Prior authorization codes
Molina Healthcare
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0001U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0002M | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0003M | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0004M | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0005U | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0006M | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0007M | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0008U | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0009M | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0009U | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0010U | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0011M | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0011U | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0012M | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0012U | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0013M | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0013U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0014U | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0016U | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0017U | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0018U | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0019U | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0022U | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0026U | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0027U | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0029U | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0030U | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0031U | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0032U | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0033U | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0034U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0036U | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0037U | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0042T | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0045U | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0046U | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0047U | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0048U | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0049U | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0050U | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0053U | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0054T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0055T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0055U | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0056U | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0057U | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0058T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0058U | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0059U | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0060U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0067U | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0069U | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0070U | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0071T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0071U | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0072T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0072U | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0073U | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0074U | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0075T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0075U | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0076T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0076U | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0078U | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0079U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0085T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0095T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0098T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0100T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0101T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0102T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0106T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0107T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0108T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0109T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0110T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0111T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0126T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0153U | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0156U | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0157U | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0158U | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0159U | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0160U | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0161U | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0162U | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0163T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0164T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0165T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0174T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0175T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0184T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0191T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0198T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 01999 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0200T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0201T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0202T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0205T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0206T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0207T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0208T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0209T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0210T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0211T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0212T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0213T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0214T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0215T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0216T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0217T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0218T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0219T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0220T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0221T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0222T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0228T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0229T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0230T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0231T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0234T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0235T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0236T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0237T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0238T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0249T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0253T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0254T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0263T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0264T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0265T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0266T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0267T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0268T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0269T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0270T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0271T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0272T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0273T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0274T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0275T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0278T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0290T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0295T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0296T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0297T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0298T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0312T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0313T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0314T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0315T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0316T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0317T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0329T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0330T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0331T | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0332T | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0333T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0335T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0338T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0339T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0342T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0347T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0348T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0349T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0350T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0351T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0352T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0353T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0354T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0355T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0356T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0357T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0358T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0362T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0373T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0394T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0395T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0396T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0397T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0398T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0400T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0401T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0402T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0403T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0404T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0405T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0408T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0409T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0410T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0411T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0412T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0413T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0414T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0415T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0416T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0417T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0418T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0419T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0420T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0421T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0422T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0423T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0424T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0425T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0426T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0427T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0428T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0429T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0430T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0431T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0432T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0433T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0434T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0435T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0436T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0437T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0439T | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0440T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0441T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0442T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0443T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0444T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0445T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0446T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0447T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0448T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0469T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0470T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0471T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0472T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0473T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0474T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0475T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0476T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0477T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0478T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0479T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0480T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0481T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0483T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0484T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0485T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0486T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0487T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0488T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0489T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0490T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0491T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0492T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0493T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0494T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0495T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0496T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0497T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0498T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0499T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0500T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0501T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0502T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0503T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0504T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0505T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0506T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0507T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0508T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0509T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0510T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0511T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0512T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0513T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0514T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0515T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0516T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0517T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0518T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0519T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0520T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0521T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0522T | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0523T | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0524T | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0525T | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0526T | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0527T | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0528T | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0529T | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0530T | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0531T | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0532T | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0533T | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0534T | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0535T | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0536T | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0537T | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0538T | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0539T | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0540T | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0541T | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 0542T | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 10040 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 11900 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 11901 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 11920 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15730 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15733 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15775 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15776 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15780 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15781 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15782 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15783 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15786 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15787 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15788 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15789 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15792 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15793 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15819 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15820 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15821 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15822 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15823 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15824 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15825 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15826 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15828 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15829 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15830 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15832 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15833 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15834 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15835 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15836 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15837 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15838 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15839 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15847 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15876 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15877 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15878 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15879 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 15999 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 17004 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 17360 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 17380 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 17999 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19294 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19300 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19316 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19318 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19324 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19325 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19328 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19330 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19340 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19342 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19350 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19355 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19396 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 19499 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 20930 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 20939 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 20999 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21073 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21089 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21120 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21121 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21122 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21123 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21125 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21127 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21137 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21138 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21139 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21141 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21142 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21143 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21145 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21146 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21147 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21150 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21151 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21154 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21155 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21159 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21160 