYP SUBCLAV-SUBCLAVIAN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35616 ART BYP SUBCLAV-AXILLARY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35621 ART BYP AXILLARY-FEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35623 ART BYP AXILLARY-POP-TIBIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35626 ART BYP AORSUBCL/CAROT/INNOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35631 ART BYP AOR-CELIAC-MSN-RENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35632 ART BYP ILIO-CELIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35633 ART BYP ILIO-MESENTERIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35634 ART BYP ILIORENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35636 ART BYP SPENORENAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35637 ART BYP AORTOILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35638 ART BYP AORTOBI-ILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35642 ART BYP CAROTID-VERTEBRAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35645 ART BYP SUBCLAV-VERTEBRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35646 ART BYP AORTOBIFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35647 ART BYP AORTOFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35650 ART BYP AXILLARY-AXILLARY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35654 ART BYP AXILL-FEM-FEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35656 ART BYP FEMORAL-POPLITEAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35661 ART BYP FEMORAL-FEMORAL Tailored Plan Services administered by TurningPoint
Con
Authorization
35663 ART BYP ILIOILIAC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35665 ART BYP ILIOFEMORAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35666 ART BYP FEM-ANT-POST TIB/PRL Tailored Plan Services administered by TurningPoint
Con
Authorization
35671 ART BYP POP-TIBL-PRL-OTHER Tailored Plan Services administered by TurningPoint
Con
Authorization
35681 COMPOSITE BYP GRFT PROSANDVEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35682 COMPOSITE BYP GRFT 2 VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35683 COMPOSITE BYP GRFT 3/> SEGMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35685 BYPASS GRAFT PATENCY/PATCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35686 BYPASS GRAFT/AV FIST PATENCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35691 ART TRNSPOSJ VERTBRL CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35693 ART TRNSPOSJ SUBCLAVIAN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35694 ART TRNSPOSJ SUBCLAV CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35695 ART TRNSPOSJ CAROTID SUBCLAV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35697 REIMPLANT ARTERY EACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35700 REOPERATION BYPASS GRAFT Tailored Plan Services administered by TurningPoint
Con
Authorization
35701 EXPLORATION N/FLWD SURG NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35702 EXPLORATION N/FLWD SURG UPPER EXTREMITY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35703 EXPLORATION N/FLWD SURG LOWER EXTREMITY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35800 EXPLORE NECK VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35820 EXPLORE CHEST VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35840 EXPLORE ABDOMINAL VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35860 EXPLORE LIMB VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35870 REPAIR VESSEL GRAFT DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35875 REMOVAL OF CLOT IN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35876 REMOVAL OF CLOT IN GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35879 REVISE GRAFT WITH VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35881 REVISE GRAFT WITH VEIN Tailored Plan Services administered by TurningPoint
Con
Authorization
35883 REVJ FEM ANAST BPG GRN OPN W/NONAUTOG PATCH GRF Tailored Plan Services administered by TurningPoint
Con
Authorization
35884 REVISE GRAFT WITH VEIN Tailored Plan Services administered by TurningPoint
Con
Authorization
35901 EXCISION GRAFT NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35903 EXCISION GRAFT EXTREMITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35905 EXCISION GRAFT THORAX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
35907 EXCISION GRAFT ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36000 PLACE NEEDLE IN VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36002 PSEUDOANEURYSM INJECTION TRT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36005 INJECTION EXT VENOGRAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36010 PLACE CATHETER IN VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36011 PLACE CATHETER IN VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36012 PLACE CATHETER IN VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36013 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36014 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36015 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36100 ESTABLISH ACCESS TO ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36140 INTRO NDL ICATH UPR/LXTR ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36160 ESTABLISH ACCESS TO AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36200 PLACE CATHETER IN AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36215 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36216 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36217 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36218 PLACE CATHETER IN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36221 PLACE CATH THORACIC AORTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36222 PLACE CATH CAROTID/INOM ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36223 PLACE CATH CAROTID/INOM ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36224 PLACE CATH CAROTD ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36225 PLACE CATH SUBCLAVIAN ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36226 PLACE CATH VERTEBRAL ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36227 PLACE CATH XTRNL CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36228 PLACE CATH INTRACRANIAL ART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36245 INS CATH ABD/L-EXT ART 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36246 INS CATH ABD/L-EXT ART 2ND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36247 INS CATH ABD/L-EXT ART 3RD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36248 INS CATH ABD/L-EXT ART ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36251 INS CATH REN ART 1ST UNILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36252 INS CATH REN ART 1ST BILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36253 INS CATH REN ART 2NDPLUS UNILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36254 INS CATH REN ART 2NDPLUS BILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36260 INSERTION OF INFUSION PUMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36261 REVISION OF INFUSION PUMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36262 REMOVAL OF INFUSION PUMP Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
36299 VESSEL INJECTION PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
36400 BL DRAW < 3 YRS FEM/JUGULAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36405 BL DRAW <3 YRS SCALP VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36406 BL DRAW <3 YRS OTHER VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36410 NON-ROUTINE BL DRAW 3/> YRS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36415 ROUTINE VENIPUNCTURE Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
36420 VEIN ACCESS CUTDOWN < 1 YR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36425 VEIN ACCESS CUTDOWN > 1 YR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36430 BLOOD TRANSFUSION SERVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36440 BL PUSH TRANSFUSE 2 YR/< Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36450 BL EXCHANGE/TRANSFUSE NB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36455 BL EXCHANGE/TRANSFUSE NON-NB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36456 PRTL EXCHANGE TRANSFUSE BLOOD/PLSM/CRYST NEWBORN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36460 TRANSFUSION SERVICE FETAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
36465 NJX NONCMPND SCLRSNT 1 VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36466 NJX NONCMPND SCLRSNT MLT VN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36470 NJX SCLRSNT 1 INCMPTNT VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36471 NJX SCLRSNT MLT INCMPTNT VN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
36473 ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36474 ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM SBSQ VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
36475 ENDOVENOUS RF 1ST VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36476 ENDOVENOUS RF VEIN ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36478 ENDOVENOUS LASER 1ST VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
36479 ENDOVENOUS LASER VEIN ADDON Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
36481 INSERTION OF CATHETER VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36500 INSERTION OF CATHETER VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36510 INSERTION OF CATHETER VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36511 APHERESIS WBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36512 APHERESIS RBC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36513 APHERESIS PLATELETS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36514 APHERESIS PLASMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36516 APHERESIS IMMUNOADS SLCTV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36522 PHOTOPHERESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36555 INSERT NON-TUNNEL CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36556 INSERT NON-TUNNEL CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36557 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36558 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36560 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36561 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36563 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36565 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36566 INSERT TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36568 INSERTION PICC WITH O IMG GDN < 5 YR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36569 INSERTION PICC WITH O IMG GDN 5 YR/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36570 INSERT PICVAD CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36571 INSERT PICVAD CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36572 INSERTION PICC WITH RS AND I < 5 YR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36573 INSERTION PICC WITH RS AND I 5 YR/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36575 REPAIR TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36576 REPAIR TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36578 REPLACE TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36580 REPLACE CVAD CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36581 REPLACE TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36582 REPLACE TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36583 REPLACE TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36584 COMPLETE REPLACEMENT PICC R S AND I Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36585 REPLACE PICVAD CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36589 REMOVAL TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36590 REMOVAL TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36591 DRAW BLOOD OFF VENOUS DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36592 COLLECT BLOOD FROM PICC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36593 DECLOT VASCULAR DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36595 MECH REMOV TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36596 MECH REMOV TUNNELED CV CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36597 REPOSITION VENOUS CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36598 INJ WITH FLUOR EVAL CV DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36600 WITHDRAWAL OF ARTERIAL BLOOD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36620 INSERTION CATHETER ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36625 INSERTION CATHETER ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36640 INSERTION CATHETER ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36660 INSERTION CATHETER ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36680 INSERT NEEDLE BONE CAVITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36800 INSERTION OF CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36810 INSERTION OF CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36815 INSERTION OF CANNULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36818 AV FUSE UPPR ARM CEPHALIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36819 AV FUSE UPPR ARM BASILIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36820 AV FUSION/FOREARM VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36821 AV FUSION DIRECT ANY SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36823 INSERTION OF CANNULA(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36825 ARTERY-VEIN AUTOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36830 ARTERY-VEIN NONAUTOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36831 OPEN THROMBECT AV FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36832 AV FISTULA REVISION OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36833 AV FISTULA REVISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36835 ARTERY TO VEIN SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36836 PERQ AV FISTULA CREATION UXTR SINGLE ACCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36837 PERQ AV FISTULA CREATION UXTR SEP ACCESS SITES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36838 DIST REVAS LIGATION HEMO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36860 EXTERNAL CANNULA DECLOTTING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36861 CANNULA DECLOTTING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36901 INTRO CATH DIALYSIS CIRCUIT DX ANGRPH FLUOR SANDI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36902 INTRO CATH DIALYSIS CIRCUIT WITH TRLUML BALO ANGIOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36903 INTRO CATH DIALYSIS CIRCUIT WITH TCAT PLMT IV STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36904 PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36905 PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36906 PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36907 TRLUML BALO ANGIOP CTR DIALYSIS SEG WITH IMG SANDI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36908 STENT PLMT CTR DIALYSIS SEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
36909 DIALYIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG SANDI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37140 REVISION OF CIRCULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37145 REVISION OF CIRCULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37160 REVISION OF CIRCULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37180 REVISION OF CIRCULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37181 SPLICE SPLEEN/KIDNEY VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37182 INSERT HEPATIC SHUNT (TIPS) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37183 REMOVE HEPATIC SHUNT (TIPS) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37184 PRIM ART M-THRMBC 1ST VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37185 PRIM ART M-THRMBC SBSQ VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37186 SEC ART THROMBECTOMY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37187 VENOUS MECH THROMBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37188 VENOUS M-THROMBECTOMY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37191 INS ENDOVAS VENA CAVA FILTR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37192 REDO ENDOVAS VENA CAVA FILTR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37193 REM ENDOVAS VENA CAVA FILTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37195 THROMBOLYTIC THERAPY STROKE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37197 REMOVE INTRVAS FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37200 TRANSCATHETER BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37211 THROMBOLYTIC ART THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37212 THROMBOLYTIC VENOUS THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37213 THROMBLYTIC ART/VEN THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37214 CESSJ THERAPY CATH REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37215 TRANSCATH STENT CCA WITH EPS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37216 TRANSCATH STENT CCA WITH O EPS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37217 STENT PLACEMT RETRO CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37218 STENT PLACEMT ANTE CAROTID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37236 OPEN/PERQ PLACE STENT 1ST Tailored Plan Services administered by TurningPoint
Con
Authorization
37237 OPEN/PERQ PLACE STENT EA ADD Tailored Plan Services administered by TurningPoint
Con
Authorization
37238 OPEN/PERQ PLACE STENT SAME Tailored Plan Services administered by TurningPoint
Con
Authorization
37239 OPEN/PERQ PLACE STENT EA ADD Tailored Plan Services administered by TurningPoint
Con
Authorization
37241 VASC EMBOLIZE/OCCLUDE VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37242 VASC EMBOLIZE/OCCLUDE ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
37243 VASC EMBOLIZE/OCCLUDE ORGAN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
37244 VASC EMBOLIZE/OCCLUDE BLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37246 TRLML BALO ANGIOP OPEN/PERQ IMG SANDI 1ST ART Tailored Plan Services administered by TurningPoint
Con
Authorization
37247 TRLML BALO ANGIOP OPEN/PERQ IMG SANDI EA ADDL ART Tailored Plan Services administered by TurningPoint
Con
Authorization
37248 TRLML BALO ANGIOP OPEN/PERQ WITH IMG SANDI 1ST VEIN Tailored Plan Services administered by TurningPoint
Con
Authorization
37249 TRLML BALO ANGIOP OPEN/PERQ WITH IMG SANDI ADDL VEIN Tailored Plan Services administered by TurningPoint
Con
Authorization
37252 INTRVASC US NONCORONARY 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37253 INTRVASC US NONCORONARY ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37254 REVSC EVASC IVT ANGIOP UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37255 REVSC EVASC IVT ANGIOP UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37256 REVSC EVASC IVT ANGIOP UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37257 REVSC EVASC IVT ANGIOP UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37258 REVSC EVASC IVT ST PLMT UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37259 REVSC EVASC IVT ST PLMT UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37260 REVSC EVASC IVT ST PLMT UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37261 REVSC EVASC IVT ST PLMT UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37263 REVSC EVASC FPVT ANGIOP UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37264 REVSC EVASC FPVT ANGIOP UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37265 REVSC EVASC FPVT ANGIOP UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37266 REVSC EVASC FPVT ANGIOP UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37267 REVSC EVASC FPVT ST PLMT UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37268 REVSC EVASC FPVT ST PLMT UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37269 REVSC EVASC FPVT ST PLMT UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37270 REVSC EVASC FPVT ST PLMT UNI CPLX LES EA ADD VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37271 REVSC EVASC FPVT ATHRC UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37272 REVSC EVASC FPVT ATHRC UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37273 REVSC EVASC FPVT ATHRC UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37274 REVSC EVASC FPVT ATHRC UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37275 REVSC EVASC FPVT ST ATHRC UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37276 REVSC EVASC FPVT ST ATHRC UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37277 REVSC EVASC FPVT ST ATHRC UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37278 REVSC EVSC FPVT ST ATHRC UNI CPLX LES EA ADD VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37280 REVSC EVASC TPVT ANGIOP UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37281 REVSC EVASC TPVT ANGIOP UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37282 REVSC EVASC TPVT ANGIOP UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37283 REVSC EVASC TPVT ANGIOP UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37284 REVSC EVASC TPVT ST PLMT UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37285 REVSC EVASC TPVT ST PLMT UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37286 REVSC EVASC TPVT ST PLMT UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37287 REVSC EVASC TPVT ST PLMT UNI CPLX LES EA ADD VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37288 REVSC EVASC TPVT ATHRC UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37289 REVSC EVASC TPVT ATHRC UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37290 REVSC EVASC TPVT ATHRC UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37291 REVSC EVASC TPVT ATHRC UNI CPLX LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37292 REVSC EVASC TPVT ST ATHRC UNI SF LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37293 REVSC EVASC TPVT ST ATHRC UNI SF LES EA ADDL VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37294 REVSC EVASC TPVT ST ATHRC UNI CPLX LES 1ST VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37295 REVSC EVSC TPVT ST ATHRC UNI CPLX LES EA ADD VSL Tailored Plan Services administered by TurningPoint
Con
Authorization
37296 REVSC EVASC IMVT ANGIOP UNI SF LES 1ST VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37297 REVSC EVASC IMVT ANGIOP UNI SF LES EA ADDL VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37298 REVSC EVASC IMVT ANGIOP UNI CPLX LES 1ST VSL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37299 REVSC EVASC IMVT ANGIOP UNI CPLX LES EA ADDL VSL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
37501 VASCULAR ENDOSCOPY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
37565 LIGATION OF NECK VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37600 LIGATION OF NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37605 LIGATION OF NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37606 LIGATION OF NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37607 LIGATION OF A-V FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37609 TEMPORAL ARTERY PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37615 LIGATION OF NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37616 LIGATION OF CHEST ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37617 LIGATION OF ABDOMEN ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37618 LIGATION OF EXTREMITY ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37619 LIGATION OF INFERIOR VENA CAVA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37650 REVISION OF MAJOR VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37660 REVISION OF MAJOR VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
37700 REVISE LEG VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37718 LIGATE/STRIP SHORT LEG VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37722 LIGATE/STRIP LONG LEG VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37735 REMOVAL OF LEG VEINS/LESION Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37760 LIGATE LEG VEINS RADICAL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37761 LIGATE LEG VEINS OPEN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37765 STAB PHLEB VEINS XTR 10-20 Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37766 PHLEB VEINS MINUS EXTREM 20PLUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37780 REVISION OF LEG VEIN Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
37785 LIGATE/DIVIDE/EXCISE VEIN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
37788 REVASCULARIZATION PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
37790 PENILE VENOUS OCCLUSION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
37799 VASCULAR SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
38100 REMOVAL OF SPLEEN TOTAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38101 REMOVAL OF SPLEEN PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38102 REMOVAL OF SPLEEN TOTAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38115 REPAIR OF RUPTURED SPLEEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38120 LAPAROSCOPY SPLENECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
38129 LAPAROSCOPE PROC SPLEEN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
38200 INJECTION FOR SPLEEN X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38204 BL DONOR SEARCH MANAGEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38205 HARVEST ALLOGENEIC STEM CELL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38206 HARVEST AUTO STEM CELLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38207 CRYOPRESERVE STEM CELLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38208 THAW PRESERVED STEM CELLS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
38209 WASH HARVEST STEM CELLS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
38210 T-CELL DEPLETION OF HARVEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38212 RBC DEPLETION OF HARVEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38213 PLATELET DEPLETE OF HARVEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38214 VOLUME DEPLETE OF HARVEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38215 HARVEST STEM CELL CONCENTRTE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38220 DX BONE MARROW ASPIRATIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38221 DX BONE MARROW BIOPSIES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38222 DX BONE MARROW BX AND ASPIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38230 BONE MARROW HARVEST ALLOGEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38232 BONE MARROW HARVEST AUTOLOG Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
38240 TRANSPLT ALLO HCT/DONOR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
38241 TRANSPLT AUTOL HCT/DONOR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
38242 TRANSPLT ALLO LYMPHOCYTES Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
38243 TRANSPLJ HEMATOPOIETIC BOOST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38300 DRAINAGE LYMPH NODE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38305 DRAINAGE LYMPH NODE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38308 INCISION OF LYMPH CHANNELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38380 THORACIC DUCT PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38381 THORACIC DUCT PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38382 THORACIC DUCT PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38500 BIOPSY/REMOVAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38505 NEEDLE BIOPSY LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38510 BIOPSY/REMOVAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38520 BIOPSY/REMOVAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38525 BIOPSY/REMOVAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38530 BIOPSY/REMOVAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38531 OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38542 EXPLORE DEEP NODE(S) NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38550 REMOVAL NECK/ARMPIT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38555 REMOVAL NECK/ARMPIT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38562 REMOVAL PELVIC LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38564 REMOVAL ABDOMEN LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38570 LAPAROSCOPY LYMPH NODE BIOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38571 LAPAROSCOPY LYMPHADENECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38572 LAPAROSCOPY LYMPHADENECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38573 LAPS PELVIC LYMPHADEC Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
