Prior authorization codes
Mass Advantage
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0051T | Heart | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0052T | Heart | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0053T | Heart | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0095T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0098T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0163T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0164T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0165T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0202T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0219T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0220T | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0221T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0222T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0274T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0275T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0466T | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0467T | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0468T | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0524T | LTAC Level – 120 Rehab Level 1 – 120 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0656T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 0657T | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15820 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15821 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15822 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15823 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15830 | Medicare Reference:; NCD 150.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15832 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15833 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15834 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15835 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15836 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15837 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15838 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15839 | Abdominoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15847 | Medicare Reference:; NCD 150.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15876 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15877 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15878 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 15879 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 17999 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 20912 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 20999 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 21210 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 21685 | admission. (5 days authorized on | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22100 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22101 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22102 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22103 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22116 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22206 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22207 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22208 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22210 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22212 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22214 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22216 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22222 | L33569 Percutaneous Vertebral | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22226 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22510 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22511 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22512 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22513 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22514 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22515 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22526 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22527 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22532 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22533 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22534 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22548 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22551 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22552 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22554 | Augmentation (PVA) for Osteoporotic | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22556 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22558 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22585 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22586 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22590 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22595 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22600 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22610 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22612 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22614 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22630 | LCD L35936 Facet Joint Interventions | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22632 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22633 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22634 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22800 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22802 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22804 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22808 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22810 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22812 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22818 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22819 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22830 | for Pain Management; Psychiatric | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22840 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22841 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22842 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22843 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22844 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22845 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22846 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22847 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22848 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22849 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22853 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22854 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22856 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22857 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22858 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22859 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22861 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22862 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22867 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22868 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22869 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22870 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 22899 | Benefit Policy Manual Chapter 1 – | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 23472 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 23473 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 23474 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 26535 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 26536 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27125 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27130 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27132 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27134 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27137 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27138 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27279 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27280 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27437 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27438 | Inpatient Acute Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27440 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27441 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27442 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27443 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27444 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27445 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27446 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27447 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27486 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 27487 | and Acute Psychiatric Hospitalization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28110 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28240 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28285 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28289 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28291 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28292 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28295 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28296 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28297 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28298 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28299 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28306 | 150.13 Percutaneous Image-Guided | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28308 | Lumbar Decompression for Lumbar | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28310 | Lumbar Decompression for Lumbar | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28740 | Lumbar Decompression for Lumbar | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 28750 | Lumbar Decompression for Lumbar | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30400 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30410 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30420 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30430 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30435 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30450 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30460 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30462 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30465 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30468 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 30520 | Rhinoplasty | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 32850 | Lung | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 32851 | Lung | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 32852 | Lung | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 32853 | Lung | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 32854 | Lung | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33221 | Cardiac Resynchronization Therapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33224 | Cardiac Resynchronization Therapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33225 | Cardiac Resynchronization Therapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33321 | Cardiac Resynchronization Therapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33875 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33877 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33880 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33881 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33883 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33886 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33930 | Medicare Reference NCD 260.9 v.3 and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33935 | Medicare Reference NCD 260.9 v.3 and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33940 | Heart | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 33945 | Heart | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34701 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34702 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34703 | Aortic, Implants, etc | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34704 | Aortic, Implants, etc | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34705 | Medicare References: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34706 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34830 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34831 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34832 | Lumbar Artificial Disc Replacement | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34841 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34842 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34843 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34845 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34846 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34847 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 34848 | (LADR) NCD 150.11 Thermal | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36465 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36466 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36468 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36470 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36471 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36473 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36474 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36475 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36476 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36478 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36479 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36482 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 36483 | 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37500 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37700 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37718 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37722 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37735 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37760 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37761 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37765 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37766 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37780 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37785 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37961 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37966 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37971 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37973 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37974 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 37975 | Outpatient Surgery and Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 38230 | Bone Marrow – Peripheral Stem Cell | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 38240 | Bone Marrow – Peripheral Stem Cell | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 38241 | Bone Marrow – Peripheral Stem Cell | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 38242 | Bone Marrow – Peripheral Stem Cell | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 41512 | admission. (5 days authorized on | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 41530 | admission. (5 days authorized on | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 41599 | admission. (5 days authorized on | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 42145 | admission. (5 days authorized on | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 44132 | Intestine | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 44133 | Intestine | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 44135 | Intestine | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 44136 | Intestine | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 47135 | Liver and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 47136 | Liver and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 48160 | Pancreas | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 48550 | Pancreas | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 48554 | Pancreas | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 48556 | Pancreas | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50300 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50320 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50340 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50360 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50365 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50370 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50380 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 50547 | Kidney | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 52341 | Radiopharmaceutical Tumor | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 52342 | Radiopharmaceutical Tumor | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 52343 | Radiopharmaceutical Tumor | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 60799 | Outpatient Surgery and Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 62287 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 62380 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63001 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63003 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63005 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63011 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63012 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63015 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63016 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63017 | Inpatient Hospital Services | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63020 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63030 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63035 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63040 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63042 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63043 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63044 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63045 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63046 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63047 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63048 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63050 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63051 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63052 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63053 | Minimally-invasive Surgical (MIS) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63054 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63055 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63056 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63057 | 63064, 63066, 63075-63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63064 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63066 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63075 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63076 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63077 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63078 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63081 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63082 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63085 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63086 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63087 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63088 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63090 | 63091, 63101, 63102, 63103 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63091 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63101 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63102 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63103 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63170 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63172 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63173 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63185 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63190 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63191 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63194 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63195 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63196 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63197 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63198 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63199 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63200 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63250 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63251 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63252 | 63265-63268, 63270-63273, 63275-63278, 63280-63283, 63285-63287, 63290 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63265 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63266 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63267 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63268 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63270 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63271 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63272 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63273 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63275 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63276 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63277 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63278 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63280 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63281 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63282 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63283 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63285 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63286 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63287 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63290 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63295 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63300 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63301 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63302 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63303 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63304 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63305 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63306 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63307 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 63308 | 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, C1821, C2614, C9757, S2348, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 64568 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67900 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67901 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67902 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67903 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67904 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67906 | required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67908 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67909 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67911 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67914 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67915 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67916 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67917 | • Continued stay review required | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67921 | • Retrospective admission requires | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67922 | • Retrospective admission requires | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67923 | • Retrospective admission requires | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67924 | • Retrospective admission requires | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67930 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67935 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67938 | 37975, 60799 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 67950 | • Retrospective admission requires | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70450 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70460 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70470 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70540 | Brain, Orbits, Face, Neck MRI | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70551 | Functional MRI Brain | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70552 | Functional MRI Brain | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 70553 | Functional MRI Brain | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 72192 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 72193 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 72194 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 74150 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 74160 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 74170 | Abdomen, Brain, Pelvis CT | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 75574 | CTA Coronary Arteries | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 76498 | Unlisted MRI | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78608 | Brain PET Scan | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78609 | Brain PET Scan | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78811 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78812 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78813 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78814 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78815 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 78816 | Medicare References: NCD 220.6.16 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81105 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81106 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81107 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81108 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81109 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81110 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81111 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81112 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81113 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81120 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81121 | Genetic Testing | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81161 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81162 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81163 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81164 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81165 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81166 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81167 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81170 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81171 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81172 | Medicare Reference: NCD 90.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81173 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81174 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81175 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81176 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81177 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81178 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81179 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81180 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81181 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81182 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81183 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81184 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81185 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81186 | 81187, 81188, 81189, 81190, 81233, 81288, 81292, 81293, 81294, 81295, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81187 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81188 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81189 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81190 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81200 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81201 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81202 | Version 2 Next Generation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81203 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81204 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81205 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81206 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81207 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81208 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81209 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81210 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81212 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81215 | Sequencing; NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81216 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81217 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81218 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81219 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81220 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81221 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81222 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81223 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81224 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81225 | 190.7 Human Tumor Stem Cell Drug 81226, 81227-81270, 81235, 81236, 81237, 81245, 81246, 81256, 81261, 81262, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81226 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81227 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81228 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81229 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81230 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81231 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81232 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81233 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81234 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81235 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81236 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81237 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81238 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81239 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81240 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81241 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81242 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81243 