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21172 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21175 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21240 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21242 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21243 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21270 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21280 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21282 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21295 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21296 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21299 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21499 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 21899 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22100 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22101 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22102 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22103 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22110 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22112 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22114 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22116 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22206 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22207 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22208 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22210 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22212 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22214 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22216 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22220 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22222 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22224 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22226 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22505 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22526 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22527 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22532 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22533 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22534 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22548 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22551 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22552 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22554 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22556 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22558 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22585 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22586 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22590 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22595 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22600 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22610 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22612 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22614 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22630 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22632 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22633 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22634 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22800 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22802 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22804 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22808 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22810 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22812 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22818 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22819 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22830 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22840 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22841 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22842 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22843 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22844 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22845 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22846 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22847 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22848 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22849 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22850 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22852 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22855 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22856 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22857 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22861 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22862 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22864 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22865 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22867 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22868 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22869 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22870 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22899 | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 22999 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 23412 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 23470 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 23929 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 24999 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 25447 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 25999 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 26499 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 26989 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27096 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27120 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27122 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27125 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27130 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27132 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27134 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27137 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27138 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27279 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27299 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27438 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27440 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27441 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27442 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27443 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27445 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27446 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27447 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27486 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27487 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27599 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 27899 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28005 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28008 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28010 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28011 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28035 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28060 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28062 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28080 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28090 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28092 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28100 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28102 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28103 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28104 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28106 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28107 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28108 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28110 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28111 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28112 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28113 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28114 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28116 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28118 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28119 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28120 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28122 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28124 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28126 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28130 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28140 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28150 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28153 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28160 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28171 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28173 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28175 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28200 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28202 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28208 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28210 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28220 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28222 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28225 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28226 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28230 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28232 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28234 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28238 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28240 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28250 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28260 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28261 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28262 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28264 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28270 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28272 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28280 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28285 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28286 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28288 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28289 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28291 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28292 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28295 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28296 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28297 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28298 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28299 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28300 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28302 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28304 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28305 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28306 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28307 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28308 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28309 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28310 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28312 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28313 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28315 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28320 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28322 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28340 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28341 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28344 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28345 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28360 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28705 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28715 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28725 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28730 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28735 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28737 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28740 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28750 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28755 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28760 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28890 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 28899 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29806 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29807 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29819 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29820 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29821 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29822 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29823 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29824 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29825 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29826 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29827 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29828 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29873 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29874 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29875 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29876 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29877 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29879 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29880 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29881 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29882 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29883 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29884 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29885 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29886 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29887 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29888 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29889 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29891 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29892 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29893 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29894 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29895 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29897 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29898 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29899 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29914 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29915 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29916 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 29999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30400 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30410 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30420 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30430 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30435 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30450 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30460 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30462 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30465 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30520 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30540 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30545 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 30999 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31253 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31257 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31259 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31295 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31296 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31297 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31298 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31299 | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31599 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31660 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31661 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 31899 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 32491 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 32994 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 32999 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33206 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33207 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33208 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33212 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33213 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33214 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33221 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33224 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33225 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33227 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33228 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33229 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33230 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33231 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33240 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33249 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33251 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33254 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33261 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33262 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33263 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33264 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33265 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33266 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33270 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33274 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33275 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33289 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33440 | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33866 | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33979 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 33999 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 34713 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 34714 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 34715 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 34716 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36299 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36460 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36465 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36466 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36468 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36470 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36471 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36475 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36476 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36478 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36479 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36482 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36483 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 36514 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37191 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37243 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37501 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37700 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37718 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37722 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37735 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37760 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37761 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37765 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37766 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37780 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37785 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 37799 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38129 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38204 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38205 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38206 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38207 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38208 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38209 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38210 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38211 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38212 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38213 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38214 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38215 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38230 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38232 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38240 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38241 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38242 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38243 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38573 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38589 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 38999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 39499 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 39599 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 40799 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 40899 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 41599 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 42299 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 42699 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 42999 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43289 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43499 