Prior authorization codes

PrimeWest

Active CPT codes that appear on the extracted prior authorization list for this health plan.

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CodeProcedure / ServiceEffectiveRevisedConfidenceSource
0001U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0002U
PolypDx All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0003U
Overa (OVA1 Next Generation) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0004U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0005U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0006U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0007U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0008U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0009U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0010U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
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[PDF] Services Requiring Prior Authorization - PrimeWest
0011U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
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[PDF] Services Requiring Prior Authorization - PrimeWest
0012M
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0012U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0013M
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0013U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0014U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0015M
Adrenal cortical tumor, biochemical assay of 25 steroid markers (24-hr urine specimen) with algorithm (risk All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0015U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0016M
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0016U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
00170
Anesthesia and facility fees for dental cleaning & restorations , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
00172
Anesthesia and facility fees for dental cleaning & restorations , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
00174
Anesthesia and facility fees for dental cleaning & restorations , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
00176
Anesthesia and facility fees for dental cleaning & restorations , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0017U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0018U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0019U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0020U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0021U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0022U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0023U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0024U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0025U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0026U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0027U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0028U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0029U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0030U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0031U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0032U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0033U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0034U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0035U
Real-time quaking-induced conversion for prion detection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0036U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0037U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0038U
Sensivea Droplet 25OH vitamin D2/D3 Microvolume LC/MS Assay by InSource Diagnostics All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0039U
Anti-dsDNA, high salt/avidity All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0040U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0041U
Lyme ImmunoBlot IgM and IgG by IGeneX Inc. , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0042U
Lyme ImmunoBlot IgM and IgG by IGeneX Inc. , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0043U
Tick-borne Relapsing Fever (TBRF) Borrelia ImmunoBlots IgM & IgG Test , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0044U
Tick-borne Relapsing Fever (TBRF) Borrelia ImmunoBlots IgM & IgG Test , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0045U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0046U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0047U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0048U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0049U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0050U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0051U
RX MNTR LC-MS/MS UR 31 PNL All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0052U
VAP Cholesterol Test All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0053U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0054U
AssuranceRX Micro Serum RX MNTR TRNSPL 96 DNA Seq All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0055U
myTAIHEART CARD HRT TRNSPL 95 DNA Seq All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0056U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0057U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0058U
Merkel SmT Oncoprotein Antibody Titer ONC MERKEL CLL CARC SRM All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0059U
Merkel Virus VP1 Capsid Antibody ONC MERKEL CLL CARC CRM All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0060U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0061U
Transcutaneous multispectral measurement of tissue oxygenation and hemoglobin using Spatial Frequency All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0062U
AI SLE IGG&IGM ALYS 80 BMRK All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0063U
NEURO AUTISM 32 AMINES ALG All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0064U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0065U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0066U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0067U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0068U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0069U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0070U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0071U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0072U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0073U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0074U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0075U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0076U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0077U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0078U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0079U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0080U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0081U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0082U
Drug test(s), definitive, 90 or more drugs or substances All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0083U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0084U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0085U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0086U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0087U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0088U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0089U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0090U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0091U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0092U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0093U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0094U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0095T
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0095U
EoE biomarker ELISA (eotaxin 3, PRG2) with algorithm All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0096U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0097U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0098T
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0098U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0099U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0100U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0101U
Hereditary colon cancer panel with mRNA analytics (15+ genes) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0102U
Hereditary breast cancer related panel (17 genes) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0103U
Hereditary ovarian cancer panel (24 genes) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0104U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0105U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0106U
Gastric emptying, serial collection of 7 timed breath specimens All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0107U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0108U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0109U
Infectious disease (Aspergillus species) real-time PCR All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0110U
Prescription drug monitoring, one or more oral oncology drugs All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0111U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0112U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0113U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0114U
Gastroenterology (Barrett’s esophagus) VIM & CCNA1 methylation analysis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0115U
Respiratory infectious agent detection by nucleic acid (DNA/RNA), 18 viral types & subtypes, 2 bacterial targets All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0116U
Prescription drug monitoring, enzyme immunoassay of 25+ drugs with LC-MS/MS confirmation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0117U
Pain management, analysis of 11 endogenous analytes with LC-MS/MS, urine (pain-index score) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0118U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0119U
Ceramides LC MS/MS with risk score for MACE All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0120U
Oncology (B-cell lymphoma classification), mRNA, gene expression profiling of 58 genes (PMBCL, DLBCL) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0121U
Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0122U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0123U
Mechanical fragility, RBC, shear stress and spectral analysis profiling All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0124U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0125U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0126U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0127U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0128U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0129U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0130U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0131U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0132U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0133U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0134U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0135U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0136U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0137U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0138U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0139U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0140U
Infectious Disease Labs (bacteria and fungi) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0141U
Infectious Disease Labs (bacteria and fungi) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0142U
Infectious Disease Labs (bacteria and fungi) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0143U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0144U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0145U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0146U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0147U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0148U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0149U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0150U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0151U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0152U
Infectious disease (bacteria, fungi, parasites, DNA viruses), DNA PCR & next-gen sequencing (>1000 potential All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0153U