38589 LAPAROSCOPE PROC LYMPHATIC Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
38700 REMOVAL OF LYMPH NODES NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38720 REMOVAL OF LYMPH NODES NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38724 REMOVAL OF LYMPH NODES NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38740 REMOVE ARMPIT LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38745 REMOVE ARMPIT LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38746 REMOVE THORACIC LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38747 REMOVE ABDOMINAL LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38760 REMOVE GROIN LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38765 REMOVE GROIN LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38770 REMOVE PELVIS LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38780 REMOVE ABDOMEN LYMPH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38790 INJECT FOR LYMPHATIC X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38792 RA TRACER ID OF SENTINL NODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38794 ACCESS THORACIC LYMPH DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
38900 IO MAP OF SENT LYMPH NODE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
38999 BLOOD/LYMPH SYSTEM PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
39000 EXPLORATION OF CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39010 EXPLORATION OF CHEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39200 RESECT MEDIASTINAL CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39220 RESECT MEDIASTINAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39401 MEDIASTINOSCPY WITH MEDSTNL BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39402 MEDIASTINOSCPY WITH LMPH NOD BX Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
39499 CHEST PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
39501 REPAIR DIAPHRAGM LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39503 REPAIR OF DIAPHRAGM HERNIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39540 REPAIR OF DIAPHRAGM HERNIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39541 REPAIR OF DIAPHRAGM HERNIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39545 REVISION OF DIAPHRAGM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39560 RESECT DIAPHRAGM SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
39561 RESECT DIAPHRAGM COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
39599 DIAPHRAGM SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
40490 BIOPSY OF LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40500 PARTIAL EXCISION OF LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40510 PARTIAL EXCISION OF LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40520 PARTIAL EXCISION OF LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40525 RECONSTRUCT LIP WITH FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40527 RECONSTRUCT LIP WITH FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40530 PARTIAL REMOVAL OF LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40650 REPAIR LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40652 REPAIR LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40654 REPAIR LIP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40700 REPAIR CLEFT LIP/NASAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40701 REPAIR CLEFT LIP/NASAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40702 REPAIR CLEFT LIP/NASAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40720 REPAIR CLEFT LIP/NASAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40761 REPAIR CLEFT LIP/NASAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
40799 LIP SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
40800 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40801 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40804 REMOVAL FOREIGN BODY MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40805 REMOVAL FOREIGN BODY MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40806 INCISION OF LIP FOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40808 BIOPSY OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40810 EXCISION OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40812 EXCISE/REPAIR MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40814 EXCISE/REPAIR MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40816 EXCISION OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40818 EXCISE ORAL MUCOSA FOR GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40819 EXCISE LIP OR CHEEK FOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40820 TREATMENT OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40830 REPAIR MOUTH LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40831 REPAIR MOUTH LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40840 RECONSTRUCTION OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40842 RECONSTRUCTION OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40843 RECONSTRUCTION OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40844 RECONSTRUCTION OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
40845 RECONSTRUCTION OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
40899 MOUTH SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
41000 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41005 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41006 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41007 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41008 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41009 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41010 INCISION OF TONGUE FOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41015 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41016 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41017 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41018 DRAINAGE OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41019 PLACE NEEDLES HANDN FOR RT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41100 BIOPSY OF TONGUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41105 BIOPSY OF TONGUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41108 BIOPSY OF FLOOR OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41110 EXCISION OF TONGUE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41112 EXCISION OF TONGUE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41113 EXCISION OF TONGUE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41114 EXCISION OF TONGUE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41115 EXCISION OF TONGUE FOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41116 EXCISION OF MOUTH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41120 PARTIAL REMOVAL OF TONGUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41130 PARTIAL REMOVAL OF TONGUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41135 TONGUE AND NECK SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41140 REMOVAL OF TONGUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41145 TONGUE REMOVAL NECK SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41150 TONGUE MOUTH JAW SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41153 TONGUE MOUTH NECK SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41155 TONGUE JAW AND NECK SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41250 REPAIR TONGUE LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41251 REPAIR TONGUE LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41252 REPAIR TONGUE LACERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41510 TONGUE TO LIP SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41512 TONGUE SUSPENSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41520 RECONSTRUCTION TONGUE FOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41530 TONGUE BASE VOL REDUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
41599 TONGUE AND MOUTH SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
41800 DRAINAGE OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41805 REMOVAL FOREIGN BODY GUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41806 REMOVAL FOREIGN BODY JAWBONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41820 EXCISION GUM EACH QUADRANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41821 EXCISION OF GUM FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41822 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41823 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41825 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41826 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41827 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41828 EXCISION OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41830 REMOVAL OF GUM TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41850 TREATMENT OF GUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41870 GUM GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41872 REPAIR GUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41874 REPAIR TOOTH SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
41899 DENTAL SURGERY PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42000 DRAINAGE MOUTH ROOF LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42100 BIOPSY ROOF OF MOUTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42104 EXCISION LESION MOUTH ROOF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42106 EXCISION LESION MOUTH ROOF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42107 EXCISION LESION MOUTH ROOF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42120 REMOVE PALATE/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42140 EXCISION OF UVULA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
42145 REPAIR PALATE PHARYNX/UVULA Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
42160 TREATMENT MOUTH ROOF LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42180 REPAIR PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42182 REPAIR PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42200 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42205 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42210 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42215 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42220 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42225 RECONSTRUCT CLEFT PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42226 LENGTHENING OF PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42227 LENGTHENING OF PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42235 REPAIR PALATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42260 REPAIR NOSE TO LIP FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42280 PREPARATION PALATE MOLD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42281 INSERTION PALATE PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
42299 PALATE/UVULA SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
42300 DRAINAGE OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42305 DRAINAGE OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42310 DRAINAGE OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42320 DRAINAGE OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42330 REMOVAL OF SALIVARY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42335 REMOVAL OF SALIVARY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42340 REMOVAL OF SALIVARY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42400 BIOPSY OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42405 BIOPSY OF SALIVARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42408 EXCISION OF SALIVARY CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42409 DRAINAGE OF SALIVARY CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42410 EXCISE PAROTID GLAND/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42415 EXCISE PAROTID GLAND/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42420 EXCISE PAROTID GLAND/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42425 EXCISE PAROTID GLAND/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42426 EXCISE PAROTID GLAND/LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42440 EXCISE SUBMAXILLARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42450 EXCISE SUBLINGUAL GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42500 REPAIR SALIVARY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42505 REPAIR SALIVARY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42507 PAROTID DUCT DIVERSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42509 PAROTID DUCT DIVERSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42510 PAROTID DUCT DIVERSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42550 INJECTION FOR SALIVARY X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42600 CLOSURE OF SALIVARY FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42650 DILATION OF SALIVARY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42660 DILATION OF SALIVARY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42665 LIGATION OF SALIVARY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
42699 SALIVARY SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
42700 DRAINAGE OF TONSIL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42720 DRAINAGE OF THROAT ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42725 DRAINAGE OF THROAT ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42800 BIOPSY OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42804 BIOPSY OF UPPER NOSE/THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42806 BIOPSY OF UPPER NOSE/THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42808 EXCISE PHARYNX LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42809 REMOVE PHARYNX FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42810 EXCISION OF NECK CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42815 EXCISION OF NECK CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42820 REMOVE TONSILS AND ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42821 REMOVE TONSILS AND ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42825 REMOVAL OF TONSILS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42826 REMOVAL OF TONSILS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42830 REMOVAL OF ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42831 REMOVAL OF ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42835 REMOVAL OF ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42836 REMOVAL OF ADENOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42842 EXTENSIVE SURGERY OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42844 EXTENSIVE SURGERY OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42845 EXTENSIVE SURGERY OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42860 EXCISION OF TONSIL TAGS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42870 EXCISION OF LINGUAL TONSIL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42890 PARTIAL REMOVAL OF PHARYNX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42892 REVISION OF PHARYNGEAL WALLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42894 REVISION OF PHARYNGEAL WALLS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42900 REPAIR THROAT WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42950 RECONSTRUCTION OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42953 REPAIR THROAT ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42955 SURGICAL OPENING OF THROAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42960 CONTROL THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42961 CONTROL THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42962 CONTROL THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42970 CONTROL NOSE/THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42971 CONTROL NOSE/THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
42972 CONTROL NOSE/THROAT BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
42975 DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
42999 THROAT SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43020 INCISION OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43030 THROAT MUSCLE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43045 INCISION OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43100 EXCISION OF ESOPHAGUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43101 EXCISION OF ESOPHAGUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43107 REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43108 REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43112 ESPHG TOT WITH THRCM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43113 REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43116 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43117 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43118 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43121 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43122 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43123 PARTIAL REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43124 REMOVAL OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43130 REMOVAL OF ESOPHAGUS POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43135 REMOVAL OF ESOPHAGUS POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43180 ESOPHAGOSCOPY RIGID TRNSO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43191 ESOPHAGOSCOPY RIGID TRNSO DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43192 ESOPHAGOSCP RIG TRNSO INJECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43193 ESOPHAGOSCP RIG TRNSO BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43194 ESOPHAGOSCP RIG TRNSO REM FB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43195 ESOPHAGOSCOPY RIGID BALLOON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43196 ESOPHAGOSCP GUIDE WIRE DILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43197 ESOPHAGOSCOPY FLEX DX BRUSH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43198 ESOPHAGOSC FLEX TRNSN BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43200 ESOPHAGOSCOPY FLEXIBLE BRUSH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43201 ESOPH SCOPE WITH SUBMUCOUS INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43202 ESOPHAGOSCOPY FLEX BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43204 ESOPH SCOPE WITH SCLEROSIS INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43205 ESOPHAGUS ENDOSCOPY/LIGATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43206 ESOPH OPTICAL ENDOMICROSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43210 EGD ESOPHAGOGASTRC FNDOPLSTY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43211 ESOPHAGOSCOP MUCOSAL RESECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43212 ESOPHAGOSCOP STENT PLACEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43213 ESOPHAGOSCOPY RETRO BALLOON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43214 ESOPHAGOSC DILATE BALLOON 30 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43215 ESOPHAGOSCOPY FLEX REMOVE FB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43216 ESOPHAGOSCOPY LESION REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43217 ESOPHAGOSCOPY SNARE LES REMV Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43220 ESOPHAGOSCOPY BALLOON <30MM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43226 ESOPH ENDOSCOPY DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43227 ESOPHAGOSCOPY CONTROL BLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43229 ESOPHAGOSCOPY LESION ABLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43231 ESOPHAGOSCOP ULTRASOUND EXAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43232 ESOPHAGOSCOPY WITH US NEEDLE BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43233 EGD BALLOON DIL ESOPH30 MM/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43235 EGD DIAGNOSTIC BRUSH WASH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43236 UPPR GI SCOPE WITH SUBMUC INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43237 ENDOSCOPIC US EXAM ESOPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43238 EGD US FINE NEEDLE BX/ASPIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43239 EGD BIOPSY SINGLE/MULTIPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43240 EGD WITH TRANSMURAL DRAIN CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43241 EGD TUBE/CATH INSERTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43242 EGD US FINE NEEDLE BX/ASPIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43243 EGD INJECTION VARICES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43244 EGD VARICES LIGATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43245 EGD DILATE STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43246 EGD PLACE GASTROSTOMY TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43247 EGD REMOVE FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43248 EGD GUIDE WIRE INSERTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43249 ESOPH EGD DILATION <30 MM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43250 EGD CAUTERY TUMOR POLYP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43251 EGD REMOVE LESION SNARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43252 EGD OPTICAL ENDOMICROSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43253 EGD US TRANSMURAL INJXN/MARK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43254 EGD ENDO MUCOSAL RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43255 EGD CONTROL BLEEDING ANY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43257 EGD WITH THRML TXMNT GERD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43259 EGD US EXAM DUODENUM/JEJUNUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43260 ERCP WITH SPECIMEN COLLECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43261 ENDO CHOLANGIOPANCREATOGRAPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43262 ENDO CHOLANGIOPANCREATOGRAPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43263 ERCP SPHINCTER PRESSURE MEAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43264 ERCP REMOVE DUCT CALCULI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43265 ERCP LITHOTRIPSY CALCULI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43266 EGD ENDOSCOPIC STENT PLACE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43270 EGD LESION ABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43273 ENDOSCOPIC PANCREATOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43274 ERCP DUCT STENT PLACEMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43275 ERCP REMOVE FORGN BODY DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43276 ERCP STENT EXCHANGE WITH DILATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43277 ERCP EA DUCT/AMPULLA DILATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43278 ERCP LESION ABLATE WITH DILATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43279 LAP MYOTOMY HELLER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43280 LAPAROSCOPY FUNDOPLASTY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43281 LAP PARAESOPHAG HERN REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43282 LAP PARAESOPH HER RPR WITH MESH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43283 LAP ESOPH LENGTHENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43284 LAPS ESOPHGL SPHNCTR AGMNTJ PLMT DEV CRRPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43285 REMOVAL ESOPHAGEAL SPHINCTER AGMNTJ DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43286 ESPHG TOT WITH LAPS MOBLJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43287 ESPHG DSTL 2/3 WITH LAPS MOBLJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43288 ESPHG THRSC MOBLJ Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43289 LAPAROSCOPE PROC ESOPH Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43300 REPAIR OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43305 REPAIR ESOPHAGUS AND FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43310 REPAIR OF ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43312 REPAIR ESOPHAGUS AND FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43313 ESOPHAGOPLASTY CONGENITAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43314 TRACHEO-ESOPHAGOPLASTY CONG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43320 FUSE ESOPHAGUS AND STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43325 REVISE ESOPHAGUS AND STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43327 ESOPH FUNDOPLASTY LAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43328 ESOPH FUNDOPLASTY THOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43330 ESOPHAGOMYOTOMY ABDOMINAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43331 ESOPHAGOMYOTOMY THORACIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43332 TRANSAB ESOPH HIAT HERN RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43333 TRANSAB ESOPH HIAT HERN RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43334 TRANSTHOR DIAPHRAG HERN RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43335 TRANSTHOR DIAPHRAG HERN RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43336 THORABD DIAPHR HERN REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43337 THORABD DIAPHR HERN REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43338 ESOPH LENGTHENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43340 FUSE ESOPHAGUS AND INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43341 FUSE ESOPHAGUS AND INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43351 SURGICAL OPENING ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43352 SURGICAL OPENING ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43360 GASTROINTESTINAL REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43361 GASTROINTESTINAL REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43400 LIGATE ESOPHAGUS VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43405 LIGATE/STAPLE ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43410 REPAIR ESOPHAGUS WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43415 REPAIR ESOPHAGUS WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43420 REPAIR ESOPHAGUS OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43425 REPAIR ESOPHAGUS OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43450 DILATE ESOPHAGUS 1/MULT PASS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43453 DILATE ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43460 PRESSURE TREATMENT ESOPHAGUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43496 FREE JEJUNUM FLAP MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43497 TRANSORAL LOWER ESOPHAGEAL MYOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43499 ESOPHAGUS SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43500 SURGICAL OPENING OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43501 SURGICAL REPAIR OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43502 SURGICAL REPAIR OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43510 SURGICAL OPENING OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43520 INCISION OF PYLORIC MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43605 BIOPSY OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43610 EXCISION OF STOMACH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43611 EXCISION OF STOMACH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43620 REMOVAL OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43621 REMOVAL OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43622 REMOVAL OF STOMACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43631 REMOVAL OF STOMACH PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43632 REMOVAL OF STOMACH PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43633 REMOVAL OF STOMACH PARTIAL Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43634 REMOVAL OF STOMACH PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43635 REMOVAL OF STOMACH PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43640 VAGOTOMY AND PYLORUS REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43641 VAGOTOMY AND PYLORUS REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43644 LAP GASTRIC BYPASS/ROUX-EN-Y Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43645 LAP GASTR BYPASS INCL SMLL I Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43648 LAP REVISE/REMV ELTRD ANTRUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43651 LAPAROSCOPY VAGUS NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43652 LAPAROSCOPY VAGUS NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43653 LAPAROSCOPY GASTROSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43659 LAPAROSCOPE PROC STOM Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43752 NASAL/OROGASTRIC WITH TUBE PLMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43753 TX GASTRO INTUB WITH ASP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43754 DX GASTR INTUB WITH ASP SPEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43755 DX GASTR INTUB WITH ASP SPECS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43756 DX DUOD INTUB WITH ASP SPEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43757 DX DUOD INTUB WITH ASP SPECS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43761 REPOSITION GASTROSTOMY TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43762 PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43763 PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43770 LAP PLACE GASTR ADJ DEVICE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43771 LAP REVISE GASTR ADJ DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43772 LAP RMVL GASTR ADJ DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43773 LAP REPLACE GASTR ADJ DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43774 LAP RMVL GASTR ADJ ALL PARTS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43775 LAP SLEEVE GASTRECTOMY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43800 RECONSTRUCTION OF PYLORUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43810 FUSION OF STOMACH AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43820 FUSION OF STOMACH AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43825 FUSION OF STOMACH AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43830 PLACE GASTROSTOMY TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43831 PLACE GASTROSTOMY TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43832 PLACE GASTROSTOMY TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43840 REPAIR OF STOMACH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43842 V-BAND GASTROPLASTY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43843 GASTROPLASTY WITH O V-BAND Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43845 GASTROPLASTY DUODENAL SWITCH Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43846 GASTRIC BYPASS FOR OBESITY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43847 GASTRIC BYPASS INCL SMALL I Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