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43644 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43645 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43647 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43648 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43653 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43659 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43770 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43771 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43772 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43773 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43774 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43775 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43842 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43843 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43845 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43846 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43847 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43848 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43881 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43882 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43886 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43887 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43888 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 43999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44238 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44715 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44720 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44721 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44799 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44899 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 44979 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 45399 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 45499 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 45999 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 46999 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47133 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47135 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47140 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47141 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47142 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47143 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47144 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47145 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47146 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47147 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47379 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47380 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47381 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47382 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47399 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47579 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47605 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47610 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47612 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47620 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 47999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48160 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48550 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48551 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48552 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48554 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48556 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 48999 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49255 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49329 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49659 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49904 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49905 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49906 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 49999 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50300 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50320 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50323 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50325 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50327 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50328 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50329 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50340 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50360 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50365 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50370 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50380 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50549 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50590 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 50949 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 51999 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 52441 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 52442 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 52649 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 53850 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 53852 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 53854 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 53899 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 54401 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 54405 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 54699 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 55559 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 55874 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 55899 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 55970 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 55980 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 57288 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 57289 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58150 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58152 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58180 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58200 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58210 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58240 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58260 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58262 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58263 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58267 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58270 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58275 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58280 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58285 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58290 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58291 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58292 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58293 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58294 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58321 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58322 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58323 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58345 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58350 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58356 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58540 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58541 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58542 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58543 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58544 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58545 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58546 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58548 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58550 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58552 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58553 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58554 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58570 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58571 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58572 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58573 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58578 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58579 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58660 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58661 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58662 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58672 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58673 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58679 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58700 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58720 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58740 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58750 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58752 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58760 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58770 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58940 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58941 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58943 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58950 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58951 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58952 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58953 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58954 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58956 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58957 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58958 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58970 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58974 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58976 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 58999 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59070 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59072 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59074 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59076 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59840 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59841 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59850 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59851 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59852 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59855 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59856 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59857 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59866 | Abortion Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59897 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59898 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 59899 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 60659 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 60699 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61863 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61864 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61867 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61868 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61885 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 61886 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62263 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62264 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62320 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62321 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62322 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62323 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62324 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62325 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62326 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62327 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62350 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62351 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62360 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62361 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62362 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62367 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62368 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62369 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62370 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 62380 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63001 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63003 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63005 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63011 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63012 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63015 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63016 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63017 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63020 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63030 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63035 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63040 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63042 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63043 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63044 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63045 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63046 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63047 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63048 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63050 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63051 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63055 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63056 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63057 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63064 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63066 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63075 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63076 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63077 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63078 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63081 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63082 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63085 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63086 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63087 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63088 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63090 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63091 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63101 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63102 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63103 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63650 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63655 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63661 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63662 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63663 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63664 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63685 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 63688 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64450 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64461 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64462 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64463 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64479 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64480 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64483 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64484 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64486 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64487 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64488 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64489 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64490 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64491 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64492 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64493 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64494 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64495 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64553 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64568 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64569 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64570 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64590 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64595 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64600 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64633 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64634 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64635 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64636 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64640 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64912 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64913 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 64999 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 65771 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 65772 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 65775 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 66999 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67299 | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67399 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67599 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67900 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67901 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67902 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67903 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67904 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67906 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67908 | * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67909 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67950 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 67999 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 68399 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 68899 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69300 | * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69399 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69714 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69715 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69717 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69718 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69799 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69930 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69949 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 69979 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70336 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70450 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70460 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70470 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70480 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70481 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70482 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70486 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70487 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70488 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70490 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70491 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70492 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70496 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70498 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70540 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70542 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70543 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70544 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70545 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70546 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70547 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70548 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70549 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70551 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70552 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70553 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70554 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 70555 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71250 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71260 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71270 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71275 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71550 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71551 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71552 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 71555 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72125 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72126 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72127 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72128 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72129 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72130 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72131 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72132 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72133 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72141 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72142 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72146 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72147 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72148 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72149 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72156 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72157 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72158 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72159 