Prior authorization codes
Blue Cross Blue Shield of Massachusetts
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0362T | (ABA).pdf Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 0373T | (ABA).pdf Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 1019T | 037 Surgical and Debulking Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 11970 | 428 Reconstructive Breast Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 11971 | 428 Reconstructive Breast Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15780 | 068 Plastic Surgery Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15781 | 068 Plastic Surgery Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15782 | 068 Plastic Surgery Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15783 | 068 Plastic Surgery Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15820 | 740 Blepharoplasty, Blepharoptosis Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15821 | 740 Blepharoplasty, Blepharoptosis Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15822 | 740 Blepharoplasty, Blepharoptosis Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15823 | 740 Blepharoplasty, Blepharoptosis Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15824 | Rhytidectomy; forehead | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15826 | Rhytidectomy; glabellar frown lines | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15828 | Rhytidectomy; cheek, chin, and neck | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15830 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15832 | 043 Suction lipectomy for lipedema.pdf Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15833 | 043 Suction lipectomy for lipedema.pdf Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15834 | 043 Suction lipectomy for lipedema.pdf Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15835 | 043 Suction lipectomy for lipedema.pdf Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15836 | 043 Suction lipectomy for lipedema.pdf Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15876 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15877 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15878 | 037 Surgical and Debulking Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 15879 | 037 Surgical and Debulking Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 17380 | Electrolysis epilation, each 30 minutes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19303 | Mastectomy, simple, complete | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19316 | 428 Reconstructive Breast Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19318 | 428 Reconstructive Breast Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19325 | 428 Reconstructive Breast Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19328 | Surgery/Management of Breast and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19330 | Surgery/Management of Breast and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19340 | Surgery/Management of Breast and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19342 | Surgery/Management of Breast and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19350 | Surgery/Management of Breast and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19355 | Implants | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19357 | Implants | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19361 | Implants | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19364 | Implants | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19366 | Implants | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19367 | 703 Reduction Mammaplasty for 19396, S2066, S2067, S2068: Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19368 | 703 Reduction Mammaplasty for 19396, S2066, S2067, S2068: Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19369 | 703 Reduction Mammaplasty for 19396, S2066, S2067, S2068: Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19371 | 703 Reduction Mammaplasty for 19396, S2066, S2067, S2068: Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19380 | 703 Reduction Mammaplasty for 19396, S2066, S2067, S2068: Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 19396 | 703 Reduction Mammaplasty for , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 20930 | does not require prior authorization. Effective 4/1/2024 | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21010 | 035 Temporomandibular Joint Disorder Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21050 | 035 Temporomandibular Joint Disorder Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21060 | 035 Temporomandibular Joint Disorder Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21073 | 4/2025 MP 035 Temporomandibular Joint Disorder clarified. CPT codes and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21116 | 4/2025 MP 035 Temporomandibular Joint Disorder clarified. CPT codes and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21121 | Genioplasty; sliding osteotomy, single piece | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21125 | Augmentation, mandibular body or angle; prosthetic material | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21137 | Reduction forehead; contouring only | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21193 | 130 Surgical Treatment of Snoring and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21194 | 130 Surgical Treatment of Snoring and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21195 | 130 Surgical Treatment of Snoring and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21196 | 130 Surgical Treatment of Snoring and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21198 | 130 Surgical Treatment of Snoring and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21199 | Obstructive Sleep Apnea Syndrome and POS , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21206 | Obstructive Sleep Apnea Syndrome and POS , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21209 | Osteoplasty, facial bones; reduction | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21240 | 035 Temporomandibular Joint Disorder Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21242 | 035 Temporomandibular Joint Disorder Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21243 | and POS , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21270 | Malar augmentation, prosthetic material | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 21685 | Obstructive Sleep Apnea Syndrome and POS , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 27279 | 320 Diagnosis and Treatment of Commercial HMO : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 29800 | and POS , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 29804 | and POS , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30400 | 068 Plastic Surgery Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30410 | and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30420 | and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30430 | and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30435 | and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 30450 | and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 31599 | Unlisted procedure, larynx | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 31660 | 284 Bronchial Thermoplasty Commercial HMO , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 31661 | 284 Bronchial Thermoplasty Commercial HMO , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36465 | 238 Treatment of Varicose Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36466 | 238 Treatment of Varicose Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36470 | 238 Treatment of Varicose Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36471 | 238 Treatment of Varicose Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36475 | 238 Treatment of Varicose Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36476 | Veins/Venous Insufficiency and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36478 | Veins/Venous Insufficiency and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36479 | Veins/Venous Insufficiency and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36482 | Veins/Venous Insufficiency and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 36483 | Complete Prior Authorization Request 37735, 37760, 37761, 37765, 37766, | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37500 | Complete Prior Authorization Request 37735, 37760, 37761, 37765, 37766, | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37700 | Complete Prior Authorization Request 37735, 37760, 37761, 37765, 37766, | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37718 | Complete Prior Authorization Request 37735, 37760, 37761, 37765, 37766, | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37722 | Complete Prior Authorization Request 37735, 37760, 37761, 37765, 37766, | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37735 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37760 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37761 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37765 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37766 | Complete Prior Authorization Request | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37780 | Form for Treatment of Varicose , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 37785 | Form for Treatment of Varicose , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38205 | 4/2020 The following codes were removed: ; ; ; ; . Effective | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38206 | 4/2020 The following codes were removed: ; ; ; ; . Effective | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38230 | 4/2020 The following codes were removed: ; ; ; ; . Effective | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38232 | 4/2020 The following codes were removed: ; ; ; ; . Effective | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38240 | 074 Hematopoietic Stem Cell All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 38241 | 075 Hematopoietic Cell All commercial , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 42145 | Obstructive Sleep Apnea Syndrome and POS , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43210 | 920 Magnetic Esophageal Ring to Commercial HMO , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43284 | 920 Magnetic Esophageal Ring to Commercial HMO , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43644 | 379 Medical and Surgical Management Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43770 | 379 Medical and Surgical Management Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43775 | 379 Medical and Surgical Management Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43845 | 379 Medical and Surgical Management Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43846 | 379 Medical and Surgical Management Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43847 | 5/2021 Prior authorization requirements clarified: ; ; in effect. added | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 43848 | of Obesity including Anorexiants Managed Care (HMO : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 53410 | Urethroplasty, 1-stage reconstruction of male anterior urethra | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 53420 | Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 53425 | Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 53430 | Urethroplasty, reconstruction of female urethra | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54120 | Amputation of penis; partial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54125 | Amputation of penis; complete | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54300 | Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54660 | Insertion testicular prosthesis | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54900 | Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 54901 | Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 55175 | Scrotoplasty; simple | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 55180 | Scrotoplasty; complex | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 55870 | Electroejaculation | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 55970 | Intersex surgery; male to female | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 55980 | Intersex surgery; female to male | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 56620 | Vulvectomy; simple | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 56625 | Vulvectomy; complete | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 56800 | Plastic repair of introitus | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 56805 | Clitoroplasty for intersex state | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 56810 | Perineoplasty, repair of perineum, nonobstetrical | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 57110 | Vaginectomy; complete removal of vaginal wall | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 57111 | Vaginectomy; with removal of paravaginal tissue (radical vaginectomy) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 57291 | Construction of artificial vagina; without graft | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 57292 | Construction of artificial vagina; with graft | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 57335 | Vaginoplasty for intersex state | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58321 | Prior authorization is no longer required for , , ; . These codes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58322 | Prior authorization is no longer required for , , ; . These codes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58323 | Prior authorization is no longer required for , , ; . These codes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58825 | 8/2025 MP 086 Assisted Reproductive Services Infertility Services. Removed from Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58970 | Follicle puncture for egg retrieval, any method | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58974 | Embryo transfer, intrauterine | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 58976 | Gamete, zygote, or embryo intrafallopian transfer, any method | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 59866 | 2/2025 Code Multifetal pregnancy reduction removed. Effective 2/1/2025 | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 64628 | 485 Intraosseous Basivertebral Nerve Commercial HMO Prior authorization is required | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 64629 | 5/2025 MP 485 Intraosseous Basivertebral Nerve Ablation clarified. CPT removed. Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67900 | 740 Blepharoplasty, Blepharoptosis Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67901 | Repair and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67902 | Repair and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67903 | Repair and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67904 | Repair and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67906 | Repair and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 67908 | Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 74740 | Prior authorization is no longer required for , , ; . These codes | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89250 | Culture of egg(s)/embryo(s), less than 4 days | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89253 | Assisted embryo hatching, microtechniques (any method) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89254 | Egg identification from follicular fluid | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89255 | Preparation of embryo for transfer (any method) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89257 | Sperm identification from aspiration (other than seminal fluid) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89258 | Cryopreservation; embryo(s) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89259 | Cryopreservation; sperm | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89260 | Sperm isolation; simple prep (eg. per col gradient, albumin gradient) for insemination or | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89261 | Sperm isolation; complex prep (eg, per col gradient, albumin gradient) for insemination or | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89264 | Sperm identification from testis tissue, fresh or cryopreserved | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89268 | Insemination of eggs | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89272 | Extended culture of egg(s)/embryo(s), 4-7 days | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89280 | Assisted egg fertilization, microtechnique; less than or equal to 10 egg | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89281 | Assisted egg fertilization, microtechnique; greater than 10 eggs | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89290 | 088 Preimplantation Genetic Testing All commercial , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89291 | 088 Preimplantation Genetic Testing All commercial , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89321 | Semen analysis, presence and/or motility of sperm | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89335 | Cryopreservation, reproductive tissue, testicular (Covered effective 11/1/2009) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89337 | Cryopreservation, mature egg(s) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89342 | Storage, (per year); embryo(s) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89343 | Storage, (per year); sperm/semen | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89344 | Storage, (per year); reproductive tissue, testicular/ovarian (except for authorized TESE) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89346 | Storage, (per year); egg | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89352 | Thawing for cryopreserved; embryo(s) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89353 | Thawing of cryopreserved; sperm/semen, each aliquot | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian (except for authorized | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 89356 | Thawing of cryopreserved; egg(s), each aliquot | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 90867 | 297 Transcranial Magnetic Stimulation Commercial HMO , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 90868 | 297 Transcranial Magnetic Stimulation Commercial HMO , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 90869 | 297 Transcranial Magnetic Stimulation Commercial HMO , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 93580 | 121 Closure Devices for Patent All commercial : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 95940 | 211 Intraoperative Neurophysiologic All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 95941 | 211 Intraoperative Neurophysiologic All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 96130 | 151 Neuropsychological and Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 96131 | 151 Neuropsychological and Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 96132 | 151 Neuropsychological and Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 96133 | 151 Neuropsychological and Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97151 | 091 Applied Behavioral Analysis Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97152 | 091 Applied Behavioral Analysis Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97153 | 091 Applied Behavioral Analysis Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97154 | 091 Applied Behavioral Analysis Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97155 | 091 Applied Behavioral Analysis Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97156 | (ABA).pdf Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97157 | (ABA).pdf Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| 97158 | (ABA).pdf Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| A0426 | 146 Ground Ambulance Commercial ; : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| A0428 | 146 Ground Ambulance Commercial ; : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| A0430 | 142 Air Ambulance Transport Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| A0431 | 142 Air Ambulance Transport Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| A4239 | 1/2023 MP#107- removed as it was deleted and replaced with . Effective 1/1/2023 | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| C1062 | 5/2021 Prior authorization requirements clarified: ; ; in effect. added | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| C9081 | 10/2021 HCPCS code & added | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| C9399 | 008 Zolgensma (onasemnogene All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| G0277 | 11/2021 HCPCS code added. Prior authorization is required. Policy #653 Hyperbaric Oxygen | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| G0453 | 211 Intraoperative Neurophysiologic All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| G2082 | 087 Esketamine Nasal Spray All commercial , : Prior authorization | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| G2083 | 087 Esketamine Nasal Spray All commercial , : Prior authorization | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| H0015 | 194 Behavioral Health Continuum of All commercial , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| H0035 | 194 Behavioral Health Continuum of All commercial , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J0174 | 946 Monoclonal Antibodies for All commercial : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J0175 | Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J1411 | 168 Gene Therapies for Hemophilia A All commercial , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J1412 | 168 Gene Therapies for Hemophilia A All commercial , : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J2001 | 5/2020 HCPCS code removed. The code is not specific to policy #087 Esketamine Nasal | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3387 | 241 Gene Therapies for Cerebral All commercial Skysona | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3389 | 229 Gene Therapy for Treatment of All commercial Zevaskyn | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3393 | 215 Gene Therapies for Thalassemia All commercial Zynteglo | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3394 | 050 Gene Therapies for Sickle Cell All commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3398 | 911 Cell and Gene Therapy for Ocular All commercial ; : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3399 | Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3402 | 028 Omidubicel as Adjunct Treatment All commercial Prior authorization is required | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3403 | 911 Cell and Gene Therapy for Ocular All commercial ; : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3490 | 008 Zolgensma (onasemnogene All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J3590 | 008 Zolgensma (onasemnogene All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J7352 | 077 Scenesse afamelanotide for the All commercial : Prior authorization is required | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| J9269 | 009 Elzonris (tagraxofusp-erzs) for the All commercial : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0553 | 1/2023 MP#107- removed as it was deleted and replaced with . Effective 1/1/2023 | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0813 | Wheelchairs Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0814 | Wheelchairs Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0815 | Wheelchairs Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0816 | Wheelchairs Managed Care (HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0820 | and POS) and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0821 | and POS) and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0822 | and POS) and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0823 | and POS) and | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0824 | Complete Prior Authorization Request Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0825 | Complete Prior Authorization Request Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0826 | Complete Prior Authorization Request Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0827 | Complete Prior Authorization Request Commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0828 | Form using Authorization Manager PPO/EPO products | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0829 | Form using Authorization Manager PPO/EPO products | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0830 | Form using Authorization Manager PPO/EPO products | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0831 | Form using Authorization Manager PPO/EPO products | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0835 | ▪ Massachusetts Collaborative Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0836 | ▪ Massachusetts Collaborative Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0837 | ▪ Massachusetts Collaborative Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0838 | ▪ Massachusetts Collaborative Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0839 | Authorization Form OR | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0840 | Authorization Form OR | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0841 | Authorization Form OR | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0842 | Authorization Form OR | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0843 | ▪ Blue Cross Blue Shield of | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0848 | ▪ Blue Cross Blue Shield of | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0849 | ▪ Blue Cross Blue Shield of | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0850 | ▪ Blue Cross Blue Shield of | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0851 | Massachusetts Precertification | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0852 | Massachusetts Precertification | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0853 | Massachusetts Precertification | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0854 | Massachusetts Precertification | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0855 | Request Form | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0856 | Request Form | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0857 | Request Form | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0858 | Request Form | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0859 | K0863; K0864; K0890; K0891; | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0860 | K0863; K0864; K0890; K0891; | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0861 | K0863; K0864; K0890; K0891; | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0862 | K0863; K0864; K0890; K0891; | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0863 | K0898: Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0864 | K0898: Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0890 | K0898: Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0891 | K0898: Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K0898 | Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| K1014 | 133 Microprocessor Controlled Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L5856 | 133 Microprocessor Controlled Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L5857 | 133 Microprocessor Controlled Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L5858 | 133 Microprocessor Controlled Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6026 | 227 Myoelectric Prosthetic and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6925 | 227 Myoelectric Prosthetic and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6935 | 227 Myoelectric Prosthetic and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6945 | 227 Myoelectric Prosthetic and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6955 | 227 Myoelectric Prosthetic and Commercial HMO | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6965 | Orthotic Components for the Upper and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L6975 | Orthotic Components for the Upper and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7007 | Orthotic Components for the Upper and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7008 | Orthotic Components for the Upper and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7009 | Orthotic Components for the Upper and POS | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7045 | Limb | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7180 | Limb | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7181 | Limb | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7190 | Limb | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| L7191 | Limb | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2041 | 066 Chimeric Antigen Receptor All commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2042 | 066 Chimeric Antigen Receptor All commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2053 | 066 Chimeric Antigen Receptor All commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2054 | 066 Chimeric Antigen Receptor All commercial | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2055 | 942 Chimeric Antigen Receptor All commercial : Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| Q2056 | Prior authorization is | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S0201 | 194 Behavioral Health Continuum of All commercial , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S1036 | 12/2022 MP#107- removed . Prior authorization is no longer required for this code | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2066 | 703 Reduction Mammaplasty for , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2067 | 703 Reduction Mammaplasty for , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2068 | 703 Reduction Mammaplasty for , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2140 | 4/2020 The following codes were removed: ; ; ; ; . Effective | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2142 | 074 Hematopoietic Stem Cell All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2150 | 074 Hematopoietic Stem Cell All commercial , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S2202 | Form for Treatment of Varicose , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S4011 | In vitro fertilization, including but not limited to identification and incubation of mature eggs | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S4026 | Procurement of donor sperm from sperm bank | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S4028 | Microsurgical epididymal sperm aspiration (MESA) | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S4030 | Sperm procurement & cryopreservation services; initial visit | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S4031 | Sperm procurement & cryopreservation services; subsequent visits | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S9480 | 194 Behavioral Health Continuum of All commercial , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S9960 | 142 Air Ambulance Transport Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |
| S9961 | 142 Air Ambulance Transport Commercial HMO , , , : Prior | 2025-07-01 | 2022-06-01 | 97% | [PDF] Medical Policy Outpatient Prior Authorization Code List for ... |