Oncology (breast), mRNA, next-gen sequencing profiling of 101 genes (triple negative breast cancer subtype) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0154U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0155U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0156U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0157U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0158U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0159U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0160U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0161U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0162U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0163T
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0163U
Oncology (colorectal) screening, ELISA of 3 plasma/serum proteins with algorithm (CRC or advanced adenomas All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0164U
Gastroenterology (IBS) immunoassay for anti-CdtB and anti-vinculin antibodies All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0165U
Peanut allergen-specific IgE (64 epitopes) quantitative ELISA All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0166U
Liver disease, 10 biochemical assays (α2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0167U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0168U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0169U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0170U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0171U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0172U
Oncology (solid tumor), BRCA1/2 mutation & homologous recombination deficiency pathways (HRD), DNA NGS All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0173U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0174U
Oncology (solid tumor), 30 protein targets by mass spectrometry (formalin-fixed paraffin-embedded tissue) with All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0175U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0176U
Cytothelial distending toxin B (CdtB) & vinculin IgG antibodies by immunoassay (ELISA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0177U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0178U
Peanut allergen-specific quantitative ELISA (minimum eliciting exposure for clinical reaction) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0179U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0203U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0204U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0205U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0206U
Neurology (Alzheimer’s disease); cell aggregation (C-PKcε) + ELISA biomarkers; positive/negative classification All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0207U
Neurology (Alzheimer’s disease); quantitative imaging of phosphorylated ERK1/2 with in situ All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0208U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0209U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0210U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0211U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0212U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0213U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0214U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0215U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0216U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0217U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0218U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0219T
Posterior intrafacet implant(s) placement , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0219U
Diagnostics continued Infectious agent (HIV), targeted viral NGS (protease, reverse transcriptase, integrase) with algorithm for antiviral All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0220U
Oncology (breast cancer), AI-based image analysis of 12 histologic & immunohistochemical features (recurrence All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0221T
Posterior intrafacet implant(s) placement , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0221U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0222T
Posterior intrafacet implant(s) placement , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0222U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0223U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0224U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0225U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0226U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0227U
Drug assay, presumptive, ≥30 drugs/metabolites, urine LC-MS/MS with multiple reaction monitoring (MRM) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0228U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0229U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0230U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0231U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0232T
Platelet Rich Plasma (PRP) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0232U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0233U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0234U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0235U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0236U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0237U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0238U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0239U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0240U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0241U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0242U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0243U
Obstetrics (preeclampsia), biochemical assay of placental-growth factor (time-resolved fluorescence All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0244U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0245U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0246U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0247U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0248U
Oncology (brain) – 3D spheroid culture 12 drug response All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0249U
Oncology (breast), semiquantitative analysis of 32 phosphoproteins/proteins, laser capture microdissection + All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0250U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0251U
Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum/plasma All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0252U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0253U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0254U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0255U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0256U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0257U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0258U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0286U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0287U
Oncology (thyroid) mRNA gene expression profiling All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0288U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0289U
Pain propensity RNA expression risk score (36 genes) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0290U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0291U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0292U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0293U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0294U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0295U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0296U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0297U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0298U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0299U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0300U
Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0329T
Continuous intraocular pressure monitoring All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0330T
Tear film imaging All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0331T
Myocardial sympathetic innervation imaging , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0332T
Myocardial sympathetic innervation imaging , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0333T
Automated visual screening All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0335T
Subtalar joint implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0338T
Transcatheter renal sympathetic denervation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0339T
Transcatheter renal sympathetic denervation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0342T
Therapeutic apheresis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0345T
Transcatheter mitral valve repair (TMVr) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0353T
OCT – Breast All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0358T
Bioelectrical impedance analysis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0373T
EIDBI Intervention Higher Intensity UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0394T
HDR electronic brachytherapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0395T
HDR electronic brachytherapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0397T
ERCP with optical endomicroscopy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0402T
Corneal Collagen Cross-Linking All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0408T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0409T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0410T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0411T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0412T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0413T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0414T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0415T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0416T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0417T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0418T
Cardiac contractility modulation system (code family) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0419T
Destruction neurofibroma, extensive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0420T
Destruction neurofibroma, extensive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0421T
Transurethral waterjet ablation of prostate All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0422T
Tactile breast imaging All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0437T
Synthetic implant for abdominal wall reinforcement All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0439T
Myocardial contrast perfusion echo All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0440T
Cryoablation of peripheral/truncal nerve(s) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0441T
Cryoablation of peripheral/truncal nerve(s) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0442T
Cryoablation of peripheral/truncal nerve(s) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0443T
Real time spectral analysis of prostate tissue by fluorescence All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0444T
Drug eluting ocular insert placement , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0445T
Drug eluting ocular insert placement , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0446T
Implantable Glucose Sensor (procedures) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0447T
Implantable Glucose Sensor (procedures) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0448T
Implantable Glucose Sensor (procedures) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0449T
Insertion of aqueous drainage device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0450T
Insertion of aqueous drainage device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0464T
VEP testing for glaucoma All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0472T
Retinal prosthesis device evaluation/programming , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0473T
Retinal prosthesis device evaluation/programming , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0474T
Insertion of anterior segment aqueous drainage device All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0479T
Fractional ablative laser fenestration of burn and traumatic scars , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0480T
Fractional ablative laser fenestration of burn and traumatic scars , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0481T