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72191 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72192 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72193 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72194 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72195 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72196 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72197 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 72198 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73200 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73201 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73202 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73206 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73218 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73219 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73220 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73221 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73222 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73223 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73225 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73700 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73701 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73702 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73706 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73718 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73719 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73720 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73721 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73722 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73723 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 73725 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74150 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74160 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74170 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74174 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74175 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74176 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74177 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74178 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74181 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74182 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74183 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74185 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74261 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74262 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74263 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74712 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 74713 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75557 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75559 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75561 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75563 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75565 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75571 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75572 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75573 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75574 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 75635 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76376 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76377 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76380 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76390 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76391 | Imaging – Advanced & Specialty | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76496 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76497 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76498 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76499 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76506 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76536 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76604 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76641 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76642 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76700 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76705 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76706 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76770 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76775 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76776 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76800 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76830 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76831 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76856 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76857 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76870 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76872 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76881 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76882 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76885 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76886 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76970 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76975 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 76999 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77003 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77014 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77021 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77022 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77046 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77047 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77048 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77049 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77078 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77084 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77299 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77371 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77372 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77373 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77385 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77386 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77387 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77399 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77401 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77402 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77412 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77423 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77424 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77425 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77499 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77520 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77522 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77523 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77525 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77600 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77605 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77610 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77615 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77620 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77750 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77761 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77762 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77763 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77767 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77768 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77770 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77771 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77772 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77778 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 77799 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78012 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78013 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78014 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78015 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78016 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78018 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78020 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78070 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78071 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78072 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78075 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78099 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78102 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78103 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78104 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78140 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78185 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78195 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78199 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78201 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78202 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78206 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78215 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78216 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78226 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78227 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78230 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78231 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78232 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78258 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78261 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78262 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78264 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78265 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78266 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78278 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78290 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78291 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78299 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78300 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78305 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78306 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78315 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78399 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78414 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78428 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78434 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78445 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78451 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78452 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78453 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78454 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78456 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78457 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78458 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78459 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78466 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78468 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78469 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78472 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78473 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78481 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78483 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78491 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78492 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78494 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78496 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78499 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78579 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78580 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78582 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78597 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78598 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78599 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78600 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78601 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78605 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78606 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78608 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78609 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78610 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78630 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78635 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78645 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78650 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78660 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78699 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78700 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78701 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78707 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78708 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78709 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78725 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78730 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78740 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78761 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78799 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78800 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78801 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78802 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78803 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78804 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78811 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78812 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78813 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78814 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78815 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78816 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78830 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78831 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78832 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 78999 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 79101 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 79403 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 79999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 80299 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81099 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81105 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81106 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81107 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81108 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81109 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81110 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81111 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81112 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81120 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81121 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81161 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81162 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81163 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81164 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81165 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81166 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81167 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81171 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81172 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81173 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81174 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81175 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81176 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81177 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81178 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81179 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81180 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81181 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81182 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81183 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81184 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81185 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81186 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81187 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81188 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81189 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81190 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81201 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81202 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81203 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81204 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81210 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81212 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81215 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81216 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81217 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81218 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81219 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81221 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81222 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81223 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81225 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81226 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81227 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81228 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81229 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81230 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81231 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81232 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81233 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81234 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81235 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81236 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81237 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81238 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81239 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81243 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81244 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81246 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81247 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81248 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81249 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81252 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81253 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81257 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81258 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81259 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81265 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81266 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81269 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81271 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81272 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81273 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81274 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81277 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81283 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81284 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81285 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81286 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81287 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81289 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81291 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81292 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81293 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81294 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81295 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81296 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81297 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81298 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81299 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81300 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81302 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81303 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81304 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81305 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81306 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81307 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81308 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81311 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81312 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81313 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81314 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81317 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81318 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81319 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81320 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81321 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81322 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81323 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81324 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81325 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81326 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81327 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81328 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81329 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81333 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81334 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81335 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81336 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81337 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81343 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81344 