Prior authorization codes
Imperial Health Plan
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0200T | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0201T | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0362T | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0373T | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0537T | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0538T | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0539T | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 0540T | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 11960 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 11971 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 14000 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 14001 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 14041 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15734 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15738 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15750 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15757 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15758 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15775 | 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15776 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15780 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15781 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15782 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15783 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15788 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15789 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15792 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15793 | 19303, 21899, 31599, 31899, 53410, 53420, 53425, 53430, 54125, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15820 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15821 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15822 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15823 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15830 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15847 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15877 | Cosmetic and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15878 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 15879 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 17106 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 17107 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 17108 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 17999 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 19303 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 19316 | Breast reconstruction | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 19318 | Breast reconstruction | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 19325 | Breast reconstruction | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20930 | Spine surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20931 | Spine surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20939 | Spine surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20974 | Bone growth stimulator | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20975 | Bone growth stimulator | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 20979 | Bone growth stimulator | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21120 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21121 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21122 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21123 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21125 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21127 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21141 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21142 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21143 | Orthognathic surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21145 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21146 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21147 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21150 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21151 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21154 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21155 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21159 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21160 | 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21172 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21175 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21179 | reconstructive procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21180 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21181 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21182 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21183 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21184 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21188 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21193 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21194 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21195 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21196 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21198 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21199 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21206 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21210 | 21215, 21240, 21242, 21244, 21245, 21246, 21247 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21215 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21230 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21235 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21240 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21242 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21244 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21245 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21246 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21247 | Orthotics Prior authorization required for orthotics codes listed with a retail | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21248 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21249 | 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21275, 21299, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21255 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21256 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21260 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21261 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21263 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21267 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21268 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21275 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21299 | 21740, 21742, 21743, 28344, 30540, 30545, 30560, 30620, 31295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21685 | Sleep apnea procedures and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21740 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21742 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21743 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 21899 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22100 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22101 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22102 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22110 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22112 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22114 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22206 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22207 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22210 | Orthopedic surgeries | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22212 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22214 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22220 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22222 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22224 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22532 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22533 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22548 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22551 | 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22554 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22556 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22558 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22590 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22595 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22600 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22610 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22612 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22630 | 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22633 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22800 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22802 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22804 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22808 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22810 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22812 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22818 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22819 | 22830, 22849, 22850, 22852, 22855, 22856, 22861, 22867, 22869, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22830 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22849 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22850 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22852 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22854 | Spine surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22855 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22856 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22858 | Spine surgery | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22861 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22867 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22869 | 22899, 23470, 23472, 24360, 24361, 24362, 24363, 24365, 25441, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 22899 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 23470 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 23472 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 24360 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 24361 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 24362 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 24363 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 24365 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 25441 | 25442, 25444, 25446, 25449, 27120, 27122, 27125, 27130, 27132, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 25442 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 25444 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 25446 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 25449 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27120 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27122 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27125 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27130 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27132 | 27134, 27137, 27138, 27412, 27445, 27446, 27447, 27486, 27487, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27134 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27137 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27138 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27412 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27415 | Cartilage Implants | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27416 | Cartilage Implants | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27445 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27446 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27447 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27486 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27487 | 27700, 29834, 29837, 29838, 29840, 29844, 29845, 29846, 29847, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 27700 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 28344 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 28890 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29834 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29837 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29838 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29840 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29844 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29845 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29846 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29847 | 29866, 29867, 29868, 29891, 29892, 29894, 29895, 29897, 29898, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29866 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29867 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29868 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29891 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29892 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29894 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29895 