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81244 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81245 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81246 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81247 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81248 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81249 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81250 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81251 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81252 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81253 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81254 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81255 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81256 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81257 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81258 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81259 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81260 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81261 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81262 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81263 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81264 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81265 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81266 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81267 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81268 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81269 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81270 | 190.7 Human Tumor Stem Cell Drug | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81271 | 81277, 81283, 81284, 81285, 81286, 81289, 81290, 81291, 81302, 81303, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81272 | Sensitivity Assays; LCD L38371 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81273 | Sensitivity Assays; LCD L38371 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81274 | 81277, 81283, 81284, 81285, 81286, 81289, 81290, 81291, 81302, 81303, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81275 | Sensitivity Assays; LCD L38371 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81276 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81277 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81278 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81283 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81284 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81285 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81286 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81287 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81288 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81289 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81290 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81291 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81292 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81293 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81294 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81295 | 81296, 81297, 81298, 81299, 81300, 81306, 81312, 81317, 81318, 81319, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81296 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81297 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81298 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81299 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81300 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81301 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81302 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81303 | 81304, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81336, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81304 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81305 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81306 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81307 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81308 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81309 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81310 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81311 | Multimarker Serum Tests Related to | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81312 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81313 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81314 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81315 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81316 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81317 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81318 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81319 | 81320, 81321, 81322, 81323, 81333, 81343, 81344, 81599, 81105‒81112, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81320 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81321 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81322 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81323 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81324 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81325 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81326 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81327 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81328 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81329 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81330 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81331 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81332 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81333 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81334 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81335 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81336 | 81337, 81346, 81350, 81355, 81361‒81364, 81384, 81410, 81411, 81412, 81413, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81337 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81338 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81340 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81341 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81342 | Ovarian Cancer Testing; LCD L35000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81343 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81344 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81345 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81346 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81347 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81350 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81355 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81361 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81364 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81365 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81370 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81371 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81372 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81373 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81374 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81375 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81376 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81377 | Molecular Pathology Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81378 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81379 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81380 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81381 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81382 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81383 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81384 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81410 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81411 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81412 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81413 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81414 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81415 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81416 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81417 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81418 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81420 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81422 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81425 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81426 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81427 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81428 | 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81430 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81431 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81432 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81433 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81434 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81435 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81436 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81437 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81438 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81439 | 81440, 81441, 81442, 81443, 81448, 81455, 81460, 81465, 81470, 81471, 81493, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81440 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81441 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81442 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81443 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81448 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81455 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81460 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81465 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81470 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81471 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81493 | 81500, 81503, 81504, 81507, 81521, 81522, 81523, 81525, 81535, 81536, 81538, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81500 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81503 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81504 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81507 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81518 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81519 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81520 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81521 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81522 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81523 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81525 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81535 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81536 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81538 | 81540, 81541, 81542, 81543, 81545, 81551, 81552 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81540 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81541 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81542 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81543 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81545 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81551 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81552 | Defibrillators | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81595 | 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 81599 | ‒ | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93303 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93304 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93305 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93307 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93308 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93320 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93321 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93322 | Transthoracic Echocardiogram | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93325 | Stress Echocardiogram Medicare | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93350 | Stress Echocardiogram Medicare | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93351 | Stress Echocardiogram Medicare | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93352 | Stress Echocardiogram Medicare | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93452 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93454 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93455 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93456 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93457 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93458 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93459 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93460 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93461 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93462 | Heart Catheterization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93463 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93464 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93465 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93466 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93467 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93468 | Medicare References: NCD 220.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93668 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93737 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 93798 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 95806 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 95807 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 95808 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 95810 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 95811 | Attended Sleep Testing Procedures | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99217 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99218 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99219 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99220 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99221 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99222 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99223 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99224 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99225 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99226 | Observation | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99234 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99235 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| 99236 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| C1821 | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| C2614 | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| C9757 | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0277 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0350 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0352 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0370 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0425 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0430 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0435 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0440 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0466 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0482 | Mobility Assistive Equipment (MAE) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0483 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0485 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0486 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0500 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0610 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0615 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0616 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0617 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0620 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0625 | NCD 280.