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81345 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81346 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81350 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81355 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81361 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81362 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81363 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81364 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81400 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81401 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81402 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81403 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81404 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81405 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81406 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81407 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81408 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81410 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81411 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81412 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81413 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81414 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81415 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81416 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81417 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81420 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81422 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81425 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81426 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81427 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81430 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81431 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81432 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81433 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81434 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81435 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81436 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81437 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81438 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81439 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81440 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81442 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81443 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81445 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81448 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81450 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81455 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81460 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81465 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81470 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81471 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81479 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81490 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81493 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81500 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81503 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81504 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81507 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81518 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81519 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81520 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81521 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81522 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81525 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81528 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81535 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81536 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81538 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81539 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81540 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81541 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81542 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81545 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81551 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81552 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81595 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81596 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 81599 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 82016 | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 82017 | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 83006 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 83987 | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 84145 | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 84999 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 85999 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86152 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86153 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86316 | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86343 | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86486 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86849 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 86999 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 87797 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 87798 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 87799 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 87899 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 87999 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88099 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88199 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88261 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88271 | 81107 81112 81172 81179 81184 81218 81236 81246 81272 81287 81320 81343 83006 88369 0008U 0017U 0059U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88299 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88369 | 81108 81120 81175 81180 81187 81219 81237 81247 81273 81305 81324 81344 86152 88373 0009U 0027U S3722 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88373 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88374 | Genetic Counseling & Testing | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88377 | 81106 81111 81171 81178 81183 81210 81235 81244 81271 81285 81314 81334 81507 88271 0009M 0016U 0058U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88399 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 88749 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 89240 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 89398 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90281 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90283 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90284 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90378 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90399 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90749 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90791 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90792 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90867 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90868 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90869 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90870 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 90899 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 91299 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 92499 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 92507 | \ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 92508 | \ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 92700 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93229 | 21145 22210 22614 22867 28035 28171 28295 28740 29887 33207 34715 38209 43888 58210 58552 58974 63040 64553 96567 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93264 | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93303 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93304 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93306 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93307 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93308 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93312 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93313 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93314 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93315 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93316 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93317 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93320 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93321 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93325 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93350 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93351 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93352 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93356 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93451 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93452 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93453 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93454 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93455 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93456 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93457 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93458 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93459 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93460 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93461 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93462 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93530 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93531 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93532 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93533 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93799 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93880 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93882 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93886 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93888 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93890 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93892 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93893 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93922 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93923 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93924 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93925 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93926 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93930 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93931 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93970 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93971 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93975 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93976 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93978 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93979 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93980 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93981 | 76536 76642 76706 76776 76831 76870 76882 76970 93882 93890 93922 93925 93931 93975 93979 93990 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93990 | 76604 76700 76770 76800 76856 76872 76885 76975 93886 93892 93923 93926 93970 93976 93980 93998 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 93998 | Ultrasound | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 94799 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95199 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95249 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95782 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95783 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95800 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95801 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95803 | Sleep Studies | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95805 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95807 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95808 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95810 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95811 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95836 | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95950 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95951 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95953 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95956 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95957 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95976 | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95977 | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95983 | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 95999 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96112 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96113 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96116 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96121 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96125 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96130 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96131 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96132 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96133 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96136 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96137 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96138 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96139 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96146 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96379 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96549 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96567 | 21146 22212 22634 22868 28060 28173 28296 28750 29888 33208 34716 38210 47380 58240 58553 58976 63042 64568 96570 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96570 | 21147 22214 22800 22869 28062 28175 28297 28755 29889 33212 36460 38211 47381 58260 58554 59070 63043 64569 96571 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96571 | 21150 22216 22802 22870 28080 28200 28298 28760 29891 33213 36465 38212 47382 58262 58570 59072 63044 64570 96573 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96573 | 21151 22220 22804 23412 28090 28202 28299 28890 29892 33214 36466 38213 47605 58263 58571 59074 63045 64590 96574 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96574 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96900 | 15730 21155 22224 22810 25447 28100 28210 28302 29807 29894 33224 36470 38215 47612 58270 58573 61863 63047 64912 96902 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96902 | 15733 21159 22226 22812 26499 28102 28220 28304 29819 29895 33225 36471 38232 47620 58275 58660 61864 63048 64913 96904 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96904 | 15786 21160 22505 22818 27120 28103 28222 28305 29820 29897 33227 36475 38573 49255 58280 58661 61867 63050 65771 96910 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96910 | 15787 21172 22526 22819 27122 28104 28225 28306 29821 29898 33228 36476 43644 49904 58285 58662 61868 63051 65772 96912 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96912 | 15819 21175 22527 22830 27125 28106 28226 28307 29822 29899 33229 36478 43645 49905 58290 58672 61885 63055 65775 96913 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96913 | 15830 21240 22532 22840 27130 28107 28230 28308 29823 29914 33230 36479 43647 49906 58291 58673 61886 63056 67900 96920 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96920 | 17004 21242 22533 22841 27132 28108 28232 28309 29824 29915 33231 36482 43648 50590* 58292 58700 62324 63057 67901 96921 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96921 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96922 | 19294 21270 22548 22843 27137 28111 28238 28312 29826 30465 33249 36514 43770 52442 58294 58740 62326 63066 67903 96931 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96931 | 20930 21280 22551 22844 27138 28112 28240 28313 29827 30520 33262 37191 43771 52649 58321 58750 62327 63075 67909 96932 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96932 | 20939 21282 22552 22845 27438 28113 28250 28315 29828 30540 33263 37243 43772 53850 58322 58752 62369 63076 67950 96933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96933 | 21073 21295 22554 22846 27440 28114 28260 28320 29873 30545 33264 37700 43773 53852 58323 58760 62370 63077 69714 96934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96934 | 21120 21296 22556 22847 27441 28116 28261 28322 29874 31253 33270 37718 43774 53854 58345 58770 62380 63078 69715 96935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96935 | Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96936 | 21122 22101 22585 22849 27443 28119 28264 28341 29876 31259 33254 37735 43842 54405 58356 58943 63003 63082 69718 C2616 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 96999 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97039 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97110 | Marketplace: Authorization required after benefit limit is reached, please refer to member handbook | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97112 | Marketplace: Authorization required after benefit limit is reached, please refer to member handbook | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97139 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97151 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97152 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97153 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97154 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97155 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97156 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97157 | * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97158 | * * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97763 | Marketplace: Authorization required after benefit limit is reached, please refer to member handbook | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97799 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97810 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97811 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97813 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 97814 | * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 99183 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 99199 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 99429 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 99499 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| 99600 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A0430 | PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A0431 | PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A0999 | PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4421 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4563 | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4604 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4641 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4649 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A4913 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A5514 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A6261 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A6262 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7025 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7027 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7028 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7029 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7030 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7031 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7032 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7033 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7034 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7035 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7036 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7037 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7038 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7039 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7044 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7045 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A7046 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9274 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9276 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9277 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9278 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9513 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9542 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9543 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9606 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9698 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9699 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9900 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9901 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| A9999 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| B4105 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| B9999 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C1823 | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C2616 | 21123 22102 22586 22850 27445 28120 28270 28344 29877 31295 33261 37760 43843 55874 58540 58950 63005 63085 69930 C9734 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C2624 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C2698 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C2699 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C5257 | ^ : No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8900 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8901 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8902 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8903 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8905 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8906 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8908 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8909 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8910 