43848 REVISION GASTROPLASTY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
43860 REVISE STOMACH-BOWEL FUSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43865 REVISE STOMACH-BOWEL FUSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43870 REPAIR STOMACH OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43880 REPAIR STOMACH-BOWEL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43882 REVISE/REMOVE ELECTRD ANTRUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43886 REVISE GASTRIC PORT OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43887 REMOVE GASTRIC PORT OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
43888 CHANGE GASTRIC PORT OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
43999 STOMACH SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
44005 FREEING OF BOWEL ADHESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44010 INCISION OF SMALL BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44015 INSERT NEEDLE CATH BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44020 EXPLORE SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44021 DECOMPRESS SMALL BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44025 INCISION OF LARGE BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44050 REDUCE BOWEL OBSTRUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44055 CORRECT MALROTATION OF BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44100 BIOPSY OF BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44110 EXCISE INTESTINE LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44111 EXCISION OF BOWEL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44120 REMOVAL OF SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44121 REMOVAL OF SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44125 REMOVAL OF SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44126 ENTERECTOMY WITH O TAPER CONG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44127 ENTERECTOMY WITH TAPER CONG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44128 ENTERECTOMY CONG ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44130 BOWEL TO BOWEL FUSION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
44132 ENTERECTOMY CADAVER DONOR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
44135 INTESTINE TRANSPLNT CADAVER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
44139 MOBILIZATION OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44140 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44141 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44143 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44144 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44145 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44146 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44147 PARTIAL REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44150 REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44151 REMOVAL OF COLON/ILEOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44155 REMOVAL OF COLON/ILEOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44156 REMOVAL OF COLON/ILEOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44157 COLECTOMY WITH ILEOANAL ANAST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44158 COLECTOMY WITH NEO-RECTUM POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44160 REMOVAL OF COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44180 LAP ENTEROLYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44186 LAP JEJUNOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44187 LAP ILEO/JEJUNO-STOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44188 LAP COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44202 LAP ENTERECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44203 LAP RESECT S/INTESTINE ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44204 LAPARO PARTIAL COLECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44205 LAP COLECTOMY PART WITH ILEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44206 LAP PART COLECTOMY WITH STOMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44207 L COLECTOMY/COLOPROCTOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44208 L COLECTOMY/COLOPROCTOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44210 LAPARO TOTAL PROCTOCOLECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44211 LAP COLECTOMY WITH PROCTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44212 LAPARO TOTAL PROCTOCOLECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44213 LAP MOBIL SPLENIC FL ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44227 LAP CLOSE ENTEROSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
44238 LAPAROSCOPE PROC INTESTINE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
44300 OPEN BOWEL TO SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44310 ILEOSTOMY/JEJUNOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44312 REVISION OF ILEOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44314 REVISION OF ILEOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44316 DEVISE BOWEL POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44320 COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44322 COLOSTOMY WITH BIOPSIES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44340 REVISION OF COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44345 REVISION OF COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44346 REVISION OF COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44360 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44361 SMALL BOWEL ENDOSCOPY/BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44363 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44364 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44365 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44366 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44369 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44370 SMALL BOWEL ENDOSCOPY/STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44372 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44373 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44376 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44377 SMALL BOWEL ENDOSCOPY/BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44378 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44379 S BOWEL ENDOSCOPE WITH STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44380 SMALL BOWEL ENDOSCOPY BR/WA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44381 SMALL BOWEL ENDOSCOPY BR/WA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44382 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44384 SMALL BOWEL ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44385 ENDOSCOPY OF BOWEL POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44386 ENDOSCOPY BOWEL POUCH/BIOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44388 COLONOSCOPY THRU STOMA SPX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44389 COLONOSCOPY WITH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44390 COLONOSCOPY FOR FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44391 COLONOSCOPY FOR BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44392 COLONOSCOPY AND POLYPECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44394 COLONOSCOPY WITH SNARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44401 COLONOSCOPY WITH ABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44402 COLONOSCOPY WITH STENT PLCMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44403 COLONOSCOPY WITH RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44404 COLONOSCOPY WITH INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44405 COLONOSCOPY WITH DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44406 COLONOSCOPY WITH ULTRASOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44407 COLONOSCOPY WITH NDL ASPIR/BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44408 COLONOSCOPY WITH DECOMPRESSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44500 INTRO GASTROINTESTINAL TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44602 SUTURE SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44603 SUTURE SMALL INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44604 SUTURE LARGE INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44605 REPAIR OF BOWEL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44615 INTESTINAL STRICTUROPLASTY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44620 REPAIR BOWEL OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44625 REPAIR BOWEL OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44626 REPAIR BOWEL OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44640 REPAIR BOWEL-SKIN FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44650 REPAIR BOWEL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44660 REPAIR BOWEL-BLADDER FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44661 REPAIR BOWEL-BLADDER FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44680 SURGICAL REVISION INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44700 SUSPEND BOWEL WITH PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44701 INTRAOP COLON LAVAGE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44705 PREPARE FECAL MICROBIOTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44715 PREPARE DONOR INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44720 PREP DONOR INTESTINE/VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44721 PREP DONOR INTESTINE/ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
44799 UNLISTED PX SMALL INTESTINE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
44800 EXCISION OF BOWEL POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44820 EXCISION OF MESENTERY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44850 REPAIR OF MESENTERY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
44899 BOWEL SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
44900 DRAIN APPENDIX ABSCESS OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44950 APPENDECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44955 APPENDECTOMY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44960 APPENDECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
44970 LAPAROSCOPY APPENDECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
44979 LAPAROSCOPE PROC APP Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
45000 DRAINAGE OF PELVIC ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45005 DRAINAGE OF RECTAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45020 DRAINAGE OF RECTAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45100 BIOPSY OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45108 REMOVAL OF ANORECTAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45110 REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45111 PARTIAL REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45112 REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45113 PARTIAL PROCTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45114 PARTIAL REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45116 PARTIAL REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45119 REMOVE RECTUM WITH RESERVOIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45120 REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45121 REMOVAL OF RECTUM AND COLON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45123 PARTIAL PROCTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45126 PELVIC EXENTERATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45130 EXCISION OF RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45135 EXCISION OF RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45136 EXCISE ILEOANAL RESERVIOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45150 EXCISION OF RECTAL STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45160 EXCISION OF RECTAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45171 EXC RECT TUM TRANSANAL PART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45172 EXC RECT TUM TRANSANAL FULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45190 DESTRUCTION RECTAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45300 PROCTOSIGMOIDOSCOPY DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45303 PROCTOSIGMOIDOSCOPY DILATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45305 PROCTOSIGMOIDOSCOPY WITH BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45307 PROCTOSIGMOIDOSCOPY FB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45308 PROCTOSIGMOIDOSCOPY REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45309 PROCTOSIGMOIDOSCOPY REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45315 PROCTOSIGMOIDOSCOPY REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45317 PROCTOSIGMOIDOSCOPY BLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45320 PROCTOSIGMOIDOSCOPY ABLATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45321 PROCTOSIGMOIDOSCOPY VOLVUL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45327 PROCTOSIGMOIDOSCOPY WITH STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45330 DIAGNOSTIC SIGMOIDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45331 SIGMOIDOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45332 SIGMOIDOSCOPY WITH FB REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45333 SIGMOIDOSCOPY AND POLYPECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45334 SIGMOIDOSCOPY FOR BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45335 SIGMOIDOSCOPY WITH SUBMUC INJ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45337 SIGMOIDOSCOPY AND DECOMPRESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45338 SIGMOIDOSCOPY WITH TUMR REMOVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45340 SIG WITH TNDSC BALLOON DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45341 SIGMOIDOSCOPY WITH ULTRASOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45342 SIGMOIDOSCOPY WITH US GUIDE BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45346 SIGMOIDOSCOPY WITH ABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45347 SIGMOIDOSCOPY WITH PLCMT STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45349 SIGMOIDOSCOPY WITH RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45350 SGMDSC WITH BAND LIGATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45378 DIAGNOSTIC COLONOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45379 COLONOSCOPY WITH FB REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45380 COLONOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45381 COLONOSCOPY SUBMUCOUS NJX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45382 COLONOSCOPY WITH CONTROL BLEED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45384 COLONOSCOPY WITH LESION REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45385 COLONOSCOPY WITH LESION REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45386 COLONOSCOPY WITH BALLOON DILAT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45388 COLONOSCOPY WITH ABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45389 COLONOSCOPY WITH STENT PLCMT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45390 COLONOSCOPY WITH RESECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45391 COLONOSCOPY WITH ENDOSCOPE US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45392 COLONOSCOPY WITH ENDOSCOPIC FNB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45393 COLONOSCOPY WITH DECOMPRESSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45395 LAP REMOVAL OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45397 LAP REMOVE RECTUM WITH POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45398 COLONOSCOPY WITH BAND LIGATION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
45399 UNLISTED PROCEDURE COLON Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
45400 LAPAROSCOPIC PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45402 LAP PROCTOPEXY WITH SIG RESECT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
45499 LAPAROSCOPE PROC RECTUM Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
45500 REPAIR OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45505 REPAIR OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45520 TREATMENT OF RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45540 CORRECT RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45541 CORRECT RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45550 REPAIR RECTUM/REMOVE SIGMOID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45560 REPAIR OF RECTOCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45562 EXPLORATION/REPAIR OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45563 EXPLORATION/REPAIR OF RECTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45800 REPAIR RECT/BLADDER FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45805 REPAIR FISTULA WITH COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45820 REPAIR RECTOURETHRAL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45825 REPAIR FISTULA WITH COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45900 REDUCTION OF RECTAL PROLAPSE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45905 DILATION OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45910 DILATION OF RECTAL NARROWING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45915 REMOVE RECTAL OBSTRUCTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
45990 SURG DX EXAM ANORECTAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
45999 RECTUM SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
46020 PLACEMENT OF SETON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46030 REMOVAL OF RECTAL MARKER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46040 INCISION OF RECTAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46045 INCISION OF RECTAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46050 INCISION OF ANAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46060 INCISION OF RECTAL ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46070 INCISION OF ANAL SEPTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46080 INCISION OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46083 INCISE EXTERNAL HEMORRHOID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46200 REMOVAL OF ANAL FISSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46220 EXCISE ANAL EXT TAG/PAPILLA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46221 LIGATION OF HEMORRHOID(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46230 REMOVAL OF ANAL TAGS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46250 REMOVE EXT HEM GROUPS 2PLUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46255 REMOVE INT/EXT HEM 1 GROUP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46257 REMOVE IN/EX HEM GRP AND FISS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46258 REMOVE IN/EX HEM GRP WITH FISTU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46260 REMOVE IN/EX HEM GROUPS 2PLUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46261 REMOVE IN/EX HEM GRPS AND FISS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46262 REMOVE IN/EX HEM GRPS WITH FIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46270 REMOVE ANAL FIST SUBQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46275 REMOVE ANAL FIST INTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46280 REMOVE ANAL FIST COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46285 REMOVE ANAL FIST 2 STAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46288 REPAIR ANAL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46320 REMOVAL OF HEMORRHOID CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46500 INJECTION INTO HEMORRHOID(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46505 CHEMODENERVATION ANAL MUSC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46600 DIAGNOSTIC ANOSCOPY SPX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46601 DIAGNOSTIC ANOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46604 ANOSCOPY AND DILATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46606 ANOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46607 DIAGNOSTIC ANOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46608 ANOSCOPY REMOVE FOR BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46610 ANOSCOPY REMOVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46611 ANOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46612 ANOSCOPY REMOVE LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46614 ANOSCOPY CONTROL BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46615 ANOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46700 REPAIR OF ANAL STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46705 REPAIR OF ANAL STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46706 REPR OF ANAL FISTULA WITH GLUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46707 REPAIR ANORECTAL FIST WITH PLUG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46710 REPR PER/VAG POUCH SNGL PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46712 REPR PER/VAG POUCH DBL PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46715 REP PERF ANOPER FISTU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46716 REP PERF ANOPER/VESTIB FISTU Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46730 CONSTRUCTION OF ABSENT ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46735 CONSTRUCTION OF ABSENT ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46740 CONSTRUCTION OF ABSENT ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46742 REPAIR OF IMPERFORATED ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46744 REPAIR OF CLOACAL ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46746 REPAIR OF CLOACAL ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46748 REPAIR OF CLOACAL ANOMALY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46750 REPAIR OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46751 REPAIR OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46753 RECONSTRUCTION OF ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46754 REMOVAL OF SUTURE FROM ANUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46760 REPAIR OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46761 REPAIR OF ANAL SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46900 DESTRUCTION ANAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46910 DESTRUCTION ANAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46916 CRYOSURGERY ANAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46917 LASER SURGERY ANAL LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46922 EXCISION OF ANAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46924 DESTRUCTION ANAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46930 DESTROY INTERNAL HEMORRHOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46940 TREATMENT OF ANAL FISSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46942 TREATMENT OF ANAL FISSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46945 INT HRHC BY LIGATION SINGLE HROID W/O IMG GDN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46946 INT HRHC BY LIGATION 2+ HROID W/O IMG GDN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46947 HEMORRHOIDOPEXY BY STAPLING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46948 INT HRHC TRANSANAL HROID DARTLZJ 2+ W/US GDN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
46999 ANUS SURGERY PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47000 NEEDLE BIOPSY OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47001 NEEDLE BIOPSY LIVER ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47010 OPEN DRAINAGE LIVER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47015 INJECT/ASPIRATE LIVER CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47100 WEDGE BIOPSY OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47120 PARTIAL REMOVAL OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47122 EXTENSIVE REMOVAL OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47125 PARTIAL REMOVAL OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47130 PARTIAL REMOVAL OF LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47133 REMOVAL OF DONOR LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
47135 TRANSPLANTATION OF LIVER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
47140 PARTIAL REMOVAL DONOR LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
47141 PARTIAL REMOVAL DONOR LIVER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
47142 PARTIAL REMOVAL DONOR LIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47143 PREP DONOR LIVER WHOLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47144 PREP DONOR LIVER 3-SEGMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47145 PREP DONOR LIVER LOBE SPLIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47146 PREP DONOR LIVER/VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47147 PREP DONOR LIVER/ARTERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47300 SURGERY FOR LIVER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47350 REPAIR LIVER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47360 REPAIR LIVER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47361 REPAIR LIVER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47362 REPAIR LIVER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47370 LAPARO ABLATE LIVER TUMOR RF Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Con
Authorization
47371 LAPARO ABLATE LIVER CRYOSURG Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Yes
Authorization
47379 LAPAROSCOPE PROCEDURE LIVER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
47380 OPEN ABLATE LIVER TUMOR RF Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Con
Authorization
47381 OPEN ABLATE LIVER TUMOR CRYO Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Con
Authorization
47382 PERCUT ABLATE LIVER RF Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Con
Authorization
47383 PERQ ABLTJ LVR CRYOABLATION Tailored Plan Pre-authorization required for all providers when billed with an Ablative Dx. For all others, authorization is required for non-participating providers only.