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0635 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0636 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0637 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0638 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0639 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0640 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0641 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0642 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0656 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0657 | INDEPENDENCE iBOT 4000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0670 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0671 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0672 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0673 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0675 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0676 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0691 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0692 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0693 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0694 | Mobility System LCD L33788 Revision | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0705 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0744 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0745 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0746 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0747 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0748 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0749 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0755 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0760 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0761 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0762 | 4 Manual Wheelchair Bases LCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0764 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0765 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0766 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0769 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0770 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0782 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0783 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0784 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0785 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0786 | L33789 Revision 7 Power Mobility | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0787 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0791 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0830 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0936 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0941 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0950 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0951 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0952 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0953 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0954 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0955 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0956 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0957 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0958 | for these items will not be paid unless a Medical Necessity and Home | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0959 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0960 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0961 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0966 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0967 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0968 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0969 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0971 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0973 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0974 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0978 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0980 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0981 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0982 | E0953 E0954 E0955 E0956 E0957 E0958 E0705 E0950 E0951 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0983 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0984 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0985 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0986 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0988 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0990 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0992 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0994 | E0980 E0981 E0982 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0952 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E0995 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1002 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1003 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1004 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1005 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1006 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1007 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1008 | Devices LCD L33792 Wheelchair | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1009 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1010 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1011 | E0983 E0984 E0985 E0988 E0990 E0992 E0994 E0971 E0973 E0974 E0978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1012 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1014 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1015 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1016 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1017 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1018 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1020 | E1011 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1028 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1029 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1030 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1031 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1035 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1036 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1037 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1038 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1039 | E1015 E1016 E1017 E1018 E1020 E0995 E1002 E1003 E1004 E1009 E1010 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1050 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1060 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1070 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1083 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1084 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1087 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1088 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1092 | E1087 E1088 E1028 E1029 E1030 E1031 E1037 E1038 E1039 E1012 E1014 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1093 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1100 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1110 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1150 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1160 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1161 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1170 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1171 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1172 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1180 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1190 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1195 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1200 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1220 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1221 | E1070 E1083 E1084 E1087 E1088 E1092 E1050 E1060 E1070 E1083 E1084 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1222 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1223 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1224 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1225 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1226 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1227 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1228 | E1195 E1200 E1221 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1060 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1229 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1230 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1231 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1232 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1233 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1234 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1235 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1236 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1237 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1238 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1239 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1240 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1270 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1280 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1295 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1296 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1297 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1298 | E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1171 E1172 E1180 E1190 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1500 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1510 | Options/Accessories LCD L33312 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1520 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1530 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1540 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1550 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1560 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1570 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1575 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1580 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1590 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1592 | Wheelchair Seating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1594 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1600 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1610 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1615 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1620 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1625 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1629 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1630 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1632 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1635 | E1699, E1902, E2204, E2331, E2341, E2342, E2343, E2351, E2358, E2500, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1699 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E1902 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2201 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2202 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2203 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2204 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2205 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2206 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2207 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2208 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2209 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2210 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2211 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2212 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2213 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2214 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2215 | E1280 E1295 E1297 E1298 E1231 E1232 E1233 E1234 E1235 E1236 E1237 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2216 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2217 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2218 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2219 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2220 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2221 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2222 | E2215 E2201 E2202 E2203 E2205 E2206 E2207 E2208 E1238 E1240 E1270 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2224 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2225 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2226 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2227 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2228 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2231 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2310 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2311 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2312 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2313 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2321 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2322 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2323 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2324 | E2218 E2219 E2220 E2221 E2222 E2209 E2210 E2211 E2212 E2213 E2214 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2325 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2326 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2327 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2328 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2329 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2330 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2331 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2340 | E2323 E2324 E2224 E2225 E2226 E2227 E2228 E2231 E2310 E2216 E2217 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2341 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2342 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2343 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2351 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2358 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2359 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2360 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2361 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2362 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2363 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2366 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2367 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2368 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2369 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2370 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2371 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2372 | E2326 E2327 E2328 E2329 E2330 E2340 E2311 E2312 E2313 E2321 E2322 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2373 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2374 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2375 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2376 