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8911 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8912 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8913 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8914 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8918 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8919 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8920 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8921 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8922 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8923 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8924 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8925 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8926 | Cardiac Imaging and Special Test | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8928 | 75559 75571 78414 78452 78466 78473 78492 93303 93308 93315 93321 93352 93453 93457 93461 93532 0439T 0504T C8924 C8929 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8929 | 75561 75572 78428 78453 78468 78481 78494 93304 93312 93316 93325 93451 93454 93458 93462 93533 0501T C8921 C8925 C8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8930 | 75563 75573 78434 78454 78469 78483 78496 93306 93313 93317 93350 93356 93455 93459 93530 0331T 0502T C8922 C8926 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8931 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8932 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8933 | 70486 70545 71270 72131 72159 73206 73718 74176 75571 77048 78071 78215 78266 78579 78630 78740 78816 C8909 C8934 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8934 | 70487 70546 71275 72132 72191 73218 73719 74177 75635 77049 78072 78216 78278 78580 78635 78761 78830 C8910 C8935 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8935 | 70488 70547 71550 72133 72192 73219 73720 74178 76376 77078 78075 78226 78290 78582 78645 78800 78831 C8911 C8936 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8936 | 70490 70548 71551 72141 72193 73220 73721 74181 76377 77084 78102 78227 78291 78597 78650 78801 78832 C8912 G0219 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C8937 | 84145 0095T 0184T 0216T 0253T 0295T 0347T 0397T 0417T 0434T 0473T 0491T 0508T 0525T C9751 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9035 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9036 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9037 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9038 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9039 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9043 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9044 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9130 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9131 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9132 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9257 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9293 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9399 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9407 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9408 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9488 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9734 | 21125 22103 22590 22852 27446 28122 28272 28345 29879 31296 33265 37761 43845 55970 58541 58951 63011 63086 90791 C9738 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9738 | 21127 22110 22595 22855 27447 28124 28280 28360 29880 31297 33266 37765 43846 55980 58542 58952 63012 63087 90792 C9739 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9739 | 21137 22112 22600 22856 27486 28126 28285 28705 29881 31298 33289 37766 43847 57288 58543 58953 63015 63088 90870 C9740 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9740 | 21138 22114 22610 22857 27487 28130 28286 28715 29882 31660 33274 37780 43848 57289 58544 58954 63016 63090 90867 C9746 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9746 | 21139 22116 22612 22861 28005 28140 28288 28725 29883 31661 33275 37785 43881 58150 58545 58956 63017 63091 90868 C9747 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9747 | 21141 22206 22630 22862 28008 28150 28289 28730 29884 32491 33979 38204 43882 58180 58546 58957 63020 63101 90869 C9748 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9748 | 21142 22207 22632 22864 28010 28153 28291 28735 29885 32994 34713 38207 43886 58152 58548 58958 63030 63102 95249 S2095 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9751 | 86316 0098T 0191T 0217T 0254T 0296T 0348T 0398T 0418T 0435T 0474T 0492T 0509T 0526T C9752 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9752 | 86343 0100T 0198T 0218T 0263T 0297T 0349T 0400T 0419T 0436T 0475T 0493T 0510T 0527T C9753 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9753 | 93264 0101T 0200T 0219T 0264T 0298T 0350T 0401T 0420T 0437T 0476T 0494T 0511T 0528T C9754 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9754 | Experimental/Investigational | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| C9755 | 95976 0106T 0202T 0221T 0266T 0313T 0352T 0403T 0422T 0441T 0478T 0496T 0513T 0530T L8608 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0194 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0255 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0256 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0260 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0261 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0265 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0266 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0277 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0292 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0293 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0294 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0295 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0296 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0297 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0300 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0301 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0302 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0303 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0304 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0328 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0329 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0371 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0372 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0373 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0447 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0462 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0465 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0466 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0467 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0470 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0471 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0481 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0483 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0561 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0562 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0601 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0641 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0652 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0691 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0692 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0693 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0694 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0747 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0748 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0749 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0760 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0762 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0764 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0766 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0769 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0770 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0782 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0783 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0784 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0785 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0786 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0849 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0855 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0983 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0984 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0986 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E0988 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1002 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1003 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1004 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1005 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1006 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1007 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1008 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1010 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1012 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1014 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1020 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1028 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1029 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1030 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1035 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1036 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1161 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1225 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1226 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1227 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1230 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1232 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1233 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1234 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1235 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1236 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1237 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1238 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1296 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1298 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1310 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1399 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1699 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E1700 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2201 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2202 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2203 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2204 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2227 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2228 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2291 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2292 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2293 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2294 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2295 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2300 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2310 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2311 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2312 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2313 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2321 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2322 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2325 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2326 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2327 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2328 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2329 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2330 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2340 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2341 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2342 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2343 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2351 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2361 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2366 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2367 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2368 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2369 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2370 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2373 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2374 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2375 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2376 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2377 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2378 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2397 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2402 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2500 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2502 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2504 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2506 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2508 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2510 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2511 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2605 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2606 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2607 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2608 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2609 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2611 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2612 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2613 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2614 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2615 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2616 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2617 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2620 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2621 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2622 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2623 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2624 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2625 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2626 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2627 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2628 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2629 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2630 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| E2631 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0151 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0152 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0153 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0155 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0156 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0157 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0158 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0159 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0160 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0161 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0162 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0219 | 70491 70549 71552 72142 72194 73221 73722 74182 76380 78012 78103 78230 78300 78598 78660 78802 0042T C8913 G0235 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0235 | Advanced Imaging and Special Tests | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0252 | 70450 70496 70552 72125 72147 72196 73223 73725 74185 76497 78014 78140 78232 78306 78601 78701 78804 C8901 C8918 G0297 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0260 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0277 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0288 | Imaging – Advanced & Specialty | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0297 | 70460 70498 70553 72126 72148 72197 73225 74150 74261 76498 78015 78185 78258 78315 78605 78707 78811 C8902 C8919 S8037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0299 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0300 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0339 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0340 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0396 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0397 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0490 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0493 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0494 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0495 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0496 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G0501 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6001 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6002 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6003 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6004 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6005 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6006 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6007 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6008 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6009 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6010 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6011 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6012 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6013 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6014 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6015 | 77371 77385 77401 77423 77520 77525 77610 77750 77763 77770 77778 A9513 C9408 G6001 G6004 G6007 G6010 G6013 G6016 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6016 | 77372 77386 77402 77424 77522 77600 77615 77761 77767 77771 79101 A9543 G0339 G6002 G6005 G6008 G6011 G6014 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G6017 | Radiation Therapy & Radio Surgery | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G9012 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| G9143 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0001 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0012 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0015 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0017 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0031 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0032 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0035 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0040 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H0046 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2012 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2013 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2014 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2015 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2016 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2017 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2018 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2019 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2020 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2034 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| H2036 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0121 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0129 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0135 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0178 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0180 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0185 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0202 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0205 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0207 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0220 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0221 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0222 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0256 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0257 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0287 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0289 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0291 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0364 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0480 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0485 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0490 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0517 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0565 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0567 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0570 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0584 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0585 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0586 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0587 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0588 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0593 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0594 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0596 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0597 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0598 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0599 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0604 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0606 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0637 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0638 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0640 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0641 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0695 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0714 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0717 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0725 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0775 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0800 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0841 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0850 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0875 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0878 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0881 