Yes
Authorization
47399 LIVER SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
47400 INCISION OF LIVER DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47420 INCISION OF BILE DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47425 INCISION OF BILE DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47460 INCISE BILE DUCT SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47480 INCISION OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47490 INCISION OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47531 INJECTION FOR CHOLANGIOGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47532 INJECTION FOR CHOLANGIOGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47533 PLMT BILIARY DRAINAGE CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47534 PLMT BILIARY DRAINAGE CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47535 CONVERSION EXT BIL DRG CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47536 EXCHANGE BILIARY DRG CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47537 REMOVAL BILIARY DRG CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47538 PERQ PLMT BILE DUCT STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47539 PERQ PLMT BILE DUCT STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47540 PERQ PLMT BILE DUCT STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47541 PLMT ACCESS BIL TREE SM BWL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47542 DILATE BILIARY DUCT/AMPULLA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47543 ENDOLUMINAL BX BILIARY TREE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47544 REMOVAL DUCT GLBLDR CALCULI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47550 BILE DUCT ENDOSCOPY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47552 BILIARY ENDO PERQ DX WITH SPECI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47553 BILIARY ENDOSCOPY THRU SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47554 BILIARY ENDOSCOPY THRU SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47555 BILIARY ENDOSCOPY THRU SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47556 BILIARY ENDOSCOPY THRU SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47562 LAPAROSCOPIC CHOLECYSTECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47563 LAPARO CHOLECYSTECTOMY/GRAPH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47564 LAPARO CHOLECYSTECTOMY/EXPLR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47570 LAPARO CHOLECYSTOENTEROSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
47579 LAPAROSCOPE PROC BILIARY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
47600 REMOVAL OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47605 REMOVAL OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47610 REMOVAL OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47612 REMOVAL OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47620 REMOVAL OF GALLBLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47700 EXPLORATION OF BILE DUCTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47701 BILE DUCT REVISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47711 EXCISION OF BILE DUCT TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47712 EXCISION OF BILE DUCT TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47715 EXCISION OF BILE DUCT CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47720 FUSE GALLBLADDER AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47721 FUSE UPPER GI STRUCTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47740 FUSE GALLBLADDER AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47741 FUSE GALLBLADDER AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47760 FUSE BILE DUCTS AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47765 FUSE LIVER DUCTS AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47780 FUSE BILE DUCTS AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47785 FUSE BILE DUCTS AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47800 RECONSTRUCTION OF BILE DUCTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47801 PLACEMENT BILE DUCT SUPPORT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
47900 SUTURE BILE DUCT INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
47999 BILE TRACT SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
48000 DRAINAGE OF ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48001 PLACEMENT OF DRAIN PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48020 REMOVAL OF PANCREATIC STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48100 BIOPSY OF PANCREAS OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48102 NEEDLE BIOPSY PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48105 RESECT/DEBRIDE PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48120 REMOVAL OF PANCREAS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48140 PARTIAL REMOVAL OF PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48145 PARTIAL REMOVAL OF PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48146 PANCREATECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48148 REMOVAL OF PANCREATIC DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48150 PARTIAL REMOVAL OF PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48152 PANCREATECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48153 PANCREATECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48154 PANCREATECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48155 REMOVAL OF PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
48160 PANCREAS REMOVAL/TRANSPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
48400 INJECTION INTRAOP ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48500 SURGERY OF PANCREATIC CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48510 DRAIN PANCREATIC PSEUDOCYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48520 FUSE PANCREAS CYST AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48540 FUSE PANCREAS CYST AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48545 PANCREATORRHAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48547 DUODENAL EXCLUSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48548 FUSE PANCREAS AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48550 DONOR PANCREATECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48551 PREP DONOR PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
48552 PREP DONOR PANCREAS/VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
48554 TRANSPL ALLOGRAFT PANCREAS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
48556 REMOVAL ALLOGRAFT PANCREAS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
48999 PANCREAS SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49000 EXPLORATION OF ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49002 REOPENING OF ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49010 EXPLORATION BEHIND ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49013 PREPERITONEAL PEL PACK F/HEMRRG ASSOC PEL TRMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49014 REEXPL PEL WND W/RMVL PREPERITONEAL PEL PACKING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49020 DRAINAGE ABDOM ABSCESS OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49040 DRAIN OPEN ABDOM ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49060 DRAIN OPEN RETROPERI ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49062 DRAIN TO PERITONEAL CAVITY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49082 ABD PARACENTESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49083 ABD PARACENTESIS WITH IMAGING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49084 PERITONEAL LAVAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49180 BIOPSY ABDOMINAL MASS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49185 SCLEROTX FLUID COLLECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49186 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5 CM OR LESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49187 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 5.1-10 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49188 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 10.1-20 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49189 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CST 20.1-30 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49190 OPEN EXC/DSTRJ INTRA-ABDL TUMOR/CYST >30 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49215 EXCISE SACRAL SPINE TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49250 EXCISION OF UMBILICUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49255 REMOVAL OF OMENTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49320 DIAG LAPARO SEPARATE PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49321 LAPAROSCOPY BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49322 LAPAROSCOPY ASPIRATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49323 LAPARO DRAIN LYMPHOCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49324 LAP INSERT TUNNEL IP CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49325 LAP REVISION PERM IP CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49326 LAP WITH OMENTOPEXY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49327 LAP INS DEVICE FOR RT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49329 LAPARO PROC ABDM/PER/OMENT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49400 AIR INJECTION INTO ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49402 REMOVE FOREIGN BODY ADBOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49405 IMAGE CATH FLUID COLXN VISC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49406 IMAGE CATH FLUID PERI/RETRO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49407 IMAGE CATH FLUID TRNS/VGNL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49411 INS MARK ABD/PEL FOR RT PERQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49412 INS DEVICE FOR RT GUIDE OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49418 INSERT TUN IP CATH PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49419 INSERT TUN IP CATH WITH PORT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49421 INS TUN IP CATH FOR DIAL OPN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49422 REMOVE TUNNELED IP CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49423 EXCHANGE DRAINAGE CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49424 ASSESS CYST CONTRAST INJECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49425 INSERT ABDOMEN-VENOUS DRAIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49426 REVISE ABDOMEN-VENOUS SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49427 INJECTION ABDOMINAL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49428 LIGATION OF SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49429 REMOVAL OF SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49435 INSERT SUBQ EXTEN TO IP CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49436 EMBEDDED IP CATH EXIT-SITE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49440 PLACE GASTROSTOMY TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49441 PLACE DUOD/JEJ TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49442 PLACE CECOSTOMY TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49446 CHANGE G-TUBE TO G-J PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49450 REPLACE G/C TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49451 REPLACE DUOD/JEJ TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49452 REPLACE G-J TUBE PERC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49460 FIX G/COLON TUBE WITH DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49465 FLUORO EXAM OF G/COLON TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49491 RPR HERN PREEMIE REDUC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49492 RPR ING HERN PREMIE BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49495 RPR ING HERNIA BABY REDUC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49496 RPR ING HERNIA BABY BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49500 RPR ING HERNIA INIT REDUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49501 RPR ING HERNIA INIT BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49505 PRP I/HERN INIT REDUC >5 YR Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49507 PRP I/HERN INIT BLOCK >5 YR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49520 REREPAIR ING HERNIA REDUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49521 REREPAIR ING HERNIA BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49525 REPAIR ING HERNIA SLIDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49540 REPAIR LUMBAR HERNIA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49550 RPR REM HERNIA INIT REDUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49553 RPR FEM HERNIA INIT BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49555 REREPAIR FEM HERNIA REDUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49557 REREPAIR FEM HERNIA BLOCKED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49591 RPR AA HERNIA 1ST < 3 CM REDUCIBLE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49592 RPR AA HERNIA 1ST < 3 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49593 RPR AA HERNIA 1ST 3-10 CM REDUCIBLE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49594 RPR AA HERNIA 1ST 3-10 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49595 RPR AA HERNIA 1ST > 10 CM REDUCIBLE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49596 RPR AA HERNIA 1ST > 10 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49600 REPAIR UMBILICAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49605 REPAIR UMBILICAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49606 REPAIR UMBILICAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49610 REPAIR UMBILICAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49611 REPAIR UMBILICAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49613 RPR AA HERNIA RECR < 3 CM REDUCIBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49614 RPR AA HERNIA RECR < 3 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49615 RPR AA HERNIA RECR 3-10 CM REDUCIBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49616 RPR AA HERNIA RECR 3-10 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49617 RPR AA HERNIA RECR > 10 CM REDUCIBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49618 RPR AA HERNIA RECR > 10 CM NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49621 RPR PARASTOMAL HERNIA 1ST/RECR REDUCIBLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49622 RPR PARASTOMAL HRNA 1ST/RECR NCRC8/STRANGULATED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49623 RMVL NONINFCT MESH/PROSTH AA/PARASTOMAL HRNA RPR Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49650 LAP ING HERNIA REPAIR INIT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49651 LAP ING HERNIA REPAIR RECUR Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49659 LAPARO PROC HERNIA REPAIR Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
49900 REPAIR OF ABDOMINAL WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49904 OMENTAL FLAP EXTRA-ABDOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49905 OMENTAL FLAP INTRA-ABDOM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
49906 FREE OMENTAL FLAP MICROVASC Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
49999 ABDOMEN SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
50010 EXPLORATION OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50020 RENAL ABSCESS OPEN DRAIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50040 DRAINAGE OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50045 EXPLORATION OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50060 REMOVAL OF KIDNEY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50065 INCISION OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50070 INCISION OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50075 REMOVAL OF KIDNEY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50080 PERQ NL/PL LITHOTRP SIMPLE UP TO 2 CM 1 LOCATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50081 PERQ NL/PL LITHOTRP COMPLEX >2 CM MLT LOCATIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50100 REVISE KIDNEY BLOOD VESSELS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50120 EXPLORATION OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50125 EXPLORE AND DRAIN KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50130 REMOVAL OF KIDNEY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50200 RENAL BIOPSY PERQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50205 RENAL BIOPSY OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50220 REMOVE KIDNEY OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50225 REMOVAL KIDNEY OPEN COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50230 REMOVAL KIDNEY OPEN RADICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50234 REMOVAL OF KIDNEY AND URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50236 REMOVAL OF KIDNEY AND URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50240 PARTIAL REMOVAL OF KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50250 CRYOABLATE RENAL MASS OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50280 REMOVAL OF KIDNEY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50290 REMOVAL OF KIDNEY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
50300 REMOVE CADAVER DONOR KIDNEY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
50320 REMOVE KIDNEY LIVING DONOR Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
50323 PREP CADAVER RENAL ALLOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50325 PREP DONOR RENAL GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50327 PREP RENAL GRAFT/VENOUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50328 PREP RENAL GRAFT/ARTERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50329 PREP RENAL GRAFT/URETERAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
50340 REMOVAL OF KIDNEY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
50360 TRANSPLANTATION OF KIDNEY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
50365 TRANSPLANTATION OF KIDNEY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
50370 REMOVE TRANSPLANTED KIDNEY Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
50380 REIMPLANTATION OF KIDNEY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
50382 CHANGE URETER STENT PERCUT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50384 REMOVE URETER STENT PERCUT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50385 CHANGE STENT VIA TRANSURETH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50386 REMOVE STENT VIA TRANSURETH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50387 CHANGE NEPHROURETERAL CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50389 REMOVE RENAL TUBE WITH FLUORO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50390 DRAINAGE OF KIDNEY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50391 INSTLL RX AGNT INTO RNAL TUB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50396 MEASURE KIDNEY PRESSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50400 REVISION OF KIDNEY/URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50405 REVISION OF KIDNEY/URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50430 NJX PX NFROSGRM AND/URTRGRM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50431 NJX PX NFROSGRM AND/URTRGRM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50432 PLMT NEPHROSTOMY CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50433 PLMT NEPHROURETERAL CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50434 CONVERT NEPHROSTOMY CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50435 EXCHANGE NEPHROSTOMY CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50436 PERQ DILATION XST TRC ENDOUROLOGIC PX WITH IMG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50437 PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50500 REPAIR OF KIDNEY WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50520 CLOSE KIDNEY-SKIN FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50525 CLOSE NEPHROVISCERAL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50526 CLOSE NEPHROVISCERAL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50540 REVISION OF HORSESHOE KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50541 LAPARO ABLATE RENAL CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50542 LAPARO ABLATE RENAL MASS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50543 LAPARO PARTIAL NEPHRECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50544 LAPAROSCOPY PYELOPLASTY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50545 LAPARO RADICAL NEPHRECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50546 LAPAROSCOPIC NEPHRECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50547 LAPARO REMOVAL DONOR KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50548 LAPARO REMOVE WITH URETER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
50549 LAPAROSCOPE PROC RENAL Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