Autologous White Blood Cell Injection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0483T
TMVI prosthetic valve – percutaneous/transapical , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0484T
TMVI prosthetic valve – percutaneous/transapical , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0485T
OCT of middle ear; unilateral/bilateral , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0486T
OCT of middle ear; unilateral/bilateral , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0489T
Autologous adipose derived regenerative cell therapy for scleroderma (harvest/prep) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0490T
Autologous adipose derived regenerative cell therapy for scleroderma (multiple injections) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0506T
Macular pigment optical density measurement by heterochromatic flicker photometer (HFP) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0507T
Near-infrared dual imaging of meibomian glands All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0509T
Pattern electroretinography (PERG) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0510T
Removal/reinsertion of sinus tarsi implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0511T
Removal/reinsertion of sinus tarsi implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0512T
Extracorporeal shock wave wound healing All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0513T
Extracorporeal shock wave wound healing All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0515T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0516T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0517T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0518T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0519T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0520T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0521T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0522T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0523T
Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0524T
Endovenous chemical ablation with balloon isolation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0525T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0526T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0527T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0528T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0529T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0530T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0531T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0532T
Intracardiac ischemia monitoring system – implant & programming , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0541T
Magnetocardiography (MCG) – myocardial ischemia , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0542T
Magnetocardiography (MCG) – myocardial ischemia , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0543T
Transapical mitral valve repair with artificial chordae All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0544T
Transcatheter mitral valve annulus reconstruction All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0545T
Transcatheter tricuspid valve annulus reconstruction All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0546T
Intraoperative radiofrequency spectroscopy – breast margin assessment All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0547T
Bone material quality by tibial microindentation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0552T
Low level laser therapy – dynamic photonic/thermokinetic All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0554T
Bone strength & fracture risk by finite element analysis – family , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0555T
Bone strength & fracture risk by finite element analysis – family , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0556T
Bone strength & fracture risk by finite element analysis – family , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0557T
Bone strength & fracture risk by finite element analysis – family , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0558T
Bone strength & fracture risk by finite element analysis – family , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0559T
Anatomic 3D printed model/guide – first & additional , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0560T
Anatomic 3D printed model/guide – first & additional , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0561T
Anatomic 3D printed model/guide – first & additional , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0562T
Anatomic 3D printed model/guide – first & additional , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0563T
Meibomian gland evacuation via wearable heat device with manual expression (bilateral) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0565T
Autologous adipose derived cellular implant for knee OA – harvest/prep All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0566T
Autologous adipose derived cellular implant for knee OA – injection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0569T
Transcatheter tricuspid valve repair – initial prosthesis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0570T
Transcatheter tricuspid valve repair – each additional prosthesis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0571T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0572T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0573T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0574T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0575T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0576T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0577T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0578T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0579T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0580T
Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0581T
Percutaneous cryoablation of malignant breast tumor All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0582T
Transurethral ablation of malignant prostate tissue – water vapor All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0583T
Tympanostomy with automated tube delivery, iontophoresis anesthesia All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0584T
Islet cell transplant – percutaneous All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0585T
Islet cell transplant – laparoscopic All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0586T
Islet cell transplant – open All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0587T
Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0588T
Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0589T
Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0590T
Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0594T
Humerus osteotomy with lengthening device All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0596T
Female intraurethral valve-pump (initial & replacement) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0597T
Female intraurethral valve-pump (initial & replacement) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0600T
Irreversible Electroporation Ablation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0601T
Irreversible Electroporation Ablation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0604T
Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0605T
Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0606T
Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0609T
Magnetic resonance spectroscopy for discogenic pain (≥3 discs, biomarkers lactid acid, carbohydrate, collagen, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0611T
Magnetic resonance spectroscopy for discogenic pain (cervical, thoracic, lumbar); biomarker analysis across ≥3 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0613T
Interatrial Septal Shunt Device All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0615T
Surgery-Procedure continued Eye-movement analysis (no spatial calibration) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0619T
Prostate commissurotomy + drug delivery (endoscopic) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0621T
Trabeculostomy ab interno (laser / with endoscope) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0622T
Trabeculostomy ab interno (laser / with endoscope) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0623T
Automated quantification & characterization of coronary atherosclerotic plaque (CTA data analysis & reporting) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0624T
Automated quantification & characterization of coronary atherosclerotic plaque (CTA data All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0625T
Coronary plaque quantification via CTA (data analysis only) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0626T
Coronary plaque quantification via CTA (data review and reconciliation of discordant data) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0627T
Allogeneic product injection to intervertebral disc , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0628T
Allogeneic product injection to intervertebral disc , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0629T
Allogeneic product injection to intervertebral disc , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0630T
Allogeneic product injection to intervertebral disc , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0631T
Transcutaneous visible light hyperspectral imaging (oxy/deoxyhemoglobin, tissue oxygenation) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0633T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0634T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0635T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0636T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0637T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0638T
CT Breast with 3D rendering , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0640T
Near-infrared spectroscopy wound studies , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0644T
Transcatheter removal/debulking of intracardiac mass All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0646T
Transcatheter tricuspid valve implantation/replacement All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0647T
Percutaneous G-tube with magnetic gastropexy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0648T
Quantitative magnetic resonance for tissue composition (fat, iron, water, etc.), multiparametric data acquisition, , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0649T
Quantitative magnetic resonance for tissue composition (fat, iron, water, etc.), multiparametric data acquisition, , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0651T
Magnetically controlled capsule endoscopy (MCCE), esophagus with interpretation/report All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0652T
Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0653T
Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0654T
Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0655T
Transperineal focal laser ablation of prostate (MR-fused) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0658T
Electrical impedance spectroscopy (skin lesions), automated melanoma risk score All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0659T
Supersaturated oxygen intracoronary infusion during PCI for AMI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0662T
Scalp cooling – measurement/calibration/placement/monitoring/removal , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0663T
Scalp cooling – measurement/calibration/placement/monitoring/removal , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0668T
Uterine allograft backbench prep/reconstruction , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0669T
Uterine allograft backbench prep/reconstruction , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0670T
Uterine allograft backbench prep/reconstruction , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
0859T
Near-infrared spectroscopy wound studies , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11920
Tattooing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11921
Tattooing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11922
Tattooing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11950
SubQ filling (collagen) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11951