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29897 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29898 | 29899, 29914, 29915, 29916, 63001, 63003, 63005, 63011, 63012, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29899 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29914 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29915 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 29916 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30400 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30410 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30420 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30430 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30435 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30450 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30460 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30462 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30465 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30540 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30545 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30560 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 30620 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31295 | 31296, 31297, 31298, 31299, 67900, 67901, 67902, 67903, 67904, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31296 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31297 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31298 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31299 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31599 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 31899 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32850 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32851 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32852 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32853 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32854 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32855 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 32856 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33285 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33289 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33927 | Ventricular assist devices (VAD) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33928 | Ventricular assist devices (VAD) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33929 | Ventricular assist devices (VAD) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33930 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33933 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33935 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33940 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33944 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33945 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33975 | Ventricular assist devices (VAD) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33976 | 33983 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33979 | 33983 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33981 | 33983 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33982 | 33983 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 33983 | Nuclear medicine and nuclear cardiology procedure. | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 36514 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37220 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37221 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37224 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37225 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37226 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37227 | Cartilage Implants 27415, 27416 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37228 | Cartilage Implants 27415, 27416 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37229 | Cartilage Implants 27415, 27416 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37230 | Cartilage Implants 27415, 27416 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37231 | Cartilage Implants 27415, 27416 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37243 | Vein Procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 37799 | Vein Procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38208 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38209 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38210 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38212 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38213 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38214 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38215 | *38232, 44137, 44715, 44720, 44721, 47133, 47140, 47141, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38232 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38240 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 38241 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 41512 | Sleep apnea procedures and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 41530 | Sleep apnea procedures and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 41599 | Sleep apnea procedures and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 42145 | Sleep apnea procedures and | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44132 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44133 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44135 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44136 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44137 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44715 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44720 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 44721 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47133 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47135 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47140 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47141 | * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47142 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47143 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47144 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47145 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47146 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 47147 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 48551 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 48552 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 48554 | 33933, 38208, 38209, 38210, 38212, 38213, 38214, 38215, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50300 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50320 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50323 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50325 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50340 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50360 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50365 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50370 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 50547 | 48554, 47135, 47143, 47147, 44132, 44133, 44135, 44136, 32855, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 52441 | Prostate procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 52442 | Prostate procedures | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 53410 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 53420 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 53425 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 53430 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54125 | 54400, 54401, 54405, 54408, 54520, 54660, 54690, 55175, 55180, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54400 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54401 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54405 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54408 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54520 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54660 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 54690 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55175 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55180 | 55866, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55866 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55874 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55970 | Gender dysphoria treatment , , The below surgical codes, when billed with one of | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 55980 | Gender dysphoria treatment , , The below surgical codes, when billed with one of | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 56625 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 56800 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 56805 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57106 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57110 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57291 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57292 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57295 | 57296, 57335, 57426,58661, 58720, 58940, 64856, 64892, 64896, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57296 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57335 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 57426 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58150 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58152 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58180 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58260 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58262 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58263 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58267 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58270 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58290 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58291 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58292 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58294 | Hysterectomy (vaginal) – | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58541 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58542 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58543 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58544 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58550 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58552 | Hysterectomy (abdominal | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58553 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58554 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58570 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58571 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58572 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58573 | and laparoscopic surgeries) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58661 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58720 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 58940 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61850 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61863 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61864 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61867 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61868 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61885 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 61886 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 62350 | Pain management | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 62351 | Pain management | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 62360 | Pain management | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 62361 | Pain management | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 62362 | Pain management | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63001 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63003 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63005 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63011 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63012 | 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63015 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63016 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63017 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63020 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63030 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63040 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63042 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63045 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63046 | 63047, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63047 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63050 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63051 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63055 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63056 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63064 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63075 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63077 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63081 | 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63085 