50551 KIDNEY ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50553 KIDNEY ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50555 KIDNEY ENDOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50557 KIDNEY ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50561 KIDNEY ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50562 RENAL SCOPE WITH TUMOR RESECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50570 KIDNEY ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50572 KIDNEY ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50574 KIDNEY ENDOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50575 KIDNEY ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50576 KIDNEY ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50580 KIDNEY ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50590 FRAGMENTING OF KIDNEY STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50592 PERC RF ABLATE RENAL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50593 PERC CRYO ABLATE RENAL TUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50600 EXPLORATION OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50605 INSERT URETERAL SUPPORT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50606 ENDOLUMINAL BX URTR RNL PLVS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50610 REMOVAL OF URETER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50620 REMOVAL OF URETER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50630 REMOVAL OF URETER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50650 REMOVAL OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50660 REMOVAL OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50684 INJECTION FOR URETER X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50686 MEASURE URETER PRESSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50688 CHANGE OF URETER TUBE/STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50690 INJECTION FOR URETER X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50693 PLMT URETERAL STENT PRQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50694 PLMT URETERAL STENT PRQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50695 PLMT URETERAL STENT PRQ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50700 REVISION OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50705 URETERAL EMBOLIZATION/OCCL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50706 BALLOON DILATE URTRL STRIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50715 RELEASE OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50722 RELEASE OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50725 RELEASE/REVISE URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50727 REVISE URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50728 REVISE URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50740 URETEROPYELOSTOMY ANAST URETER RENAL PELVIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50750 FUSION OF URETER AND KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50760 FUSION OF URETERS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50770 SPLICING OF URETERS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50780 REIMPLANT URETER IN BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50782 REIMPLANT URETER IN BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50783 REIMPLANT URETER IN BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50785 REIMPLANT URETER IN BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50800 IMPLANT URETER IN BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50810 FUSION OF URETER AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50815 URINE SHUNT TO INTESTINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50820 CONSTRUCT BOWEL BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50825 CONSTRUCT BOWEL BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50830 REVISE URINE FLOW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50840 REPLACE URETER BY BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50845 APPENDICO-VESICOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50860 TRANSPLANT URETER TO SKIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50900 REPAIR OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50920 CLOSURE URETER/SKIN FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50930 CLOSURE URETER/BOWEL FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50940 RELEASE OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50945 LAPAROSCOPY URETEROLITHOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50947 LAPARO NEW URETER/BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50948 LAPARO NEW URETER/BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
50949 LAPAROSCOPE PROC URETER Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
50951 ENDOSCOPY OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50953 ENDOSCOPY OF URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50955 URETER ENDOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50957 URETER ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50961 URETER ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50970 URETER ENDOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50972 URETER ENDOSCOPY AND CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50974 URETER ENDOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50976 URETER ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
50980 URETER ENDOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51020 CYSTOTOMY/CYSTOSTOMY FULG AND /INSJ RADACT MATRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51040 INCISE AND DRAIN BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51045 INCISE BLADDER/DRAIN URETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51050 REMOVAL OF BLADDER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51060 REMOVAL OF URETER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51065 REMOVE URETER CALCULUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51080 DRAINAGE OF BLADDER ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51100 DRAIN BLADDER BY NEEDLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51101 DRAIN BLADDER BY TROCAR/CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51102 DRAIN BL WITH CATH INSERTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51500 REMOVAL OF BLADDER CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51520 REMOVAL OF BLADDER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51525 REMOVAL OF BLADDER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51530 REMOVAL OF BLADDER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51535 REPAIR OF URETER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51550 PARTIAL REMOVAL OF BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51555 PARTIAL REMOVAL OF BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51565 REVISE BLADDER AND URETER(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51570 REMOVAL OF BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51575 REMOVAL OF BLADDER AND NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51580 REMOVE BLADDER/REVISE TRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51585 REMOVAL OF BLADDER AND NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51590 REMOVE BLADDER/REVISE TRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51595 REMOVE BLADDER/REVISE TRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51596 REMOVE BLADDER/CREATE POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51597 REMOVAL OF PELVIC STRUCTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51600 INJECTION FOR BLADDER X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51605 PREPARATION FOR BLADDER XRAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51610 INJECTION FOR BLADDER X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51700 IRRIGATION OF BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51701 INSERT BLADDER CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51702 INSERT TEMP BLADDER CATH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51703 INSERT BLADDER CATH COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51705 CHANGE OF BLADDER TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51710 CHANGE OF BLADDER TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
51715 ENDOSCOPIC INJECTION/IMPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
51720 TREATMENT OF BLADDER LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51725 SIMPLE CYSTOMETROGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51726 COMPLEX CYSTOMETROGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51727 CYSTOMETROGRAM WITH UP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51728 CYSTOMETROGRAM WITH VP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51729 CYSTOMETROGRAM WITH VPANDUP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51736 URINE FLOW MEASUREMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51741 ELECTRO-UROFLOWMETRY FIRST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51784 ANAL/URINARY MUSCLE STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51785 ANAL/URINARY MUSCLE STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51792 URINARY REFLEX STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51797 INTRAABDOMINAL PRESSURE TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51798 US URINE CAPACITY MEASURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51800 REVISION OF BLADDER/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51820 REVISION OF URINARY TRACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51840 ATTACH BLADDER/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51841 ATTACH BLADDER/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51845 REPAIR BLADDER NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51860 REPAIR OF BLADDER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51865 REPAIR OF BLADDER WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51880 REPAIR OF BLADDER OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51900 REPAIR BLADDER/VAGINA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51920 CLOSE BLADDER-UTERUS FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51925 HYSTERECTOMY/BLADDER REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51940 CORRECTION OF BLADDER DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51960 REVISION OF BLADDER AND BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51980 CONSTRUCT BLADDER OPENING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51990 LAPARO URETHRAL SUSPENSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
51992 LAPARO SLING OPERATION Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
51999 LAPAROSCOPE PROC BLA Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
52000 CYSTOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52001 CYSTOSCOPY REMOVAL OF CLOTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52005 CYSTOSCOPY AND URETER CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52007 CYSTOSCOPY AND BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52010 CYSTOSCOPY AND DUCT CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52204 CYSTOSCOPY WITH BIOPSY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52214 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52224 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52234 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52235 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52240 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52250 CYSTOSCOPY AND RADIOTRACER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52260 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52265 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52270 CYSTOSCOPY AND REVISE URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52275 CYSTOSCOPY AND REVISE URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52276 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52277 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52281 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52282 CYSTOSCOPY IMPLANT STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52283 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52284 CYSTO W/DILAT RX BALO CATH URTL STRIX/STEN MALE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52285 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52287 CYSTOSCOPY CHEMODENERVATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52290 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52300 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52301 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52305 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52310 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52315 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52317 REMOVE BLADDER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52318 REMOVE BLADDER STONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52320 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52325 CYSTOSCOPY STONE REMOVAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52327 CYSTOSCOPY INJECT MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52330 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52332 CYSTOSCOPY AND TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52334 CREATE PASSAGE TO KIDNEY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52341 CYSTO WITH URETER STRICTURE TX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52342 CYSTO WITH UP STRICTURE TX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52343 CYSTO WITH RENAL STRICTURE TX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52344 CYSTO/URETERO STRICTURE TX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52345 CYSTO/URETERO WITH UP STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52346 CYSTOURETERO WITH RENAL STRICT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52351 CYSTOURETERO AND OR PYELOSCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52352 CYSTOURETERO WITH STONE REMOVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52353 CYSTOURETERO WITH LITHOTRIPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52354 CYSTOURETERO WITH BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52355 CYSTOURETERO WITH EXCISE TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52356 CYSTO/URETERO WITH LITHOTRIPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52400 CYSTOURETERO WITH CONGEN REPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52402 CYSTOURETHRO CUT EJACUL DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52441 CYSTOURETHRO WITH IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52442 CYSTOURETHRO WITH ADDL IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52450 INCISION OF PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52500 REVISION OF BLADDER NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52601 PROSTATECTOMY (TURP) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52630 REMOVE PROSTATE REGROWTH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52640 RELIEVE BLADDER CONTRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52648 LASER SURGERY OF PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52649 PROSTATE LASER ENUCLEATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
52700 DRAINAGE OF PROSTATE ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53000 INCISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53010 INCISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53020 INCISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53025 INCISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53040 DRAINAGE OF URETHRA ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53060 DRAINAGE OF URETHRA ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53080 DRAINAGE OF URINARY LEAKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53085 DRAINAGE OF URINARY LEAKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53200 BIOPSY OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53210 REMOVAL OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53215 REMOVAL OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53220 TREATMENT OF URETHRA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53230 REMOVAL OF URETHRA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53235 REMOVAL OF URETHRA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53240 SURGERY FOR URETHRA POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53250 REMOVAL OF URETHRA GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53260 TREATMENT OF URETHRA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53265 TREATMENT OF URETHRA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53270 REMOVAL OF URETHRA GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53275 REPAIR OF URETHRA DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53400 REVISE URETHRA STAGE 1 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53405 REVISE URETHRA STAGE 2 Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
53410 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
53415 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
53420 RECONSTRUCT URETHRA STAGE 1 Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
53425 RECONSTRUCT URETHRA STAGE 2 Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
53430 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
53431 RECONSTRUCT URETHRA/BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53440 MALE SLING PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53442 REMOVE/REVISE MALE SLING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53444 INSERT TANDEM CUFF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53445 INSERT URO/VES NCK SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53446 REMOVE URO SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53447 REMOVE/REPLACE UR SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53448 REMOV/REPLC UR SPHINCTR COMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53449 REPAIR URO SPHINCTER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53450 REVISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
53460 REVISION OF URETHRA Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
53500 URETHRLYS TRANSVAG WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53502 REPAIR OF URETHRA INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53505 REPAIR OF URETHRA INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53510 REPAIR OF URETHRA INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53515 REPAIR OF URETHRA INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53520 REPAIR OF URETHRA DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53600 DILATE URETHRA STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53601 DILATE URETHRA STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53605 DILATE URETHRA STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53620 DILATE URETHRA STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53621 DILATE URETHRA STRICTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53660 DILATION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53661 DILATION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53665 DILATION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53850 PROSTATIC MICROWAVE THERMOTX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53852 PROSTATIC RF THERMOTX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53854 TRURL DSTRJ PRST8 TISS RF WV THERMOTHERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53855 INSERT PROST URETHRAL STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
53860 TRANSURETHRAL RF TREATMENT Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
53899 UROLOGY SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
54000 SLITTING OF PREPUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54001 SLITTING OF PREPUCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54015 DRAIN PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54050 DESTRUCTION PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54055 DESTRUCTION PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54056 CRYOSURGERY PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54057 LASER SURG PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54060 EXCISION OF PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54065 DESTRUCTION PENIS LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54100 BIOPSY OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54105 BIOPSY OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54110 TREATMENT OF PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54111 TREAT PENIS LESION GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54112 TREAT PENIS LESION GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54115 TREATMENT OF PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54120 PARTIAL REMOVAL OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54125 REMOVAL OF PENIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
54130 REMOVE PENIS AND NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54135 REMOVE PENIS AND NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54150 CIRCUMCISION WITH REGIONL BLOCK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54160 CIRCUMCISION NEONATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54161 CIRCUM 28 DAYS OR OLDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54162 LYSIS PENIL CIRCUMIC LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54163 REPAIR OF CIRCUMCISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54164 FRENULOTOMY OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54200 TREATMENT OF PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54205 TREATMENT OF PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54220 TREATMENT OF PENIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54230 PREPARE PENIS STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54231 DYNAMIC CAVERNOSOMETRY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54235 PENILE INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54240 PENIS STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54250 PENIS STUDY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54300 REVISION OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54304 REVISION OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54308 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54312 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54316 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54318 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54322 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54324 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54326 RECONSTRUCTION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54328 REVISE PENIS/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54332 REVISE PENIS/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54336 REVISE PENIS/URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54340 RPR HYPOSPADIAS COMPLCTJS CLSR INC/EXC SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54344 RPR HYPOSPADIAS COMPLCTJS MOBLJ FLAPS AND URTP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54348 RPR HYPOSPADIAS COMPLCTJS DSJ AND URTP FLAP/GRF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54352 REVISION PRIOR HYPOSPADIAS REPAIR DSJ AND EXC RCNSTJ Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
54360 PENIS PLASTIC SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
54380 REPAIR PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
54385 REPAIR PENIS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
54390 REPAIR PENIS AND BLADDER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54400 INSERT SEMI-RIGID PROSTHESIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
54401 INSERT SELF-CONTD PROSTHESIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Yes
Authorization
54405 INSERT MULTI-COMP PENIS PROS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54406 REMOVE MUTI-COMP PENIS PROS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54408 REPAIR MULTI-COMP PENIS PROS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54410 REMOVE/REPLACE PENIS PROSTH Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54411 REMOV/REPLC PENIS PROS COMP Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54415 REMOVE SELF-CONTD PENIS PROS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
54416 REMV/REPL PENIS CONTAIN PROS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
54417 REMV/REPLC PENIS PROS COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54420 REVISION OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54430 REVISION OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54435 REVISION OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54437 REPAIR CORPOREAL TEAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54440 REPAIR OF PENIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54450 PREPUTIAL STRETCHING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54500 BIOPSY OF TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54505 BIOPSY OF TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54512 EXCISE LESION TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54520 REMOVAL OF TESTIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