SubQ filling (collagen) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11952
SubQ filling (collagen) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11954
SubQ filling (collagen) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
11980
Subcutaneous hormone pellets , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13100
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13101
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13102
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13120
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13121
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13122
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13131
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13132
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13151
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
13152
Scar Revisions (incl. keloids) , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15200
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15730
Midface Flap or Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15733
Midface Flap or Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15769
Grafting of autologous soft tissue, fat by liposuction , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15771
Grafting of autologous soft tissue, fat by liposuction , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15772
Grafting of autologous soft tissue, fat by liposuction , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15773
Grafting of autologous soft tissue, fat by liposuction , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15774
Grafting of autologous soft tissue, fat by liposuction , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15775
Punch graft for hair transplant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15776
Punch graft for hair transplant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15780
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15781
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15782
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15783
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15786
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15787
Dermabrasion , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15788
Chemical Peel , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15789
Chemical Peel , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15792
Chemical Peel , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15793
Chemical Peel , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15820
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15821
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15822
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15823
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15824
Rhytidectomy , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15825
Rhytidectomy , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15826
Rhytidectomy , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15828
Rhytidectomy , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15829
Rhytidectomy , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15830
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15832
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15833
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15834
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15835
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15836
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15837
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15838
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15839
Excision of excessive SubQ , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15847
Cosmetic Abdominoplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15876
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15877
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15878
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
15879
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17000
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17003
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17004
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17106
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17107
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17108
Lesion Destruction , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17340
Cryotherapy for acne All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17360
Chemical exfoliation for acne All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17380
Electrolysis epilation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
17999
Ablative laser treatment (non-contact, full field and fractional ablation, open wound, per day, total treatment All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19294
IORT applicator placement (add-on) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19300
Mastectomy, SubQ , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19302
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19303
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19316
Mastopexy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19318
Mastectomy, SubQ , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19325
Gender affirming surgery – Female to Male 19303, 19302, 19300, 19318, 53420, 53425, 53430, 54400, 54401, 54405, 54660, 55175, 55180, 15200, 31599, 17380, 17999, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19328
Removal of mammary implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19330
Breast Implant Removal , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19340
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19342
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19350
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19355
Correction of inverted nipples All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19357
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19361
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19364
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19367
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19368
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
19369
Breast Reconstruction (post-cancer) , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
20932
Allograft add on codes for osteoarticular/hemicortical/intercalary , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
20933
Allograft add on codes for osteoarticular/hemicortical/intercalary , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
20934
Allograft add on codes for osteoarticular/hemicortical/intercalary , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
20975
Electrical stimulation to aid bone healing – invasive (operative) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21010
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21025
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21026
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21050
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21060
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21070
Mandible – Coronoidectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21073
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21079
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21080
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21081
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21085
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21087
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21089
Mandibular Ortho Repositioning device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21110
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21120
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21121
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21122
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21123
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21125
Mandibular augmentation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21127
Mandibular augmentation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21141
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21142
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21143
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21145
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21146
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21147
Lefort I , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21150
Lefort II , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21151
Lefort II , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21188
Midface Reconstruction (other) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21193
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21194
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21195
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21196
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21198
With Osteotomy Segmental All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21206
Maxilla – Osteotomy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21208
Facial Osteoplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21209
Facial bones reduction All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21210
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21240
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21242
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21243
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21244
With Transosteal Bone Plate All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21245
Subperiosteal Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21246
Subperiosteal Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21247
With Autografts All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21248
Endosteal Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21249
Endosteal Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21255
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21270
Malar augmentation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21299
Maxilla – Osteotomy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21480
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21485
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21490
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21497
TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21499
Mandibular Ortho Repositioning device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21685
Sleep Apnea – Hyoid Myotomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
21899
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22532
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22533
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22534
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22548
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22551
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22552
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22554
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22556
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22558
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22585
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22586
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22590
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22595
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22600
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22610
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22612
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22614
Spinal Fusions , , , , , , , , , , , , ; , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22630
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22632
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22633
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22634
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22800
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22802
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22804
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22808
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22810
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22812
Blue light cystoscopy imaging agent C9738 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22856
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22857
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22858
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22860