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2377 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2378 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2381 | E2370 E2371 E2372 E2359 E2360 E2361 E2362 E2361 E2362 E2363 E2325 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2382 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2383 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2384 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2385 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2386 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2387 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2388 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2389 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2390 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2391 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2392 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2394 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2395 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2396 | E2373 E2374 E2375 E2376 E2377 E2378 E2381 E2366 E2367 E2368 E2369 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2397 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2500 | E2502, E2504, E2506, E2508, E2510, E2511, E2626, E2627, E2628, E2629, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2502 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2504 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2506 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2508 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2510 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2511 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2601 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2602 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2603 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2604 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2605 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2606 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2607 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2608 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2611 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2612 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2613 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2614 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2615 | E2392 E2394 E2395 E2396 E2382 E2383 E2384 E2385 E2386 E2387 E2388 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2616 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2619 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2620 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2621 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2622 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2623 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2624 | E2615 E2397 E2601 E2602 E2603 E2604 E2605 E2606 E2389 E2390 E2391 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2625 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2626 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2627 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2628 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2629 | E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0455, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2630 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2631 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2632 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| E2633 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0068 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0069 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0070 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0151 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0152 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0153 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0155 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0156 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0157 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0158 | Medicare Reference: NCD 290.1 G0159, G0160, G0161, G0162, G2168, G2169, G0299, G0300, G0333, G0490, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0159 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0160 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0161 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0162 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0299 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0300 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0333 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0378 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0379 | Medicare Reference: None | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0422 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0423 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0424 | Cardiac / Pulmonary , , , , and | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0490 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0493 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0494 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0495 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0496 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G0498 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G2168 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G2169 | Medicare Reference: NCD 290.1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| G9147 | Version 2 Home Health Visits to a | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J0178 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J0585 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J0881 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J0885 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J0897 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J1459 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J1561 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J1569 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J1602 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J1745 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2350 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2353 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2357 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2469 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2505 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J2778 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J3262 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J3380 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J3489 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J3590 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7320 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7321 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7322 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7323 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7324 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7325 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7326 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7327 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J7328 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9022 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9034 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9035 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9041 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9145 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9173 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9217 | Version 1 Anti-Cancer Chemotherapy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9228 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9264 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9271 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9299 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9305 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9306 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9312 | Medicare References: NCD 110.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| J9355 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0001 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0002 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0003 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0004 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0005 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0006 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0007 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0008 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0009 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0010 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0011 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0012 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0013 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0014 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0015 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0017 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0018 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0019 | E2620 E2621 E2622 E2623 E2624 E2607 E2608 E2611 E2612 E2613 E2614 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0020 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0037 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0038 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0039 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0040 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0041 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0042 | K0018 K0019 E2625 E2631 E2632 E2633 K0001 K0002 K0003 E2616 E2619 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0043 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0044 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0045 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0046 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0047 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0050 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0051 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0052 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0053 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0056 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0065 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0069 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0070 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0071 | K0037 K0038 K0039 K0040 K0041 K0042 K0004 K0006 K0007 K0015 K0017 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0072 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0073 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0077 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0098 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0105 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0195 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0455 | K0606, K0730, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0606 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0730 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0733 | K0069 K0070 K0071 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0020 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0800 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0801 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0802 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0806 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0807 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0808 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0812 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0813 | K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0814 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0815 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0816 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0820 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0821 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0822 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0823 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0824 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0825 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0826 | K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0827 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0828 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0829 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0830 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0831 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0835 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0836 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0837 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0838 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0839 | K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0840 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0841 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0842 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0843 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0848 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0849 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0850 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0851 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0852 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0853 | K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0854 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0855 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0856 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0857 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0858 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0859 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0860 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0861 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0862 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0863 | K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0884, K0885, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0864 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0868 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0869 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0870 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0871 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0877 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0878 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0879 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0884 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0885 | K0886, K0890, K0891, K0898, K0899, K0900, K1001, K1002, K1003, K1004, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0886 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0890 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0891 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0898 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0899 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K0900 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1001 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1002 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1003 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1004 | K1006, K1016, K1018, K1020, K1023, K1024, K1025, K1027, K1028, K1029, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1006 