54522 ORCHIECTOMY PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54530 REMOVAL OF TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54535 EXTENSIVE TESTIS SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54550 EXPLORATION FOR TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54560 EXPLORATION FOR TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54600 REDUCE TESTIS TORSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54620 SUSPENSION OF TESTIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54640 ORCHIOPEXY INGUINAL OR SCROTAL APPROACH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54650 ORCHIOPEXY (FOWLER-STEPHENS) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54660 REVISION OF TESTIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
54670 REPAIR TESTIS INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54680 RELOCATION OF TESTIS(ES) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54690 LAPAROSCOPY ORCHIECTOMY Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
54692 LAPAROSCOPY ORCHIOPEXY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
54699 LAPAROSCOPE PROC TESTIS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
54700 DRAINAGE OF SCROTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54800 BIOPSY OF EPIDIDYMIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54830 REMOVE EPIDIDYMIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54840 REMOVE EPIDIDYMIS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54860 REMOVAL OF EPIDIDYMIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54861 REMOVAL OF EPIDIDYMIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54865 EXPLORE EPIDIDYMIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54900 FUSION OF SPERMATIC DUCTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
54901 FUSION OF SPERMATIC DUCTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55000 DRAINAGE OF HYDROCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55040 REMOVAL OF HYDROCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55041 REMOVAL OF HYDROCELES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55060 REPAIR OF HYDROCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55100 DRAINAGE OF SCROTUM ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55110 EXPLORE SCROTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55120 REMOVAL OF SCROTUM LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55150 REMOVAL OF SCROTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55175 REVISION OF SCROTUM Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
55180 REVISION OF SCROTUM Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
55200 INCISION OF SPERM DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55250 REMOVAL OF SPERM DUCT(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55300 PREPARE SPERM DUCT X-RAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55400 REPAIR OF SPERM DUCT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55500 REMOVAL OF HYDROCELE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55520 REMOVAL OF SPERM CORD LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55530 REVISE SPERMATIC CORD VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55535 REVISE SPERMATIC CORD VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55540 REVISE HERNIA AND SPERM VEINS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55550 LAPARO LIGATE SPERMATIC VEIN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
55559 LAPARO PROC SPERMATIC CORD Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
55600 INCISE SPERM DUCT POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55605 INCISE SPERM DUCT POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55650 REMOVE SPERM DUCT POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55680 REMOVE SPERM POUCH LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55705 BIOPSY PROSTATE ANY APPROACH NONIMAGING-GUIDED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55706 PROSTATE SATURATION SAMPLING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55707 BIOPSY PROSTATE TRANSRECTAL ULTRASOUND-GUIDED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55708 BX PROSTATE TRANSRECTAL US GID W/MRI FUS GDN 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55709 BX PROSTATE TRANSPERINEAL ULTRASOUND-GUIDED Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55710 BX PROSTATE TRANSPERINEAL US GID W/MRI FUS GDN 1 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55711 BX PROSTATE TRANSRECTAL MRI-US GID TRGT LES 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55712 BX PROSTATE TPRNL MRI-US GID TRGT LES 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55713 BX PROSTATE IN-BORE CT/MRI BX ADDL TRGT LES 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55714 BX PROSTATE IN-BORE CT/MRI TRGT LES ONLY 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55715 BX PROSTATE EA ADDL MRI-US FUSION/IN-BORE CT/MRI Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55720 DRAINAGE OF PROSTATE ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55725 DRAINAGE OF PROSTATE ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55801 REMOVAL OF PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55810 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55812 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55815 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55821 REMOVAL OF PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55831 REMOVAL OF PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55840 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55842 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55845 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55860 SURGICAL EXPOSURE PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55862 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55865 EXTENSIVE PROSTATE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55866 LAPS SURG PRST8ECT RPBIC RAD W/NERVE SPARING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55867 LAPS SURG PRST8ECT SMPL STOT ROBOTIC ASSISTANCE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55868 LAPS SURG PRST8ECT RPBIC RADICAL W/LYMPH NODE BX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55869 LAPS SURG PRST8ECT RPBIC RAD W/BI PEL LYMPHADEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55870 ELECTROEJACULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55873 CRYOABLATE PROSTATE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55874 TPRNL PLMT BIODEGRDABL MATRL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55875 TRANSPERI NEEDLE PLACE PROS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
55876 PLACE RT DEVICE/MARKER PROS Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
55899 GENITAL SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
55920 PLACE NEEDLES PELVIC FOR RT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56405 I AND D OF VULVA/PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56420 DRAINAGE OF GLAND ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56440 SURGERY FOR VULVA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56441 LYSIS OF LABIAL LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56442 HYMENOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56501 DESTROY VULVA LESIONS SIM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56515 DESTROY VULVA LESION/S COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56605 BIOPSY OF VULVA/PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56606 BIOPSY OF VULVA/PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56620 PARTIAL REMOVAL OF VULVA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56625 COMPLETE REMOVAL OF VULVA Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
56630 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56631 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56632 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56633 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56634 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56637 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56640 EXTENSIVE VULVA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56700 PARTIAL REMOVAL OF HYMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56740 REMOVE VAGINA GLAND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56800 REPAIR OF VAGINA Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
56805 REPAIR CLITORIS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
56810 REPAIR OF PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56820 EXAM OF VULVA WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
56821 EXAM/BIOPSY OF VULVA WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57000 EXPLORATION OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57010 DRAINAGE OF PELVIC ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57020 DRAINAGE OF PELVIC FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57022 I AND D VAGINAL HEMATOMA PP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57023 I AND D VAG HEMATOMA NON-OB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57061 DESTROY VAG LESIONS SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57065 DESTROY VAG LESIONS COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57100 BIOPSY OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57105 BIOPSY OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57106 REMOVE VAGINA WALL PARTIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57107 REMOVE VAGINA TISSUE PART Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57109 VAGINECTOMY PARTIAL WITH NODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57110 REMOVE VAGINA WALL COMPLETE Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
57111 REMOVE VAGINA TISSUE COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57120 CLOSURE OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57130 REMOVE VAGINA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57135 REMOVE VAGINA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57150 TREAT VAGINA INFECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57155 INSERT UTERI TANDEM/OVOIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57156 INS VAG BRACHYTX DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57160 INSERT PESSARY/OTHER DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57170 FITTING OF DIAPHRAGM/CAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57180 TREAT VAGINAL BLEEDING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57200 REPAIR OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57210 REPAIR VAGINA/PERINEUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57220 REVISION OF URETHRA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57230 REPAIR OF URETHRAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57240 ANTERIOR COLPORRHAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57250 REPAIR RECTUM AND VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57260 CMBN ANT PST COLPRHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57265 CMBN AP COLPRHY WITH NTRCL RPR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57267 INSERT MESH/PELVIC FLR ADDON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57268 REPAIR OF BOWEL BULGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57270 REPAIR OF BOWEL POUCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57280 SUSPENSION OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57282 COLPOPEXY EXTRAPERITONEAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57283 COLPOPEXY INTRAPERITONEAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57284 REPAIR PARAVAG DEFECT OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57285 REPAIR PARAVAG DEFECT VAG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57287 REVISE/REMOVE SLING REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57288 REPAIR BLADDER DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57289 REPAIR BLADDER AND VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57291 CONSTRUCTION OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57292 CONSTRUCT VAGINA WITH GRAFT Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
57295 REVISE VAG GRAFT VIA VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57296 REVISE VAG GRAFT OPEN ABD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57300 REPAIR RECTUM-VAGINA FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57305 REPAIR RECTUM-VAGINA FISTULA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57307 FISTULA REPAIR AND COLOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57308 FISTULA REPAIR TRANSPERINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57310 REPAIR URETHROVAGINAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57311 REPAIR URETHROVAGINAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57320 REPAIR BLADDER-VAGINA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57330 REPAIR BLADDER-VAGINA LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57335 REPAIR VAGINA Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
57400 DILATION OF VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57410 PELVIC EXAMINATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57415 REMOVE VAGINAL FOREIGN BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57420 EXAM OF VAGINA WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57421 EXAM/BIOPSY OF VAG WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57423 REPAIR PARAVAG DEFECT LAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57425 LAPAROSCOPY SURG COLPOPEXY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57426 REVISE PROSTH VAG GRAFT LAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57452 EXAM OF CERVIX WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57454 BX/CURETT OF CERVIX WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57455 BIOPSY OF CERVIX WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57456 ENDOCERV CURETTAGE WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57460 BX OF CERVIX WITH SCOPE LEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57461 CONZ OF CERVIX WITH SCOPE LEEP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57465 COMPUTER-AIDED MAPG CERVIX UTERI DRG COLPOSCOPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57500 BIOPSY OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57505 ENDOCERVICAL CURETTAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57510 CAUTERIZATION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57511 CRYOCAUTERY OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57513 LASER SURGERY OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57520 CONIZATION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57522 CONIZATION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57530 REMOVAL OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57531 REMOVAL OF CERVIX RADICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57540 REMOVAL OF RESIDUAL CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57545 REMOVE CERVIX/REPAIR PELVIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57550 REMOVAL OF RESIDUAL CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57555 REMOVE CERVIX/REPAIR VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57556 REMOVE CERVIX REPAIR BOWEL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57558 DANDC OF CERVICAL STUMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57700 REVISION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57720 REVISION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
57800 DILATION OF CERVICAL CANAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58100 BIOPSY OF UTERUS LINING Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58110 BX DONE WITH COLPOSCOPY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58120 DILATION AND CURETTAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58140 MYOMECTOMY ABDOM METHOD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58145 MYOMECTOMY VAG METHOD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58146 MYOMECTOMY ABDOM COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58150 TOTAL HYSTERECTOMY Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58152 TOTAL HYSTERECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58180 PARTIAL HYSTERECTOMY Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58200 EXTENSIVE HYSTERECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58210 EXTENSIVE HYSTERECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58240 REMOVAL OF PELVIS CONTENTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58260 VAGINAL HYSTERECTOMY Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58262 VAG HYST INCLUDING T/O Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58263 VAG HYST WITH T/O AND VAG REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58267 VAG HYST WITH URINARY REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58270 VAG HYST WITH ENTEROCELE REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58275 HYSTERECTOMY/REVISE VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58280 HYSTERECTOMY/REVISE VAGINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58285 EXTENSIVE HYSTERECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58290 VAG HYST COMPLEX Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58291 VAG HYST INCL T/O COMPLEX Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58292 VAG HYST T/O AND REPAIR COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58294 VAG HYST WITH ENTEROCELE COMPL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58300 INSERT INTRAUTERINE DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58301 REMOVE INTRAUTERINE DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58321 ARTIFICIAL INSEMINATION Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58322 ARTIFICIAL INSEMINATION Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58323 SPERM WASHING Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58340 CATHETER FOR HYSTEROGRAPHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58345 REOPEN FALLOPIAN TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58346 INSERT HEYMAN UTERI CAPSULE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58350 REOPEN FALLOPIAN TUBE Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58353 ENDOMETR ABLATE THERMAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58356 ENDOMETRIAL CRYOABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58400 SUSPENSION OF UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58410 SUSPENSION OF UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58520 REPAIR OF RUPTURED UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58540 REVISION OF UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58541 LSH UTERUS 250 G OR LESS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58542 LSH WITH T/O UT 250 G OR LESS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58543 LSH UTERUS ABOVE 250 G Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58544 LSH WITH T/O UTERUS ABOVE 250 G Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58545 LAPAROSCOPIC MYOMECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58546 LAPARO-MYOMECTOMY COMPLEX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58548 LAP RADICAL HYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58550 LAPARO-ASST VAG HYSTERECTOMY Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58552 LAPARO-VAG HYST INCL T/O Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58553 LAPARO-VAG HYST COMPLEX Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58554 LAPARO-VAG HYST WITH T/O COMPL Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58555 HYSTEROSCOPY DX SEP PROC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58558 HYSTEROSCOPY BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58559 HYSTEROSCOPY LYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58560 HYSTEROSCOPY RESECT SEPTUM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58561 HYSTEROSCOPY REMOVE MYOMA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58562 HYSTEROSCOPY REMOVE FB Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58563 HYSTEROSCOPY ABLATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58565 HYSTEROSCOPY STERILIZATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58570 TLH UTERUS 250 G OR LESS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58571 TLH WITH T/O 250 G OR LESS Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58572 TLH UTERUS OVER 250 G Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58573 TLH WITH T/O UTERUS OVER 250 G Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58575 LAPS TOT HYST RESJ MAL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
58578 LAPARO PROC UTERUS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
58579 HYSTEROSCOPE PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
58580 TRANSCERVICAL ABLATION UTERINE FIBROID RF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58600 DIVISION OF FALLOPIAN TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58605 DIVISION OF FALLOPIAN TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58611 LIGATE OVIDUCT(S) ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58615 OCCLUDE FALLOPIAN TUBE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58660 LAPAROSCOPY LYSIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58661 LAPAROSCOPY REMOVE ADNEXA Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Yes
Authorization
58662 LAPAROSCOPY EXCISE LESIONS Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
58670 LAPAROSCOPY TUBAL CAUTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58671 LAPAROSCOPY TUBAL BLOCK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58672 LAPAROSCOPY FIMBRIOPLASTY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58673 LAPAROSCOPY SALPINGOSTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58674 LAPS ABLTJ UTERINE FIBROIDS WITH INTRAOP US GDN Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
58679 LAPARO PROC OVIDUCT-OVARY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
58700 REMOVAL OF FALLOPIAN TUBE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58720 REMOVAL OF OVARY/TUBE(S) Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58740 ADHESIOLYSIS TUBE OVARY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58750 REPAIR OVIDUCT Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58752 REVISE OVARIAN TUBE(S) Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58760 FIMBRIOPLASTY Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58770 CREATE NEW TUBAL OPENING Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58800 DRAINAGE OF OVARIAN CYST(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58805 DRAINAGE OF OVARIAN CYST(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58820 DRAIN OVARY ABSCESS OPEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58822 DRAIN OVARY ABSCESS PERCUT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58825 TRANSPOSITION OVARY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58900 BIOPSY OF OVARY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58920 PARTIAL REMOVAL OF OVARY(S) Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58925 REMOVAL OF OVARIAN CYST(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58940 REMOVAL OF OVARY(S) Tailored Plan Pre-authorization required for all providers when billed with a Gender Reassignment Dx. For all others, auth is required for non-participating providers only.