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22861
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22862
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22864
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22865
Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22867
Interspinous/interlaminar stabilization without fusion , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22868
Interspinous/interlaminar stabilization without fusion , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22869
Interspinous/interlaminar stabilization without fusion , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
22870
Interspinous/interlaminar stabilization without fusion , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
27198
Posterior Pelvic Ring Fx – Closed treatment with manipulation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
27279
Sacroiliac Joint Stabilization (Fusion) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
27280
Sacroiliac Joint Stabilization (Fusion) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
29800
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
29804
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30120
Planing of skin of nose All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30400
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30410
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30420
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30430
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30435
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30450
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
30468
Nasal valve collapse repair with implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31243
Nasal/sinus endoscopy, cryoablation nasal tissues/nerves All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31591
Laryngoplasty, medialization, unilateral All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31592
Cricotracheal resection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31599
Gender affirming surgery – Female to Male 19303, 19302, 19300, 19318, 53420, 53425, 53430, 54400, 54401, 54405, 54660, 55175, 55180, 15200, 31599, 17380, 17999, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31647
Bronchial valve insertion/removal , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31648
Bronchial valve insertion/removal , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31649
Bronchial valve insertion/removal , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31651
Bronchial valve insertion/removal , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
31899
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32491
Lung Volume Reduction Surgery All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32851
Lung , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32852
Lung , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32853
Lung , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32854
Lung , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
32994
Pulmonary tumor cryoablation (percutaneous) – chest wall/pleura included All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33140
Transmyocardial laser revascularization , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33141
Transmyocardial laser revascularization , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33240
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33241
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33270
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33271
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33272
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33273
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33274
Leadless pacemaker , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33275
Leadless pacemaker , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33289
Wireless PA pressure sensor implantation (CardioMEMS) – complete All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33340
Left atrial appendage closure All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33361
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33362
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33363
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33364
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33365
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33366
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33367
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33368
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33369
TAVR/TAVI All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33390
Valvuloplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33391
Valvuloplasty, aortic valve, complex All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33418
Transcatheter mitral valve repair (TMVr) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33419
Transcatheter mitral valve repair (TMVr) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33440
Ross Konno procedure (aortic valve replacement with pulmonary autograft) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33741
Transcatheter atrial septostomy (congenital) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33745
Transcatheter intracardiac shunt (congenital) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33746
Transcatheter intracardiac shunt (congenital) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33927
Artificial Heart Procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33928
Artificial Heart Procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33929
Artificial Heart Procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33935
Heart-Lung All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33945
Heart All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33975
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33976
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33979
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33981
LVAD/VAD – part 2 , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33982
LVAD/VAD – part 2 , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33983
LVAD/VAD – part 2 , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33995
Percutaneous VAD (right heart – venous only) insertion All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
33997
Removal of percutaneous right heart VAD cannula All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34717
Endovascular repair of iliac artery bifurcation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34718
Endovascular repair of iliac artery bifurcation , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34841
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34842
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34843
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34844
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34845
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34846
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34847
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
34848
Endoprosthesis for Aorta Repair All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
35400
Angioscopy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36456
Partial exchange transfusion, newborn All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36465
Sclerotherapy – Varicose Veins , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36466
Sclerotherapy – Varicose Veins , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36468
Sclerotherapy – Spider Veins All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36470
Sclerotherapy – Varicose Veins , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36471
Sclerotherapy – Varicose Veins , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36473
Endovenous Ablation Therapy of Incompetent Vein , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36474
Endovenous Ablation Therapy of Incompetent Vein , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36475
Endovenous Radiofrequency Ablation , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36476
Endovenous Radiofrequency Ablation , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36478
Endovenous Radiofrequency Ablation , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36479
Endovenous Radiofrequency Ablation , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36482
Endovenous ablation with chemical adhesive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
36483
Endovenous ablation with chemical adhesive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37246
Transluminal Balloon Angioplasty (non-dialysis) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37247
Transluminal Balloon Angioplasty (non-dialysis) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37248
Transluminal Balloon Angioplasty (non-dialysis) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37249
Transluminal Balloon Angioplasty (non-dialysis) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37788
Penile revascularization All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
37790
Penile venous occlusive procedure All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38225
CAR T support services (prep/transport/cryopreservation) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38226
CAR T support services (prep/transport/cryopreservation) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38227
CAR T support services (prep/transport/cryopreservation) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38228
CAR T support services (prep/transport/cryopreservation) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38240
Transplants Bone Marrow/Stem Cell , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38241
Transplants Bone Marrow/Stem Cell , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
38242
Bone Marrow/Stem Cell All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
40799
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
41512
Sleep Apnea – Tongue Base Suspension All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
41530
Tongue ablation, radiofrequency All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
41899
Miscellaneous dental code All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
42140
Sleep Apnea – Uvulectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
42145
Sleep Apnea – UPPP All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
42975
Drug induced sleep endoscopy (DISE) for sleep disordered breathing All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43284
LINX – esophageal sphincter augmentation device (Fact 4), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43285
LINX – esophageal sphincter augmentation device (Fact 4), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43644
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43645
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43647
Gastric Neurostimulator Electrodes , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43648
Gastric Neurostimulator Electrodes , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43659
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43770
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43771
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43772
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43773
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43774
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43775
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43842
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43843
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43845
Bariatrics – Gastric restriction w/limited absorption All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43846
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43847
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43848
Bariatrics – Gastric Bypass Revision , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43860
Bariatrics – Gastric Bypass Revision , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43865
Bariatrics – Gastric Bypass Revision , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43881
Gastric Neurostimulator Electrodes , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43882
Gastric Neurostimulator Electrodes , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43886
Bariatrics – Gastric restriction with port , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43887