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63087 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63090 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63101 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63102 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63170 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63172 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63173 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63185 | 63190, 63191, 63197, 63200, 0200T, 0201T | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63190 | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63191 | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63197 | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63200 | UMC APPROVAL DATE: 12/18/2024 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63650 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63655 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 63685 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64405 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64555 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64568 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64590 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64722 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64744 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64856 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64892 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 64896 | 92507, 92508 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 66180 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67900 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67901 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67902 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67903 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67904 | 67906, 67908, 67909, 67912, 67950, 67961, 67966, Q2026 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67906 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67908 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67909 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67912 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67950 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67961 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 67966 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 69714 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 69930 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77014 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77331 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77370 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77371 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77372 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77373 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77385 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77386 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77387 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77399 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77401 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77402 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77407 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77412 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77470 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77520 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77522 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77523 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 77525 | 77412, G6003, G6004, G6005, G6006, G6007, G6008, G6009, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90283 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90284 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90867 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90868 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90869 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 90870 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 92507 | F64.0 F64.1 F64.2 F64.8 F64.9 Z87.890 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 92508 | F64.0 F64.1 F64.2 F64.8 F64.9 Z87.890 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 92526 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 93653 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 93656 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 95965 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 95966 | Potentially unproven | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96116 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96121 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96130 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96131 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96132 | Behavioral Health Services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96133 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96136 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96137 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96138 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96139 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 96146 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97012 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97016 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97018 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97022 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97024 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97026 | Outpatient therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97028 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97032 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97033 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97034 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97035 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97036 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97039 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97110 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97112 | (PT/OT/ST, chiropractic) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97113 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97116 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97124 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97139 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97140 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97150 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97151 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97152 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97153 | 97154, 97155, 97156, 97157, 97158, 0362T, 0373T ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97154 | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97155 | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97156 | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97157 | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97158 | ***Behavioral | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97164 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97168 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97530 | 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97533 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97535 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97537 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97542 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97545 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97546 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97750 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97755 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97760 | 97761, 97799, G0129, G0283,*98940, *98941, *98942 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97761 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 97799 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 98242 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 98940 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 98941 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 98942 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 99205 | Transplant of tissue or organs | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 99503 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| 99505 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A0430 | Non-emergency air | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A0431 | Non-emergency air | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A0435 | Non-emergency air | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A0436 | Non-emergency air | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A4238 | Continuous Glucosemonitor | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A4239 | Continuous Glucosemonitor | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A9513 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A9590 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A9606 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A9607 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| A9699 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| C2624 | services (including | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| C9172 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| C9399 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0466 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0616 | Cardiovascular | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0747 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0748 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0749 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0760 | Stimulators | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E0766 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E1230 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E1239 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E2102 | Continuous Glucosemonitor | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E2103 | Continuous Glucosemonitor | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| E2510 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0129 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0151 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0152 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0153 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0155 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0156 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0157 | Home health care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0158 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0159 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0160 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0161 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0162 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0283 | * , * , * | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0299 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0300 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0339 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0340 | services | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0493 | G0494, G0495, G0496, G2168, G2169, S9122, S9123, S9124, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0494 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0495 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G0496 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G2168 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G2169 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6001 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6002 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6003 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6004 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6005 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6006 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6007 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6008 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6009 | G6010, G6011, G6012, G6013, G6014 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6010 | linked services) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6011 | linked services) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6012 | linked services) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6013 | linked services) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6014 | linked services) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6015 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6016 | Therapeutic radiology | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| G6017 | Radiation therapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0129 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0172 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0174 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0175 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0177 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0178 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0179 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0185 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0222 