Con
Authorization
58943 REMOVAL OF OVARY(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58950 RESECT OVARIAN MALIGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58951 RESECT OVARIAN MALIGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58952 RESECT OVARIAN MALIGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58953 TAH RAD DISSECT FOR DEBULK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58954 TAH RAD DEBULK/LYMPH REMOVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58956 BSO OMENTECTOMY WITH TAH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58958 RESCJ RECR OVR TBL PP UTR MAL OMNTC PEL LMPHADEC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58960 EXPLORATION OF ABDOMEN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
58970 RETRIEVAL OF OOCYTE Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58974 TRANSFER OF EMBRYO Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Con
Authorization
58976 TRANSFER OF EMBRYO Tailored Plan Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Yes
Authorization
58999 GENITAL SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
59000 AMNIOCENTESIS DIAGNOSTIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59001 AMNIOCENTESIS THERAPEUTIC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59012 FETAL CORD PUNCTURE PRENATAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59015 CHORION BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59020 FETAL CONTRACT STRESS TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59025 FETAL NON-STRESS TEST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59030 FETAL SCALP BLOOD SAMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59050 FETAL MONITOR WITH REPORT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59051 FETAL MONITOR/INTERPRET ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59070 TRANSABDOM AMNIOINFUS WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59072 UMBILICAL CORD OCCLUD WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59074 FETAL FLUID DRAINAGE WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59076 FETAL SHUNT PLACEMENT WITH US Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59100 REMOVE UTERUS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59120 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59121 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59130 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59136 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59140 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59150 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59151 TREAT ECTOPIC PREGNANCY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59160 D AND C AFTER DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59200 INSERT CERVICAL DILATOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59300 EPISIOTOMY OR VAGINAL REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59320 REVISION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59325 REVISION OF CERVIX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59350 REPAIR OF UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59400 OBSTETRICAL CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59409 OBSTETRICAL CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59410 OBSTETRICAL CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59412 ANTEPARTUM MANIPULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59414 DELIVER PLACENTA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59425 ANTEPARTUM CARE ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59426 ANTEPARTUM CARE ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59430 CARE AFTER DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59510 CESAREAN DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59514 CESAREAN DELIVERY ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59515 CESAREAN DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59525 REMOVE UTERUS AFTER CESAREAN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59610 VBAC DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59612 VBAC DELIVERY ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59614 VBAC CARE AFTER DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59618 ATTEMPTED VBAC DELIVERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59620 ATTEMPTED VBAC DELIVERY ONLY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59622 ATTEMPTED VBAC AFTER CARE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59812 TREATMENT OF MISCARRIAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59820 CARE OF MISCARRIAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59821 TREATMENT OF MISCARRIAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59830 TREAT UTERUS INFECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59840 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59841 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59850 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59851 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59852 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59855 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59856 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59857 ABORTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59866 ABORTION (MPR) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59870 EVACUATE MOLE OF UTERUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
59871 REMOVE CERCLAGE SUTURE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
59897 FETAL INVAS PX WITH US Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
59898 LAPARO PROC OB CARE/DELIVER Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
59899 MATERNITY CARE PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
60000 DRAIN THYROID/TONGUE CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60100 BIOPSY OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60200 REMOVE THYROID LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60210 PARTIAL THYROID EXCISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60212 PARTIAL THYROID EXCISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60220 PARTIAL REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60225 PARTIAL REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60240 REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60252 REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60254 EXTENSIVE THYROID SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60260 REPEAT THYROID SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60270 REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60271 REMOVAL OF THYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60280 REMOVE THYROID DUCT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60281 REMOVE THYROID DUCT LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60300 ASPIR/INJ THYROID CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60500 EXPLORE PARATHYROID GLANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60502 RE-EXPLORE PARATHYROIDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60505 EXPLORE PARATHYROID GLANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60512 AUTOTRANSPLANT PARATHYROID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60520 REMOVAL OF THYMUS GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60521 REMOVAL OF THYMUS GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60522 REMOVAL OF THYMUS GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60540 EXPLORE ADRENAL GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60545 EXPLORE ADRENAL GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60600 REMOVE CAROTID BODY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60605 REMOVE CAROTID BODY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
60650 LAPAROSCOPY ADRENALECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
60659 LAPARO PROC ENDOCRINE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
60699 ENDOCRINE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
61000 REMOVE CRANIAL CAVITY FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61001 REMOVE CRANIAL CAVITY FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61020 REMOVE BRAIN CAVITY FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61026 INJECTION INTO BRAIN CANAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61050 REMOVE BRAIN CANAL FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61055 INJECTION INTO BRAIN CANAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61070 BRAIN CANAL SHUNT PROCEDURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61105 TWIST DRILL HOLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61107 DRILL SKULL FOR IMPLANTATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61108 DRILL SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61120 BURR HOLE FOR PUNCTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61140 PIERCE SKULL FOR BIOPSY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61150 PIERCE SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61151 PIERCE SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61154 PIERCE SKULL AND REMOVE CLOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61156 PIERCE SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61210 PIERCE SKULL IMPLANT DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61215 INSERT BRAIN-FLUID DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61250 PIERCE SKULL AND EXPLORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61253 PIERCE SKULL AND EXPLORE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61304 OPEN SKULL FOR EXPLORATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61305 OPEN SKULL FOR EXPLORATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61312 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61313 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61314 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61315 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61316 IMPLT CRAN BONE FLAP TO ABDO Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61320 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61321 OPEN SKULL FOR DRAINAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61322 DECOMPRESSIVE CRANIOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61323 DECOMPRESSIVE LOBECTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61330 DECOMPRESS EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61333 EXPLORE ORBIT/REMOVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61340 SUBTEMPORAL DECOMPRESSION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61343 INCISE SKULL (PRESS RELIEF) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61345 RELIEVE CRANIAL PRESSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61450 INCISE SKULL FOR SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61458 INCISE SKULL FOR BRAIN WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61460 INCISE SKULL FOR SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61500 REMOVAL OF SKULL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61501 REMOVE INFECTED SKULL BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61510 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61512 REMOVE BRAIN LINING LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61514 REMOVAL OF BRAIN ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61516 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61517 IMPLT BRAIN CHEMOTX ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61518 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61519 REMOVE BRAIN LINING LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61520 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61521 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61522 REMOVAL OF BRAIN ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61524 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61526 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61530 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61531 IMPLANT BRAIN ELECTRODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61533 IMPLANT BRAIN ELECTRODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61534 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61535 REMOVE BRAIN ELECTRODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61536 REMOVAL OF BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61537 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61538 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61539 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61540 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61541 INCISION OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61543 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61544 REMOVE AND TREAT BRAIN LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61545 EXCISION OF BRAIN TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61546 REMOVAL OF PITUITARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61548 REMOVAL OF PITUITARY GLAND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61550 RELEASE OF SKULL SEAMS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61552 RELEASE OF SKULL SEAMS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61556 INCISE SKULL/SUTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61557 INCISE SKULL/SUTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61558 EXCISION OF SKULL/SUTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61559 EXCISION OF SKULL/SUTURES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61563 EXCISION OF SKULL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61564 EXCISION OF SKULL TUMOR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61566 REMOVAL OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61567 INCISION OF BRAIN TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61570 REMOVE FOREIGN BODY BRAIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61571 INCISE SKULL FOR BRAIN WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61575 SKULL BASE/BRAINSTEM SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61576 SKULL BASE/BRAINSTEM SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61580 CRANIOFACIAL APPROACH SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61581 CRANIOFACIAL APPROACH SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61582 CRANIOFACIAL APPROACH SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61583 CRANIOFACIAL APPROACH SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61584 ORBITOCRANIAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61585 ORBITOCRANIAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61586 RESECT NASOPHARYNX SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61590 INFRATEMPORAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61591 INFRATEMPORAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61592 ORBITOCRANIAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61595 TRANSTEMPORAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61596 TRANSCOCHLEAR APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61597 TRANSCONDYLAR APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61598 TRANSPETROSAL APPROACH/SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61600 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61601 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61605 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61606 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61607 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61608 RESECT/EXCISE CRANIAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61611 TRANSECT ARTERY SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61613 REMOVE ANEURYSM SINUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61615 RESECT/EXCISE LESION SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61616 RESECT/EXCISE LESION SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61618 REPAIR DURA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61619 REPAIR DURA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61623 ENDOVASC TEMPORY VESSEL OCCL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61624 TCAT PERM OCCLS/EMBOLIZATION PERQ CNS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61626 TCAT PERM OCCLS/EMBOLJ PERQ NON-CNS HEAD/NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61630 INTRACRANIAL ANGIOPLASTY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61635 INTRACRAN ANGIOPLSTY WITH STENT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61640 DILATE IC VASOSPASM INIT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61641 PERQ BALO DILA IC VSPSM EA VSL SM VASC TER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61642 PERQ BALO DILA IC VSPSM EA VSL DIFF VASC TER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61645 PERQ ART M-THROMBECT AND/NFS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61650 EVASC PRLNG ADMN RX AGNT 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61651 EVASC PRLNG ADMN RX AGNT ADD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61680 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61682 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61684 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61686 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61690 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61692 INTRACRANIAL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61697 BRAIN ANEURYSM REPR COMPLX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61698 BRAIN ANEURYSM REPR COMPLX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61700 BRAIN ANEURYSM REPR SIMPLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61702 INNER SKULL VESSEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61703 CLAMP NECK ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61705 REVISE CIRCULATION TO HEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61708 REVISE CIRCULATION TO HEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61710 REVISE CIRCULATION TO HEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61711 FUSION OF SKULL ARTERIES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61850 IMPLANT NEUROELECTRODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61860 IMPLANT NEUROELECTRODES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61880 REVISE/REMOVE NEUROELECTRODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61885 INSRT/REDO NEUROSTIM 1 ARRAY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61886 IMPLANT NEUROSTIM ARRAYS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61888 REVISE/REMOVE NEURORECEIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61889 INSERTION SKULL-MNTD CRANIAL NSTIM PG/RECEIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61891 REVJ/RPLCMT SKULL-MNTD CRANIAL NSTIM PG/RECEIVER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
61892 REMOVAL SKULL-MNTD CRANIAL NSTIM PG/RCVR W/CRNOP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62000 TREAT SKULL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62005 TREAT SKULL FRACTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62010 TREATMENT OF HEAD INJURY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62100 REPAIR BRAIN FLUID LEAKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62115 REDUCTION OF SKULL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62117 REDUCTION OF SKULL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62120 REPAIR SKULL CAVITY LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62121 INCISE SKULL REPAIR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62140 REPAIR OF SKULL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62141 REPAIR OF SKULL DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62142 REMOVE SKULL PLATE/FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62143 REPLACE SKULL PLATE/FLAP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62145 REPAIR OF SKULL AND BRAIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62146 REPAIR OF SKULL WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62147 REPAIR OF SKULL WITH GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62148 RETR BONE FLAP TO FIX SKULL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62160 NEUROENDOSCOPY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62161 DISSECT BRAIN WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62162 REMOVE COLLOID CYST WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62164 REMOVE BRAIN TUMOR WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62165 REMOVE PITUIT TUMOR WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62180 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62190 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62192 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62194 REPLACE/IRRIGATE CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62200 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62201 BRAIN CAVITY SHUNT WITH SCOPE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62220 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62223 ESTABLISH BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62225 REPLACE/IRRIGATE CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62230 REPLACE/REVISE BRAIN SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62252 CSF SHUNT REPROGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62256 REMOVE BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62258 REPLACE BRAIN CAVITY SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62263 EPIDURAL LYSIS MULT SESSIONS Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62264 EPIDURAL LYSIS ON SINGLE DAY Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62267 INTERDISCAL PERQ ASPIR DX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62268 DRAIN SPINAL CORD CYST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62269 NEEDLE BIOPSY SPINAL CORD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62270 DIAGNOSTIC LUMBAR SPINAL PUNCTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62272 THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62273 INJECT EPIDURAL PATCH Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62280 TREAT SPINAL CORD LESION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62281 TREAT SPINAL CORD LESION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62282 TREAT SPINAL CANAL LESION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62284 INJECTION FOR MYELOGRAM Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
62287 DCMPRN PERQ NUCLEUS PULPOSUS 1/MLT LEVELS LUMBAR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
62290 NJX PX DISCOGRAPHY LUMBAR Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
62291 NJX PX DISCOGRAPHY CRV/THRC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62292 INJECTION INTO DISK LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62294 INJECTION INTO SPINAL ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62302 MYELOGRAPHY LUMBAR INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62303 MYELOGRAPHY LUMBAR INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62304 MYELOGRAPHY LUMBAR INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62305 MYELOGRAPHY LUMBAR INJECTION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62324 NJX DX/THER SBST INTRLMNR CRV/THRC WITH O IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62325 NJX DX/THER SBST INTRLMNR CRV/THRC WITH IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62326 NJX DX/THER SBST INTRLMNR LMBR/SAC WITH O IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62327 NJX DX/THER SBST INTRLMNR LMBR/SAC WITH IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62328 DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62329 THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62350 IMPLANT SPINAL CANAL CATH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62351 IMPLANT SPINAL CANAL CATH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62355 REMOVE SPINAL CANAL CATHETER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62360 INSERT SPINE INFUSION DEVICE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62361 IMPLANT SPINE INFUSION PUMP Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62362 IMPLANT SPINE INFUSION PUMP Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
62365 REMOVE SPINE INFUSION DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62367 ANALYZE SPINE INFUS PUMP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62368 ANALYZE SP INF PUMP WITH REPROG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62369 ANAL SP INF PMP WITH REPRGANDFILL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
62370 ANL SP INF PMP WITH MDREPRGANDFIL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
63003 REMOVE SPINE LAMINA 1/2 THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63011 REMOVE SPINE LAMINA 1/2 SCRL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63016 REMOVE SPINE LAMINA >2 THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63046 LAM FACETECTOMY AND FORAMOTOMY 1 VRT SGM THORACIC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63055 DECOMPRESS SPINAL CORD THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63064 DECOMPRESS SPINAL CORD THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63066 DECOMPRESS SPINE CORD ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63077 SPINE DISK SURGERY THORAX Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63078 SPINE DISK SURGERY THORAX Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63085 REMOVE VERT BODY DCMPRN THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63086 REMOVE VERTEBRAL BODY ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63087 REMOV VERTBR DCMPRN THRCLMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63088 REMOVE VERTEBRAL BODY ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63090 REMOVE VERT BODY DCMPRN LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63091 REMOVE VERTEBRAL BODY ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63101 REMOVE VERT BODY DCMPRN THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63102 REMOVE VERT BODY DCMPRN LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63103 REMOVE VERTEBRAL BODY ADD-ON Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63170 INCISE SPINAL CORD TRACT(S) Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63172 DRAINAGE OF SPINAL CYST Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63173 DRAINAGE OF SPINAL CYST Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63185 INCISE SPINE NRV HALF SEGMNT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63190 INCISE SPINE NRV >2 SEGMNTS Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63191 INCISE SPINE ACCESSORY NERVE Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63197 LAM W/CORDOTOMY SCTJ SPINOTHALAMIC TRC 1STG THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63200 RELEASE SPINAL CORD LUMBAR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63250 REVISE SPINAL CORD VSLS CRVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63251 REVISE SPINAL CORD VSLS THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63252 REVISE SPINE CORD VSL THRLMB Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63265 EXCISE INTRASPINL LESION CRV Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63266 EXCISE INTRSPINL LESION THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63267 EXCISE INTRSPINL LESION LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63268 EXCISE INTRSPINL LESION SCRL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63270 EXCISE INTRSPINL LESION CRVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63271 EXCISE INTRSPINL LESION THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63272 EXCISE INTRSPINL LESION LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63273 EXCISE INTRSPINL LESION SCRL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63275 BX/EXC XDRL SPINE LESN CRVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63276 BX/EXC XDRL SPINE LESN THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63277 BX/EXC XDRL SPINE LESN LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63278 BX/EXC XDRL SPINE LESN SCRL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63280 BX/EXC IDRL SPINE LESN CRVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63281 BX/EXC IDRL SPINE LESN THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63282 BX/EXC IDRL SPINE LESN LMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63283 BX/EXC IDRL SPINE LESN SCRL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63285 BX/EXC IDRL IMED LESN CERVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63286 BX/EXC IDRL IMED LESN THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63287 BX/EXC IDRL IMED LESN THRLMB Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63290 BX/EXC XDRL/IDRL LSN ANY LVL Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63295 REPAIR LAMINECTOMY DEFECT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63301 REMOVE VERT XDRL BODY THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63302 REMOVE VERT XDRL BODY THRLMB Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63303 REMOV VERT XDRL BDY LMBR/SAC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63305 REMOVE VERT IDRL BODY THRC Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63306 REMOV VERT IDRL BDY THRCLMBR Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
63307 REMOV VERT IDRL BDY LMBR/SAC Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
63700 REPAIR OF SPINAL HERNIATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63702 REPAIR OF SPINAL HERNIATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63704 REPAIR OF SPINAL HERNIATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63706 REPAIR OF SPINAL HERNIATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63707 REPAIR SPINAL FLUID LEAKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63709 REPAIR SPINAL FLUID LEAKAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63710 GRAFT REPAIR OF SPINE DEFECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63740 INSTALL SPINAL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63741 INSTALL SPINAL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63744 REVISION OF SPINAL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
63746 REMOVAL OF SPINAL SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64400 INJECTION AA AND /STRD TRIGEMINAL NERVE EACH BRANCH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64405 INJECTION AA AND /STRD GREATER OCCIPITAL NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64408 INJECTION AA AND /STRD VAGUS NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64415 INJECTION AA AND /STRD BRACHIAL PLEXUS W/IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64416 INJECTION AA AND /STRD BRACH PLEX CONT NFS CATH IMG Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64417 INJECTION AA AND /STRD AXILLARY NERVE W/IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64418 INJECTION AA AND /STRD SUPRASCAPULAR NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64420 INJECTION AA AND /STRD INTERCOSTAL NRV SINGLE LVL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64421 INJECTION AA AND /STRD INTERCOSTAL NRV EA ADDL LVL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64425 INJECTION AA AND /STRD ILIOINGUINAL IH NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64430 INJECTION AA AND /STRD PUDENDAL NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64435 INJECTION AA AND /STRD PARACERVICAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64445 INJECTION AA AND /STRD SCIATIC NERVE W/IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64446 INJECTION AA AND /STRD SCIATIC NRV CONT NFS CATH IMG Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64447 INJECTION AA AND /STRD FEMORAL NERVE W/IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64448 INJECTION AA AND /STRD FEMORAL NERVE CONT NFS CATH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64449 INJECTION AA AND /STRD LUMBAR PLEXUS CONT NFS CATH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64450 INJECTION AA AND /STRD OTHER PERIPHERAL NERVE/BRANCH Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64451 INJECTION AA AND /STRD NERVES NRVTG SI JOINT W/IMG Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64454 INJECTION AA AND /STRD GENICULAR NRV BRANCHES W/IMG Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64455 NJX AA AND /STRD PLANTAR COMMON DIGITAL NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64461 PVB THORACIC SINGLE INJ SITE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64462 PVB THORACIC 2NDPLUS INJ SITE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64463 PVB THORACIC CONT INFUSION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64486 TAP BLOCK UNIL BY INJECTION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64487 TAP BLOCK UNI BY INFUSION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64488 TAP BLOCK BI INJECTION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64489 TAP BLOCK BI BY INFUSION Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64505 N BLOCK SPENOPALATINE GANGL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64553 IMPLANT NEUROELECTRODES Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64555 IMPLANT NEUROELECTRODES Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64561 IMPLANT NEUROELECTRODES Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64566 NEUROELTRD STIM POST TIBIAL Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Yes
Authorization
64568 OPEN IMPLANTATION CRANIAL NERVE NEA AND PULSE GEN Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
64569 REVISE/REPL VAGUS N ELTRD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64570 REMOVE VAGUS N ELTRD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64575 OPEN IMPLANTATION NEA PERIPHERAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64580 OPEN IMPLANTATION NEA NEUROMUSCULAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64581 OPEN IMPLANTATION NEA SACRAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64585 REVISE/REMOVE NEUROELECTRODE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64590 INS/RPLC PERPH SAC/GSTRC NPG/RCVR PCKT CRTJ AND CONN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64595 REV/RMV PRPH SAC/GSTRC NPG/RCV DTCH CONN ELTR RA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64596 INSJ/RPLCMT PERQ ELTRD RA PN W/INT NSTIM 1ST RA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64597 INSJ/RPLCMT PERQ ELTRD RA PN INT NSTIM EA ADD RA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64598 REVISION/REMOVAL NSTIM ELTRD ARRAY PN INT NSTIM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64600 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64605 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64610 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64611 CHEMODENERV SALIV GLANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64612 DESTROY NERVE FACE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64615 CHEMODENERV MUSC MIGRAINE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64616 CHEMODENERV MUSC NECK DYSTON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64617 CHEMODENER MUSCLE LARYNX EMG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64620 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64624 DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64625 RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64630 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64632 N BLOCK INJ COMMON DIGIT Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64640 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64642 CHEMODENERV 1 EXTREMITY 1-4 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64643 CHEMODENERV 1 EXTREM 1-4 EA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64644 CHEMODENERV 1 EXTREM 5/> MUS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64645 CHEMODENERV 1 EXTREM 5/> EA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64646 CHEMODENERV TRUNK MUSC 1-5 Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64647 CHEMODENERV TRUNK MUSC 6/> Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64650 CHEMODENERV ECCRINE GLANDS Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64653 CHEMODENERV ECCRINE GLANDS Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64680 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64681 INJECTION TREATMENT OF NERVE Tailored Plan Pre-authorization is required for all providers unless performed on the same day as surgery.