Bariatrics – Gastric restriction with port , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43888
Bariatrics – Gastric restriction with port , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
43999
Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44135
Intestine , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44136
Intestine , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44388
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44389
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44390
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44391
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44392
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44394
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44401
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44402
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44403
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44404
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44405
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44406
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44407
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
44408
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45378
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45379
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45380
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45381
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45382
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45383
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45384
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45385
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45386
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45388
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45389
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45390
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45391
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45392
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45393
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
45398
Real-time quaking-induced conversion for prion detection 0035U All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
47135
Liver , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
47399
Liver , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
47620
Cholecystectomy w/ transduodenal sphincterotomy/sphincteroplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
48160
Pancreas , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
48554
Pancreas , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
50360
Kidney , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
50365
Kidney , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
50380
Kidney Autotransplantation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
51715
Endoscopic urethral implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
52284
Cystourethroscopy w/drug delivery for urethral stricture All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53400
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53405
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53410
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53415
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53420
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53425
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53430
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53451
Periurethral balloon continence device – unilateral/bilateral , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53452
Periurethral balloon continence device – unilateral/bilateral , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
53854
Transurethral RF water vapor therapy (Rezūm) – malignant tissue All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54125
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54150
Circumcision , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54160
Circumcision , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54161
Circumcision , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54163
Circumcision , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54400
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54401
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54405
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54520
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54660
Insertion of testicular prosthesis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
54690
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55175
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55180
Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55866
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55874
Transperineal peri prostatic biodegradable material placement All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55899
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55970
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
55980
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
56625
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
56800
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
56805
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57106
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57110
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57291
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57292
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57295
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57296
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57335
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
57426
Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58150
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58180
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58260
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58262
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58275
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58290
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58291
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58345
Transcervical introduction of catheter to fallopian tube All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58541
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58542
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58543
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58544
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58550
58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58552
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58553
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58554
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58570
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58571
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58572
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58573
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58661
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58674
Uterine fibroid ablation, radiofrequency All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58700
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58720
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 15775, 15776, 15820, 15821, 15822, 15823, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58953
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58956
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
58999
Biomechanical mapping, transvaginal (obsolete/replace) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61850
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61860
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61863
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61864
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61867
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61868
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61885
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
61886
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
62380
Endoscopic decompression of spinal nerve roots All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63001
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63002
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63003
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63004
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63005
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63006
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63007
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63008
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63009
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63010
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63011
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63012
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63013
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63014
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63015
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63016
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63017
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63018
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63019
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63020
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63021
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63022
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63023
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63024
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63025
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63026
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63027
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63028
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63029
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63030
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63031
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63032
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63033
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63034
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63035
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63036
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63037
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63038
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63039
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63040
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63041
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63042
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63043
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63044
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63045
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63046
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63047
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63048
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63049
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63050
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63051
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63052
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63053
Laminectomy/Hemilaminectomy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63650
SCS (Spinal Cord Stimulator) Insertion , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63655
SCS (Spinal Cord Stimulator) Insertion , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63685
SCS (Spinal Cord Stimulator) Insertion , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
63688
Spinal Neurostimulator PG revision/removal All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64553
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64555
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64561
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64566
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64568
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64569
Revision/replacement cranial nerve (e.g., vagus) neurostimulator electrode array All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64575
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64580
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64581
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64582
Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64583
Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64584
Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64585