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0885 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0888 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0894 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0895 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J0897 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1095 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1096 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1230 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1290 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1300 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1301 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1303 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1322 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1324 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1325 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1428 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1438 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1439 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1442 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1447 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1453 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1454 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1458 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1459 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1460 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1555 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1556 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1557 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1559 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1560 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1561 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1562 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1566 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1568 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1569 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1570 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1571 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1572 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1573 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1575 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1595 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1599 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1602 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1627 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1628 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1640 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1645 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1650 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1652 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1675 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1740 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1743 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1744 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1745 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1746 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1750 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1756 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1786 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1826 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1830 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1833 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1930 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1931 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1943 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1950 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J1955 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2020 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2062 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2170 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2182 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2186 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2248 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2315 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2323 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2326 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2350 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2353 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2354 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2357 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2425 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2469 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2502 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2503 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2504 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2505 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2507 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2562 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2597 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2724 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2778 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2783 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2786 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2787 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2793 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2796 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2797 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2820 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2840 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2860 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2916 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J2941 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3031 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3060 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3090 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3095 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3110 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3111 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3145 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3240 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3245 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3262 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3285 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3304 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3315 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3316 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3355 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3357 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3358 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3380 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3385 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3396 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3397 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3398 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3489 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3490 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3590 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J3591 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7170 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7175 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7177 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7178 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7179 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7180 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7181 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7182 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7183 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7185 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7186 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7187 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7188 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7189 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7190 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7191 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7192 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7193 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7194 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7195 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7196 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7197 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7198 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7199 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7200 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7201 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7202 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7203 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7205 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7207 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7209 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7210 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7211 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7308 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7309 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7310 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7311 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7312 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7313 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7314 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7316 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7318 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7320 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7321 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7322 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7323 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7324 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7325 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7326 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7327 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7328 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7329 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7330 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7331 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7332 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7340 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7401 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7504 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7511 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7527 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7599 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7639 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7682 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7686 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7699 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7799 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J7999 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8498 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8499 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8520 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8521 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8597 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8655 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8670 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8700 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J8999 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9000 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9015 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9017 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9019 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9022 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9023 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9025 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9027 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9032 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9033 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9034 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9035 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9039 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9040 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9041 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9042 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9043 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9044 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9045 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9047 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9050 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9055 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9057 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9065 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9070 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9098 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9120 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9130 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9145 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9150 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9153 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9155 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9160 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9171 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9173 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9176 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9178 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9179 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9185 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9190 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9200 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9201 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9202 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9203 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9204 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9205 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9206 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9207 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9208 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9210 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9211 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9214 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9215 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9216 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9217 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9218 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9219 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9225 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9226 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9228 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9229 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9230 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9245 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9261 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9262 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9263 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9264 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9266 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9267 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9268 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9269 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9271 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9280 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9285 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9293 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9295 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9299 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9301 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9302 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9303 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9305 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9306 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9307 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9308 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9310 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9311 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9312 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9313 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9315 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9325 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9328 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9330 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9340 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9351 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9352 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9354 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9355 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9357 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9360 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9371 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9390 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9395 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9400 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9600 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| J9999 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0008 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0009 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0010 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0011 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0012 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0014 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0108 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0553 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0554 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0606 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0800 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0801 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0802 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0806 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0807 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0808 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0812 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0813 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0814 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0815 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0816 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0820 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0821 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0822 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0823 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0824 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0825 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0826 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0827 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0828 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0829 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0830 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0831 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0835 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0836 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0837 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0838 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0839 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0840 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0841 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0842 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0843 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0848 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0849 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0850 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0851 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0852 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0853 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0854 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0855 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0856 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0857 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0858 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0859 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0860 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0861 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0862 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0863 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0864 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0868 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0869 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0870 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0871 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0877 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0878 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0879 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0880 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0884 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0885 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0886 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0890 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0891 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0898 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0899 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| K0900 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0452 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0480 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0482 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0484 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0486 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0622 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0637 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0640 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0650 