Con
Authorization
64702 REVISE FINGER/TOE NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64704 REVISE HAND/FOOT NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64708 REVISE ARM/LEG NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64712 REVISION OF SCIATIC NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64713 REVISION OF ARM NERVE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64714 REVISE LOW BACK NERVE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64716 REVISION OF CRANIAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64718 REVISE ULNAR NERVE AT ELBOW Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64719 REVISE ULNAR NERVE AT WRIST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64721 CARPAL TUNNEL SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64722 RELIEVE PRESSURE ON NERVE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64726 RELEASE FOOT/TOE NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64727 INTERNAL NERVE REVISION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64732 INCISION OF BROW NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64734 INCISION OF CHEEK NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64736 INCISION OF CHIN NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64738 INCISION OF JAW NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64740 INCISION OF TONGUE NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64742 INCISION OF FACIAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64744 INCISE NERVE BACK OF HEAD Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64746 INCISE DIAPHRAGM NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64755 INCISION OF STOMACH NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64760 INCISION OF VAGUS NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64763 INCISE HIP/THIGH NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64766 INCISE HIP/THIGH NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64771 SEVER CRANIAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64772 INCISION OF SPINAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64774 REMOVE SKIN NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64776 REMOVE DIGIT NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64778 DIGIT NERVE SURGERY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64782 REMOVE LIMB NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64783 LIMB NERVE SURGERY ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64784 REMOVE NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64786 REMOVE SCIATIC NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64787 IMPLANT NERVE END Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64788 REMOVE SKIN NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64790 REMOVAL OF NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64792 REMOVAL OF NERVE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64795 BIOPSY OF NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64802 SYMPATHECTOMY CERVICAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64804 REMOVE SYMPATHETIC NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64809 REMOVE SYMPATHETIC NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64818 REMOVE SYMPATHETIC NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64820 SYMPATHECTOMY DIGITAL ARTERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64821 REMOVE SYMPATHETIC NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64822 REMOVE SYMPATHETIC NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64823 SYMPATHECTOMY SUPFC PALMAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64831 REPAIR OF DIGIT NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64832 REPAIR NERVE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64834 REPAIR OF HAND OR FOOT NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64835 REPAIR OF HAND OR FOOT NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64836 REPAIR OF HAND OR FOOT NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64837 REPAIR NERVE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64840 REPAIR OF LEG NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64856 REPAIR/TRANSPOSE NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64857 REPAIR ARM/LEG NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64858 REPAIR SCIATIC NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64859 NERVE SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64861 REPAIR OF ARM NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64862 REPAIR OF LOW BACK NERVES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64864 REPAIR OF FACIAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64865 REPAIR OF FACIAL NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64866 FUSION OF FACIAL/OTHER NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64868 FUSION OF FACIAL/OTHER NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64872 SUBSEQUENT REPAIR OF NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64874 REPAIR AND REVISE NERVE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64876 REPAIR NERVE/SHORTEN BONE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64885 NERVE GRAFT HEAD/NECK Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64886 NERVE GRAFT HEAD/NECK >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64890 NERVE GRAFT HAND/FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64891 NERVE GRAFT HAND/FOOT >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64892 NERVE GRAFT ARM/LEG <4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64893 NERVE GRAFT ARM/LEG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64895 NERVE GRAFT HAND/FOOT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64896 NERVE GRAFT HAND/FOOT >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64897 NERVE GRAFT ARM/LEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64898 NERVE GRAFT ARM/LEG >4 CM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64901 NERVE GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64902 NERVE GRAFT ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64905 NERVE PEDICLE TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64907 NERVE PEDICLE TRANSFER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64910 NERVE REPAIR WITH ALLOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64911 NEURORRAPHY WITH VEIN AUTOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64912 NRV RPR WITH NRV ALGRFT 1ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
64913 NRV RPR WITH NRV ALGRFT EA ADDL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
64999 NERVOUS SYSTEM SURGERY Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
65091 REVISE EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65093 REVISE EYE WITH IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65101 REMOVAL OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65103 REMOVE EYE/INSERT IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65105 REMOVE EYE/ATTACH IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65110 REMOVAL OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65112 REMOVE EYE/REVISE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65114 REMOVE EYE/REVISE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65125 REVISE OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65130 INSERT OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65135 INSERT OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65140 ATTACH OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65150 REVISE OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65155 REINSERT OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65175 REMOVAL OF OCULAR IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65205 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65210 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65220 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65222 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65235 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65260 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65265 REMOVE FOREIGN BODY FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65270 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65272 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65273 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65275 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65280 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65285 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65286 REPAIR OF EYE WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65290 REPAIR OF EYE SOCKET WOUND Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65400 REMOVAL OF EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65410 BIOPSY OF CORNEA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65420 REMOVAL OF EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65426 REMOVAL OF EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65430 CORNEAL SMEAR Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65435 CURETTE/TREAT CORNEA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65436 CURETTE/TREAT CORNEA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65450 TREATMENT OF CORNEAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65600 REVISION OF CORNEA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65710 CORNEAL TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65730 CORNEAL TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65750 CORNEAL TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65755 CORNEAL TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65756 CORNEAL TRNSPL ENDOTHELIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65757 PREP CORNEAL ENDO ALLOGRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65760 REVISION OF CORNEA Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
65765 REVISION OF CORNEA Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
65767 CORNEAL TISSUE TRANSPLANT Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
65770 REVISE CORNEA WITH IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65771 RADIAL KERATOTOMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65772 CORRECTION OF ASTIGMATISM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65775 CORRECTION OF ASTIGMATISM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65778 COVER EYE WITH MEMBRANE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65779 COVER EYE WITH MEMBRANE SUTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65780 OCULAR RECONST TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65781 OCULAR RECONST TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65782 OCULAR RECONST TRANSPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65785 IMPLTJ NTRSTRML CRNL RNG SEG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65800 DRAINAGE OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65810 DRAINAGE OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65815 DRAINAGE OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65820 RELIEVE INNER EYE PRESSURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65850 INCISION OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65855 TRABECULOPLASTY LASER SURG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65860 INCISE INNER EYE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65865 INCISE INNER EYE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65870 INCISE INNER EYE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65875 INCISE INNER EYE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65880 INCISE INNER EYE ADHESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65900 REMOVE EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65920 REMOVE IMPLANT OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
65930 REMOVE BLOOD CLOT FROM EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66020 INJECTION TREATMENT OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66030 INJECTION TREATMENT OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66130 REMOVE EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66150 GLAUCOMA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66155 GLAUCOMA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66160 GLAUCOMA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66170 GLAUCOMA SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66172 INCISION OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66174 TRLUML DILAT AQUEOUS O/F CAN WO RETENTION DEV/ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66175 TRLUML DILAT AQUEOUS O/F CAN W/RETENTION DEV/ST Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66179 AQUEOUS SHUNT EYE WITH O GRAFT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66180 IMPLANT EYE SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66183 INSERT ANT DRAINAGE DEVICE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66184 REVISION OF AQUEOUS SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66185 REVISE EYE SHUNT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66225 REPAIR/GRAFT EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66250 FOLLOW-UP SURGERY OF EYE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66500 INCISION OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66505 INCISION OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66600 REMOVE IRIS AND LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66605 REMOVAL OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66625 REMOVAL OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66630 REMOVAL OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66635 REMOVAL OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66680 REPAIR IRIS AND CILIARY BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66682 REPAIR IRIS AND CILIARY BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66700 DESTRUCTION CILIARY BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66710 CILIARY TRANSSLERAL THERAPY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66711 ECP CILIARY BODY DSTRJ W/O RMVL CRYSTALLINE LENS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66720 DESTRUCTION CILIARY BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66740 DESTRUCTION CILIARY BODY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66761 REVISION OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66762 REVISION OF IRIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66770 REMOVAL OF INNER EYE LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66820 INCISION SECONDARY CATARACT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66821 AFTER CATARACT LASER SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66825 REPOSITION INTRAOCULAR LENS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66830 REMOVAL OF LENS LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66840 REMOVAL OF LENS MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66850 REMOVAL OF LENS MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66852 REMOVAL OF LENS MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66920 EXTRACTION OF LENS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66930 EXTRACTION OF LENS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66940 EXTRACTION OF LENS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66982 XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX WO ECP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66983 CATARACT SURG WITH IOL 1 STAGE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66984 XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66985 INSERT LENS PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66986 EXCHANGE LENS PROSTHESIS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66987 XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX W/ECP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66988 XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/ECP Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66989 XCAPSL CTRC RMVL INSJ IO LENS PRSTH CPLX INSJ 1+ Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66990 OPHTHALMIC ENDOSCOPE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
66991 XCAPSL CTRC RMVL INSJ IO LENS PROSTH INSJ 1+ Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
66999 EYE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
67005 PARTIAL REMOVAL OF EYE FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67010 PARTIAL REMOVAL OF EYE FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67015 RELEASE OF EYE FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67025 REPLACE EYE FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67027 IMPLANT EYE DRUG SYSTEM Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67028 INJECTION EYE DRUG Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67030 INCISE INNER EYE STRANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67031 LASER SURGERY EYE STRANDS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67036 REMOVAL OF INNER EYE FLUID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67039 LASER TREATMENT OF RETINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67040 LASER TREATMENT OF RETINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67041 VIT FOR MACULAR PUCKER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67042 VIT FOR MACULAR HOLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67043 VIT FOR MEMBRANE DISSECT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67101 REPAIR DETACHED RETINA CRTX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67105 REPAIR DETACHED RETINA PC Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67107 REPAIR DETACHED RETINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67108 REPAIR DETACHED RETINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67110 REPAIR DETACHED RETINA Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67113 REPAIR RETINAL DETACH CPLX Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67115 RELEASE ENCIRCLING MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67120 REMOVE EYE IMPLANT MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67121 REMOVE EYE IMPLANT MATERIAL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67141 PROPH RETINAL DTCHMNT W/O DRG CRTX DIATHERMY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67145 PROPH RETINAL DTCHMNT W/O DRG PHOTOCOAGULATION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67208 TREATMENT OF RETINAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67210 TREATMENT OF RETINAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67218 TREATMENT OF RETINAL LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67220 TREATMENT OF CHOROID LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67221 OCULAR PHOTODYNAMIC THER Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67225 EYE PHOTODYNAMIC THER ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67227 DSTRJ EXTENSIVE RETINOPATHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67228 TREATMENT X10SV RETINOPATHY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67229 TR RETINAL LES PRETERM INF Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67250 REINFORCE EYE WALL Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67255 REINFORCE/GRAFT EYE WALL Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
67299 EYE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
67311 REVISE EYE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67312 REVISE TWO EYE MUSCLES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67314 REVISE EYE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67316 REVISE TWO EYE MUSCLES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67318 REVISE EYE MUSCLE(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67320 REVISE EYE MUSCLE(S) ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67331 EYE SURGERY FOLLOW-UP ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67332 REREVISE EYE MUSCLES ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67334 REVISE EYE MUSCLE WITH SUTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67335 EYE SUTURE DURING SURGERY Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67340 REVISE EYE MUSCLE ADD-ON Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67343 RELEASE EYE TISSUE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67345 DESTROY NERVE OF EYE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67346 BIOPSY EYE MUSCLE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
67399 EYE MUSCLE SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
67400 EXPLORE/BIOPSY EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67405 EXPLORE/DRAIN EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67412 EXPLORE/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67413 EXPLORE/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67414 EXPLR/DECOMPRESS EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67415 ASPIRATION ORBITAL CONTENTS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67420 EXPLORE/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67430 EXPLORE/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67440 EXPLORE/DRAIN EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67445 EXPLR/DECOMPRESS EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67450 EXPLORE/BIOPSY EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67500 INJECT/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67505 INJECT/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67515 INJECT/TREAT EYE SOCKET Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67550 INSERT EYE SOCKET IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67560 REVISE EYE SOCKET IMPLANT Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67570 DECOMPRESS OPTIC NERVE Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
67599 ORBIT SURGERY PROCEDURE Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
67700 DRAINAGE OF EYELID ABSCESS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67710 INCISION OF EYELID Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
67715 INCISION OF EYELID FOLD Tailored Plan Pre-authorization is required for all providers.
Con
Authorization
67800 REMOVE EYELID LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67801 REMOVE EYELID LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67805 REMOVE EYELID LESIONS Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67808 REMOVE EYELID LESION(S) Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67810 BIOPSY EYELID AND LID MARGIN Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67820 REVISE EYELASHES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67825 REVISE EYELASHES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67830 REVISE EYELASHES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67835 REVISE EYELASHES Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67840 REMOVE EYELID LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67850 TREAT EYELID LESION Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67875 CLOSURE OF EYELID BY SUTURE Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67880 REVISION OF EYELID Tailored Plan Pre-authorization required for non-participating providers only.
Con
Authorization
67882 REVISION OF EYELID Tailored Plan Pre-authorization required for non-participating providers only.
Yes
Authorization
67901 REPAIR EYELID DEFECT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
67902 REPAIR EYELID DEFECT Tailored Plan Pre-authorization is required for all providers.
Yes
Authorization
67903 REPAIR EYELID DEFECT Tailored Plan Pre-authorization is required for all providers.