Revision/removal peripheral neurostimulator electrode array All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64590
Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64595
Revision/removal peripheral or gastric neurostimulator pulse generator/receiver All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64620
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64624
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64625
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64628
Basivertebral nerve ablation – destruction CPT , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64629
Basivertebral nerve ablation – destruction CPT , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64632
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64633
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64634
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
64640
Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65760
Corneal shape altering procedures , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65765
Corneal shape altering procedures , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65767
Corneal shape altering procedures , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65770
Corneal shape altering procedures , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65771
Refractive Surgery (LASIK/RK/LRI/CLR) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65772
Correction of surgically induced astigmatism , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
65775
Correction of surgically induced astigmatism , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67516
Experimental continued Suprachoroidal injection of pharmacologic agent All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67900
service/diagnosis
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67901
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67902
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67903
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67904
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67906
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67908
Ptosis Repair , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67909
Reduction of Overcorrection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67911
Correction of lid retraction All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
67912
Correction of lagophthalmos All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
68841
Drug eluting punctal implant (lacrimal canaliculus) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69300
Otoplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69710
Hearing Device Implant/Removal , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69711
Hearing Device Implant/Removal , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69714
Temporal Bone Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69716
Osseointegrated skull implant – magnetic transcutaneous (implant) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69717
Temporal Bone Implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69719
Osseointegrated skull implant – magnetic transcutaneous (revision/replacement) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69726
Osseointegrated skull implant – removal (percutaneous) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69727
Osseointegrated skull implant – removal (magnetic transcutaneous) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69728
Removal of Hearing Device Implant with ≥100 sq mm bone removal All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69729
Implantation of Hearing Device Implant with ≥100 sq mm bone removal All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
69930
Cochlear Implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
74261
Diagnostics continued CT Colonography , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
74262
Diagnostics continued CT Colonography , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
74263
Diagnostics continued CT Colonography , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
75580
Noninvasive CT FFR (new code 1/1/24) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
76391
MR elastography All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
76999
Pulse-echo ultrasound bone density measurement, tibia All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77046
Breast MRI , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77047
Breast MRI , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77048
Breast MRI , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77049
Breast MRI , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77061
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77062
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77063
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77065
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77066
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
77067
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
80305
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
80306
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
80307
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81105
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81106
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81107
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81108
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81109
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81110
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81111
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81112
Platelet antigen genotyping (HPA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81120
Selected pharmacogenetic/hematology genes (condensed) , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81121
Selected pharmacogenetic/hematology genes (condensed) , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81161
Genetic Testing Genetic Testing – General (all tests) All genetic testing (incl. but not limited to CPT +; categories below) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81162
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81163
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81164
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81165
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81166
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81167
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81168
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81169
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81170
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81171
Gene Analysis & Molecular Pathology (except ) All
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81172
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81177
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81190
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81198
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81234
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[PDF] Services Requiring Prior Authorization - PrimeWest
81345
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81346
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81347
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81348
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81349
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81350
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81351
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81352
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81353
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81354
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81355
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81356
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81357
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81358
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81359
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81360
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81361
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81362
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81363
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81364
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81365
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81366
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81367
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81368
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81369
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81370
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81371
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81372
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81373
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81374
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81375
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81376
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81377
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81378
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81379
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81380
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81381
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81382
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81383
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81384
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81385
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81386
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81387
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81388
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81389
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81390
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81391
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81392
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81393
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81394
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81395
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81396
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81397
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81398
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81399
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81400
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81401
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81402
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81403
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81404
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81405
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81406
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81407
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81408
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81409
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81410
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81411
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81412
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81413
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81414
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81415
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81416
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81417
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81418
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81419
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81420
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81421
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81422
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81423
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81424
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81425
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81426
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81427
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81428
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81429
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81430
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81431
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81432
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81433
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81434
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81435
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81436
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81437