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0700 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0710 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L0999 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1000 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1005 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1110 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1499 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1640 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1680 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1685 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1700 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1710 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1720 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1730 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1755 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1834 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1840 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1844 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1846 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1860 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1900 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1904 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1907 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1920 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1940 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1945 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1950 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1960 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1970 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1980 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L1990 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2000 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2005 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2010 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2020 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2030 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2034 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2036 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2037 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2038 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2050 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2060 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2080 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2090 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2106 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2108 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2126 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2128 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2232 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2800 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L2999 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L3649 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L3761 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L3999 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L4631 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L5856 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L5999 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L6026 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L7259 | L0480 L0622 L0700 L1110 L1700 L1755 L1846 L1907 L1950 L1990 L2020 L2037 L2080 L2126 L4631 L8614 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L7499 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L7700 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8039 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8499 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8608 | 95977 0107T 0205T 0222T 0267T 0314T 0353T 0404T 0423T 0442T 0479T 0497T 0514T 0531T Q4161 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8614 | L0482 L0637 L0710 L1640 L1710 L1834 L1860 L1920 L1960 L2000 L2030 L2038 L2090 L2128 L5856 L8692 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8625 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8692 | L0484 L0640 L1000 L1680 L1720 L1840 L1900 L1940 L1970 L2005 L2034 L2050 L2106 L2232 L6026 S1040 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8694 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8698 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8699 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8701 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| L8702 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| P9603 | 22999 31599 40799 44899 49659 58999 68399 77799 84999 88299 94799 99600 B9999 J7799 L2999 P9604 S9110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| P9604 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q0138 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q0139 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q0507 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q0508 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q0509 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q2039 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q2041 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q2042 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q2043 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q2050 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q3027 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q3028 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4050 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4051 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4074 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4082 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4100 | 21499 29999 38999 43999 47999 58578 67399 77299 79999 87999 92499 99199 A9699 H0046 K0899 L8701 S0590 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4161 | 95983 0108T 0206T 0228T 0268T 0315T 0354T 0405T 0424T 0443T 0480T 0498T 0515T 0532T Q4162 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4162 | 99499 0109T 0207T 0229T 0269T 0316T 0355T 0408T 0425T 0444T 0481T 0499T 0516T 0533T Q4163 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4163 | Prior Authorization Codification List | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4164 | 31299 0055T 0111T 0209T 0231T 0271T 0329T 0357T 0410T 0427T 0446T 0484T 0501T 0518T 0535T Q4165 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4165 | 33440 0058T 0126T 0210T 0234T 0272T 0330T 0358T 0411T 0428T 0447T 0485T 0502T 0519T 0536T Q4189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4176 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4177 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4178 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4179 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4180 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4181 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4182 | Hyperbaric Therapy | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4183 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4184 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4185 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4186 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4187 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4188 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4189 | 33866 0071T 0163T 0211T 0235T 0273T 0333T 0362T 0412T 0429T 0448T 0486T 0503T 0520T 0541T Q4192 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4190 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4191 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4192 | 67299 0072T 0164T 0212T 0236T 0274T 0335T 0373T 0413T 0430T 0469T 0487T 0504T 0521T 0542T Q4195 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4193 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4194 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4195 | 82016 0075T 0165T 0213T 0237T 0275T 0338T 0394T 0414T 0431T 0470T 0488T 0505T 0522T A4563 Q4196 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4196 | 82017 0076T 0174T 0214T 0238T 0278T 0339T 0395T 0415T 0432T 0471T 0489T 0506T 0523T C1823 Q4197 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4197 | 83987 0085T 0175T 0215T 0249T 0290T 0342T 0396T 0416T 0433T 0472T 0490T 0507T 0524T C8937 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4198 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4200 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4201 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4202 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4203 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q4204 | A9901 E0297 E0481 E0783 E1008 E1233 E2228 E2328 E2375 E2609 E2628 K0802 K0828 K0851 K0870 Q4183 S1034 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5101 | A9542 J0180 J0584 J0775 J1325 J1570 J1756 J2354 J2860 J3385 J7189 J7309 J7340 J9032 J9150 J9211 J9271 J9340 Q5103 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5103 | B4105 J0185 J0585 J0800 J1428 J1571 J1786 J2357 J2916 J3396 J7190 J7310 J7401 J9033 J9153 J9214 J9280 J9351 Q5104 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5104 | C9035 J0202 J0586 J0841 J1438 J1572 J1826 J2425 J2941 J3397 J7191 J7311 J7504 J9034 J9155 J9215 J9285 J9352 Q5107 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5107 | C9036 J0205 J0587 J0850 J1439 J1573 J1830 J2469 J3031 J3398 J7192 J7312 J7511 J9035^ J9160 J9216 J9293 J9354 Q5108 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5108 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5109 | C9038 J0220 J0593 J0878 J1447 J1595 J1930 J2503 J3090 J3490 J7194 J7314 J7639 J9040 J9173 J9218 J9299 J9357 Q5110 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5110 | C9039 J0221 J0594 J0881 J1453 J1599 J1931 J2504 J3095 J3590 J7195 J7316 J7682 J9041 J9176 J9219 J9301 J9360 Q5111 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5111 | C9043 J0222 J0596 J0885 J1454 J1602 J1943 J2505 J3110 J3591 J7196 J7318 J7686 J9042 J9178 J9225 J9302 J9371 Q5116 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5116 | C9044 J0256 J0597 J0888 J1458 J1627 J1950 J2507 J3111 J7170 J7197 J7320 J8520 J9043 J9179 J9226 J9303 J9390 Q5117 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5117 | C9130 J0257 J0598 J0894 J1459 J1628 J1955 J2562 J3145 J7175 J7198 J7321 J8521 J9044 J9185 J9228 J9305 J9395 Q5118 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q5118 | C9131 J0287 J0599 J0895 J1460 J1640 J2020 J2597 J3240 J7177 J7199 J7322 J8655 J9045 J9190 J9229 J9306 J9400 Q9991 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q9991 | C9132 J0289 J0604 J0897 J1555 J1645 J2062 J2724 J3245 J7178 J7200 J7323 J8670 J9047 J9200 J9230 J9307 J9600 Q9992 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| Q9992 | C9257^ J0291 J0606 J1095 J1556 J1650 J2170 J2778 J3262 J7179 J7201 J7324 J8700 J9050 J9201 J9245 J9308 J9999 S0073 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0073 | ^ | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0122 | C9399 J0480 J0638 J1230 J1559 J1675 J2186 J2786 J3304 J7181 J7203 J7326 J9015 J9057 J9203 J9262 J9311 Q0139 S0126 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0126 | C9407 J0485 J0640 J1290 J1560 J1740 J2248 J2787 J3315 J7182 J7205 J7327 J9017 J9065 J9204 J9263 J9312 Q2043 S0128 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0128 | C9488 J0490 J0641 J1300 J1561 J1743 J2315 J2793 J3316 J7183 J7207 J7328 J9019 J9070 J9205 J9264 J9313 Q2050 S0132 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0132 | ^J9035: No PA required when associated with ocular Dx's. (See ICD10 Dx Codes). Not indicated for ocular conditions, use C5257. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0145 | 90283 J0129 J0565 J0714 J1303 J1566 J1745 J2326 J2797 J3357 J7186 J7210 J7330 J9023 J9120 J9207 J9267 J9325 Q3028 S0148 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0148 | 90284 J0135 J0567 J0717 J1322 J1568 J1746 J2350 J2820 J3358 J7187 J7211 J7331 J9025 J9130 J9208 J9268 J9328 Q4074 S0157 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0157 | 90378 J0178 J0570 J0725 J1324 J1569 J1750 J2353 J2840 J3380 J7188 J7308 J7332 J9027 J9145 J9210 J9269 J9330 Q5101 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0201 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S0590 | 21899 30999 39499 44238 48999 58579 67599 77399 80299 88099 92700 99429 A9900 J7599 L0999 L8702 S8189 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S1034 | C2624 E0300 E0483 E0784 E1010 E1234 E2291 E2329 E2376 E2611 E2629 K0806 K0829 K0852 K0871 Q4184 S1035 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S1035 | E0194 E0301 E0641 E0785 E1012 E1235 E2292 E2330 E2377 E2612 E2630 K0807 K0830 K0853 K0877 Q4185 S1036 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S1036 | E2402 E0302 E0652 E0786 E1014 E1236 E2293 E2340 E2378 E2613 E2631 K0808 K0831 K0854 K0878 Q4186 S1037 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S1037 | E0255 E0303 E0691 E0849 E1020 E1237 E2294 E2341 E2397 E2614 K0008 K0813 K0835 K0855 K0879 Q4187 V2530 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S1040 | Prosthetics & Orthotics | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2053 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2054 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2055 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2060 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2061 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2065 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2095 | 21143 22208 22633 22865 28011 28160 28292 28737 29886 33206 34714 38208 43887 58200 58550 58970 63035 63103 93229 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2107 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2140 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2142 | Transplant Services (Including Solid Organ and Bone Marrow) | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2150 | 0538T 38205 38240 38243 44721 47140 47143 47146 48550 48554 50320 50327 50340 50370 S2054 S2061 S2140 S2152 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S2152 | 0539T 38206 38241 44715 47133 47141 47144 47147 48551 48556 50323 50328 50360 50380 S2055 S2065 S2142 Q2041 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3722 | 81109 81121 81176 81181 81188 81233 81239 81265 81274 81311 81329 81345 86153 88374 0010U 0046U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3800 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3840 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3841 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3842 | 81173 81216 81231 81283 81299 81322 81355 81406 81422 81437 81465 81520 81551 0007M 0029U 0050U 0073U S3844 81307 0161U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3844 | 81174 81217 81232 81286 81300 81323 81361 81407 81425 81438 81470 81521 81595 0011M 0030U 0053U 0074U S3845 81308 0162U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3845 | 81185 81221 81238 81289 81302 81325 81362 81408 81426 81439 81471 81525 81596 0012M 0031U 0055U 0075U S3846 81522 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3846 | 81186 81222 81248 81291 81303 81326 81363 81410 81427 81440 81479 81528 81599 0012U 0032U 0056U 0076U S3850 81542 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3850 | 81189 81223 81249 81292 81304 81327 81364 81411 81430 81442 81490 81535 84999 0013M 0033U 0057U 0078U S3852 81552 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3852 | Laboratory Services | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3854 | 81163 81201 81226 81253 81294 81313 81335 81401 81413 81432 81445 81500 81538 0002M 0014U 0036U 0067U G9143 S3861 0156U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3861 | 81164 81202 81227 81257 81295 81317 81336 81402 81414 81433 81448 81503 81539 0003M 0018U 0037U 0069U S3800 S3865 0157U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3865 | 81165 81203 81228 81258 81296 81318 81337 81403 81415 81434 81450 81504 81540 0004M 0019U 0045U 0070U S3840 S3866 0158U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3866 | 81166 81212 81229 81259 81297 81319 81346 81404 81416 81435 81455 81518 81541 0005U 0022U 0047U 0071U S3841 S3870 0159U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S3870 | 81167 81215 81230 81269 81298 81321 81350 81405 81417 81436 81460 81519 81545 0006M 0026U 0048U 0072U S3842 81277 0160U | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S5111 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S5130 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S5135 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S5150 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S5151 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8037 | 70470 70540 70554 72127 72149 72198 73700 74160 74262 77021 78016 78195 78261 78445 78606 78708 78812 C8903 C8920 S8042 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8042 | 70480 70542 70555 72128 72156 73200 73701 74170 74263 77022 78018 78201 78262 78456 78608 78709 78813 C8905 C8931 S8085 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8080 | Imaging – Advanced & Specialty | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8085 | 70481 70543 71250 72129 72157 73201 73702 74174 74712 77046 78020 78202 78264 78457 78609 78725 78814 C8906 C8932 S8092 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8092 | 70482 70544 71260 72130 72158 73202 73706 74175 74713 77047 78070 78206 78265 78458 78610 78730 78815 C8908 C8933 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8189 | 22899 31299 39599 44799 49329 58679 67999 77499 81099 88199 93799 99499 A9999 J7699 L1499 P9603 S8930 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S8930 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9110 | 23929 31899 40899 44979 49999 59897 68899 78099 85999 88399 95199 A0999 C2698 J7999 L3649 Q0507 T1999 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9122 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9123 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9124 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9128 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9129 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9131 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9470 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9960 | PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9961 | PA required for Non-Emergent Air Ambulance transportation services. Emergency transport does not require PA. | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| S9977 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1000 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1002 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1003 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1005 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1019 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1022 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1023 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1025 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1026 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1027 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1028 | 0912 1002 - * # * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1030 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1031 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T1999 | Unlisted/Miscellaneous Codes | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T2013 | 0913 2106 * * *+ * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T2025 | 15999 25999 33999 42299 45499 50949 59899 69799 78299 86849 89240 96379 A4641 E0769 J8499 L5999 Q0509 V2199 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T2040 | 0901 1001 - ***< * * * * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T2042 | * * * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| T2043 | * | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V2199 | 17999 26989 36299 42699 45999 51999 60659 69949 78399 86999 89398 96549 A4649 E0770 J8597 L7499 Q2039 V2797 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V2530 | E0256 E0304 E0692 E0855 E1028 E1238 E2295 E2342 E2500 E2615 K0009 K0814 K0836 K0856 K0880 Q4188 V2531 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V2531 | E0260 E0328 E0693 E0983 E1029 E1296 E2300 E2343 E2502 E2616 K0010 K0815 K0837 K0857 K0884 Q4190 V5171 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V2797 | 19499 27299 37501 42999 46999 53899 60699 69979 78599 87797 90399 96999 A4913 E1399 J8999 L8039 Q4050 V2799 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V2799 | 20999 27599 37799 43289 47379 54699 64999 76496 78699 87798 90749 97039 A6261 E1699 J9999 L8499 Q4051 V5298 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5171 | E0261 E0329 E0694 E0984 E1030 E1298 E2310 E2351 E2504 E2617 K0011 K0816 K0838 K0858 K0885 Q4191 V5172 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5172 | E0265 E0371 E0747 E0986 E1035 E1310 E2311 E2361 E2506 E2620 K0012 K0820 K0839 K0859 K0886 Q4193 V5181 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5181 | D05.80 D05.81 DO5.82 D05.90 D05.91 D05.92 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5211 | A7025 E0277 E0373 E0749 E1002 E1161 E1700 E2313 E2367 E2510 E2622 K0108 K0822 K0841 K0861 K0891 Q4198 V5212 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5212 | A9274 E0292 E0447 E0760 E1003 E1225 E2201 E2321 E2368 E2511 E2623 K0553 K0823 K0842 K0862 K0900 Q4200 V5213 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5213 | A9276 E0293 E0462 E0762 E1004 E1226 E2202 E2322 E2369 E2605 E2624 K0554 K0824 K0843 K0863 L3761 Q4201 V5214 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5214 | A9277 E0294 E0465 E0764 E1005 E1227 E2203 E2325 E2370 E2606 E2625 K0606 K0825 K0848 K0864 L7700 Q4202 V5215 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5215 | A9278 E0295 E0466 E0766 E1006 E1230 E2204 E2326 E2373 E2607 E2626 K0800 K0826 K0849 K0868 L8625 Q4203 V5221 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5221 | A9900 E0296 E0467 E0782 E1007 E1232 E2227 E2327 E2374 E2608 E2627 K0801 K0827 K0850 K0869 L8694 Q4204 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5298 | 21089 27899 38129 43499 47399 55559 66999 76499 78799 87799 90899 97139 A6262 G0501 K0812 L8698 Q4082 V5299 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |
| V5299 | 21299 28899 38589 43659 47579 55899 67299 76999 78999 87899 91299 97799 A9698 G9012 K0898 L8699 Q4100 | 2020-01-01 | Not listed | 97% | [PDF] Applies to Marketplace Prior Authorization Codification List |