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1007 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1014 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1015 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1016 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1018 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1020 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1023 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1024 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1025 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1027 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1028 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1029 | K1031, K1032, K1033, Q0479, Q0480, Q0481, Q0482, Q0483, Q0488, Q0489, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1031 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1032 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| K1033 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5000 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5010 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5020 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5050 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5060 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5100 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5105 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5150 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5160 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5200 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5210 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5220 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5230 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5250 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5270 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5280 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5301 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5312 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5321 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5331 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5341 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5400 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5410 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5420 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5430 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5450 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5460 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5500 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5505 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5510 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5520 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5530 | Medicare References: NCD 230.10 L5535 L5540 L5560 L5700 L5701 L5702 L5703 L5704 L5705 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5535 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5540 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5560 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5570 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5580 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5585 | Implantation; NCD 230.15 Version 1 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5590 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5595 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5600 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5610 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5611 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5613 | Erection Devices (VED); LCD L33317 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5614 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5616 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5617 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5618 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5620 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5622 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5624 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5626 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5628 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5629 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5630 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5631 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5632 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5634 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5636 | L5637 L5638 L5640 L5655 L5656 L5658 L5661 L5665 L5666 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5637 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5638 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5639 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5640 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5642 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5643 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5644 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5645 | L5646 L5648 L5650 L5668 L5670 L5671 L5672 L5673 L5676 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5646 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5647 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5648 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5649 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5650 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5651 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5652 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5653 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5654 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5655 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5656 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5658 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5661 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5665 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5666 | L5679 L5680 L5682 L5684 L5685 L5686 L5710 L5711 L5712 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5668 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5670 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5671 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5672 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5673 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5676 | L5688 L5690 L5692 L5694 L5695 L5696 L5785 L5790 L5810 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5677 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5678 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5679 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5680 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5681 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5682 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5683 | L5822 L5824 L5826 L5828 L5830 L5840 L6010 L6020 L6026 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5684 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5685 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5686 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5688 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5690 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5692 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5694 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5695 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5696 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5697 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5698 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5699 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5700 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5701 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5702 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5703 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5704 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5705 | Medicare References: NCD 230.10 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5706 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5707 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5710 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5711 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5712 | L5714 L5716 L5722 L5920 L5925 L5940 L5950 L5962 L5970 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5714 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5716 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5718 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5722 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5724 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5726 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5728 | Electrical Continence Aid; NCD 50.2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5780 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5781 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5782 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5785 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5790 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5795 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5810 | L5811 L5812 L5816 L5971 L5972 L5974 L5975 L5976 L5978 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5811 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5812 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5814 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5816 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5818 | Revision 8 External Breast Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5822 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5824 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5826 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5828 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5830 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5840 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5845 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5848 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5850 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5855 | L5910 L5982 L5984 L5985 L6628 L6629 L6630 L6670 L6672 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5856 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5857 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5858 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5859 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5910 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5920 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5925 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5930 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5940 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5950 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5960 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5961 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5962 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5964 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5966 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5968 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5969 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5970 | L5986 L6386 L6388 L6600 L6605 L6610 L6632 L6635 L6637 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5971 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5972 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5973 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5974 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5975 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5976 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5978 | L6611 L6615 L6616 L6620 L6623 L6625 L6645 L6647 L6650 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5979 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5980 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5981 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5982 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5984 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5985 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5986 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5987 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5988 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5990 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L5999 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6000 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6010 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6020 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6026 | L6050 L6055 L6100 L6586 L6588 L6110 L6120 L6130 L6200 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6050 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6055 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6100 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6110 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6120 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6130 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6200 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6205 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6250 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6300 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6310 | Version 1 Incontinence Control | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6320 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6350 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6360 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6370 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6380 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6382 | Electronic Speech Aids; NCD 230.17 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6384 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6386 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6388 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6400 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6450 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6500 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6550 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6570 | LCD L33738 Revision 5 Facial | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6580 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6582 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6584 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6586 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6588 | L6881 L6882 L5845 L5848 L6205 L7180 L7007 L7008 L7009 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6590 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6600 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6605 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6610 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6611 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6615 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6616 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6620 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6621 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6623 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6624 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6625 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6628 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6629 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6630 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6632 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6635 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6637 | L6640 