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0223 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0224 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0225 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0491 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0584 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0585 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0586 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0587 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0588 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0589 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0640 | Chemotherapy Chemotherapy injectable drugs ( – ), leucovorin ( ) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0641 | levoleucovorin ( , ), chemotherapy injectable drugs that | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0642 | levoleucovorin ( , ), chemotherapy injectable drugs that | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0791 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0885 | Cardiology Prior authorization required for participating physicians for | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0896 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J0897 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1300 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1301 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1302 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1304 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1305 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1306 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1411 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1412 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1413 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1437 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1439 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1442 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1447 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1448 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1449 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1453 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1454 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1456 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1459 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1551 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1554 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1555 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1556 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1557 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1558 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1559 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1561 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1566 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1568 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1569 | J1572, J1575, J1576, J1599, J1745, J1437, J1439, J2782, Q5136, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1572 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1575 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1576 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1599 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1627 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1745 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1747 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1748 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J1823 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2267 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2326 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2327 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2329 | Q5122, Q5125, Q5127, Q5130, J3247, J0584, J1413, J1302, J3380, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2350 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2356 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2506 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2507 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2777 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2778 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2779 | Q5124, Q5128, J3032, J3401, J9332, J9334, J3399, J1748 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2781 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2782 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2820 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J2998 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3032 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3111 | Q5122, Q5125, Q5127, Q5130, J3247, J0584, J1413, J1302, J3380, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3241 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3247 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3380 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3393 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3394 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3398 | J0129, J0224, J1301, J0896, J9311, J9312, Q5123, J1412, J2998, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3399 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3401 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3490 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J3590 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7171 | Injectable medications | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7320 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7321 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7322 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7323 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7324 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7326 | J7327, J7329, J7331, J7332, 90283, 90284, J1459, J1551, J1554, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7327 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7329 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7331 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J7332 | J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9000 | Chemotherapy Chemotherapy injectable drugs ( – ), leucovorin ( ) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9311 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9312 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9332 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9333 | A9513, A9590, A9606, A9607, A9699, J9381, J3490, J3590, C9172, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9334 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9381 | C9399, J1823, J2777, J0177, J0178, J0179, J2777, J2778, J2779, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| J9999 | Chemotherapy Chemotherapy injectable drugs ( – ), leucovorin ( ) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0801 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0806 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0808 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0831 | Non-Prosthetic Durable medical | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0835 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0836 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0837 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0838 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0839 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0840 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0841 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0842 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0843 | equipment | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0848 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0849 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0850 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0851 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0852 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0854 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0855 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0856 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0857 | (DME) | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0858 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0859 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0860 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0861 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0862 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0863 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0864 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0877 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0884 | K0890, K0891, K0898, K0899 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0890 | End-stage renal Advance notification is required if a plan member is referred to an | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0891 | End-stage renal Advance notification is required if a plan member is referred to an | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0898 | End-stage renal Advance notification is required if a plan member is referred to an | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| K0899 | End-stage renal Advance notification is required if a plan member is referred to an | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L5301 | Prosthetics | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L5856 | Prosthetics | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L5968 | Prosthetics | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L5981 | Prosthetics | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L5987 | Prosthetics | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8600 | Breast reconstruction | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8614 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8619 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8682 | L8683 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8683 | Therapeutic radiology 77385, 77386, G6015, G6016, 77371, 77372, 77373, G0339, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8690 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8691 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| L8692 | Cochlear and other auditory | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2026 | HCPCS code. Notification required for injectable chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2041 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2042 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2053 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2054 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2055 | Q2056, C9399, J3490, J3590 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q2056 | Nuclear medicine and nuclear cardiology procedure. | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5101 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5108 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5110 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5111 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5120 | Q5122, Q5125, Q5127, Q5130, J3247, J0584, J1413, J1302, J3380, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5122 | Cancer supportive care | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5123 | J9333, J0491, J2327, J1300, J1747, J2326, J2781, J3241, J2356, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5124 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5125 | J0885 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5127 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5128 | Inpatient only | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5130 | J1305, J0223, J1411, J7320, J7321, J7322, J7323, J7324, J7326, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| Q5136 | J0175, J2507, J0174, J1306, J3398, J1304, J2350, J2267, J0222, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S2060 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S2061 | 50320, 50323, 50340, 50360, 50365, 50370, 50547, 48551, 48552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S2152 | 0540T, J3393, J3394, Q2041, Q2042, Q2053, Q2054, Q2055, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9122 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9123 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9124 | S9127, S9128, S9129, S9131, S9474 | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9127 | Hysterectomy (abdominal 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58550, 58552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9128 | Hysterectomy (abdominal 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58550, 58552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9129 | Hysterectomy (abdominal 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58550, 58552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9131 | Hysterectomy (abdominal 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58550, 58552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |
| S9474 | Hysterectomy (abdominal 58150, 58152, 58180, 58541, 58542, 58543, 58544, 58550, 58552, | 2026-07-06 | Not listed | 97% | [PDF] PRIOR AUTHORIZATION LIST | Imperial Health Plan |