L6641 L6642 L6676 L6677 L6680 L6682 L6684 L6686 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6638 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6640 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6641 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6642 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6645 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6646 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6647 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6648 | Devices; NCD 50.3 Version 2 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6650 | L6655 L6660 L6665 L6687 L6688 L6689 L6690 L6691 L6692 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6655 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6660 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6665 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6670 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6672 | L6675 L6694 L6695 L6698 L7364 L7366 L7367 L8020 L8030 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6675 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6676 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6677 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6680 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6682 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6684 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6686 | L6703 L6704 L6706 L6708 L6711 L6805 L7368 L7400 L7401 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6687 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6688 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6689 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6690 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6691 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6692 | L6810 L6890 L6895 L6915 L7360 L7362 L7405 L7700 L8000 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6693 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6694 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6695 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6696 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6697 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6698 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6703 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6704 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6706 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6707 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6708 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6709 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6711 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6712 | Urinary Drainage Bags; LCD L33787 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6713 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6714 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6715 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6721 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6722 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6805 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6810 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6880 | Prostheses; Medicare Benefit Policy | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6881 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6882 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6883 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6884 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6885 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6890 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6895 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6900 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6905 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6910 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6915 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6920 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6925 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6930 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6935 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6940 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6945 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6950 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6955 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6960 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6965 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6970 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L6975 | Manual Chapter 15 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7007 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7008 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7009 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7040 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7045 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7170 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7180 | L7040 L7045 L7170 L5969 L5999, L7499, L7510, L7520, L7600, L7900, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7181 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7185 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7186 | Cochlear | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7190 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7191 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7259 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7360 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7362 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7364 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7366 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7367 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7368 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7400 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7401 | L7402 L7403 L7404 L8032 L8047 L8400 L8410 L8415 L8417 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7402 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7403 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7404 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7405 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7499 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7510 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7520 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7600 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7700 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7900 | L7902, L8010, L8033 L8039, L8048, L8049, L8499, L8505, L8604, L8608, L8679, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L7902 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8000 | L8001 L8002 L8015 L8420 L8430 L8435 L8440 L8460 L8465 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8001 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8002 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8010 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8015 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8020 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8030 | Authorization. However, medical record documentation must be | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8031 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8032 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8033 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8035 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8039 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8040 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8041 | Revision 7 Lower Limb Prostheses | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8042 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8043 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8044 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8045 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8046 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8047 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8048 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8049 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8400 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8410 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8415 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8417 | L8500 L8501 L8507 L8509 L8510 L8511 L8607 L8610 L8612 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8420 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8430 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8435 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8440 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8460 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8465 | L8512 L8513 L8514 L8515 L8600 L8617 L8618 L8621 L8622 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8470 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8480 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8485 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8499 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8500 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8501 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8505 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8507 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8509 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8510 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8511 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8512 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8513 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8514 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8515 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8600 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8603 | 9. Durable Medical Equipment (DME) | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8604 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8605 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8606 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8607 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8608 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8609 | Implantation; NCD 230.15 Version 1 L5150 L5160 L5200 L5210 L5220 L5230 L5570 L5580 L5585 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8610 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8612 | L8613 L8615 L8616 L8641 L8642 L8658 L8670 L8684 L8694 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8613 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8614 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8615 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8616 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8617 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8618 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8619 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8621 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8622 | L8623 L8695 L8696 L8630 L5629 L5630 L5631 L5652 L5653 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8623 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8624 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8625 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8627 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8628 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8629 | L8603 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8630 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8631 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8641 | Lumbar Decompression for Lumbar | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8642 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8658 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8659 | LCD L34824 Revision 8 Vacuum | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8670 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8679 | L8680, L8685, L8686, L8687, L8688, L8692, L8693, L8698, L8699, L8701, L8702 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8680 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8681 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8682 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8683 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8684 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8685 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8686 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8687 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8688 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8689 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8690 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8691 | L5420 L5500 L5505 L5643 L5647 L5649 L5651 L5681 L5683 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8692 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8693 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8694 | L5618 L5620 L5622 L5624 L5626 L5628 L5642 L5644 L5645 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8695 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8696 | L5654 L5677 L5678 L5679 L5697 L5698 L5699 L5850 L5855 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8698 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8699 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8701 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| L8702 | Note: The below codes exceed $1, 000 and require Prior Authorization | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0479 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0480 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0481 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0482 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0483 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0488 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0489 | Q0490, Q0491, Q0492, Q0493, T2029 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0490 | Note: The below codes do NOT require Prior Authorization, however, claims | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0491 | Note: The below codes do NOT require Prior Authorization, however, claims | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0492 | Note: The below codes do NOT require Prior Authorization, however, claims | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q0493 | Note: The below codes do NOT require Prior Authorization, however, claims | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5103 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5106 | Version 1 Anti-Cancer Chemotherapy J9145, J3380, J2350, J9022, J9041, J9173, J3489, J1602, J2357, J1459, J9217, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5107 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5111 | Version 1 Erythropoiesis Stimulating J7321, J3262, J9228, J7327, Q5115, J7328, Q5103, J3590, J7320, J7322, | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5115 | Version 1 Erythropoiesis Stimulating | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| Q5118 | Agents (ESAs) in Cancer and Related | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| S2202 | LTAC Level – 120 Rehab Level 1 – 120 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| S2348 | S2350, S2351 | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| S2350 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| S2351 | Intradiscal Procedures (TIPs) NCD | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |
| T2029 | Note: The below codes do NOT require Prior Authorization, however, claims | 2026-07-06 | Not listed | 97% | [PDF] 1 Prior Authorization Code List - Mass Advantage |