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81438
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81439
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81440
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81441
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81442
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81443
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81444
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81445
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81446
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81447
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81448
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81449
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81450
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81451
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81452
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81453
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81454
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81455
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81456
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81457
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81458
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81459
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81460
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81461
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81462
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81463
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81464
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81465
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81466
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81467
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81468
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81469
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81470
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81471
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81472
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81473
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81474
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81475
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81476
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81477
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81478
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81479
Gene Analysis & Molecular Pathology (except ) All
2026-07-062026-02-2497%
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81490
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81491
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2026-07-062026-02-2497%
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81492
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2026-07-062026-02-2497%
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81493
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81494
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81495
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2026-07-062026-02-2497%
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81496
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81497
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81498
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81499
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81500
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81501
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81502
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81503
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81504
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81505
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81506
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81507
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2026-07-062026-02-2497%
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81508
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81509
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81510
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2026-07-062026-02-2497%
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81511
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81512
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2026-07-062026-02-2497%
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81513
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
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81514
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2026-07-062026-02-2497%
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81515
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2026-07-062026-02-2497%
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81516
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81517
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2026-07-062026-02-2497%
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81518
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2026-07-062026-02-2497%
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81519
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2026-07-062026-02-2497%
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81520
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81521
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81522
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81523
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81524
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2026-07-062026-02-2497%
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81525
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2026-07-062026-02-2497%
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81526
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2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81527
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81528
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81529
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81530
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81531
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81532
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81533
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81534
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81535
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81536
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81537
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81538
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81539
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81540
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81541
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81542
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81543
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81544
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81545
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81546
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81547
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81548
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81549
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81550
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81551
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81552
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81553
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81554
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81555
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81556
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81557
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81558
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81559
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81560
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81561
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81562
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81563
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81564
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81565
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81566
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81567
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81568
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81569
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81570
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81571
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81572
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81573
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81574
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81575
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81576
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81577
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81578
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81579
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81580
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81581
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81582
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81583
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81584
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81585
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81586
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81587
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81588
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81589
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81590
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81591
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81592
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81593
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81594
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81595
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81596
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81597
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81598
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
81599
Multianalyte Assays (MAAA) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
82013
Acetylcholinesterase All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
84433
Thiopurine S methyltransferase (enzyme) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
86849
Unlisted Immunology Procedure All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
87467
Hepatitis B surface antigen (HBsAg), quantitative All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88120
Urinary tract FISH (cytopathology) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88121
Urinary tract FISH (cytopathology) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88245
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88248
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88249
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88267
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88269
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88271
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88272
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88273
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88274
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88275
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88280
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88283
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88285
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88289
Chromosome analysis , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88299
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88364
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88365
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88366
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88367
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88368
Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88369
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88373
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88374
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
88377
Cytogenetics / In situ hybridization , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90867
Transcranial Magnetic Stimulation (TMS) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90868
Transcranial Magnetic Stimulation (TMS) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90869
Transcranial Magnetic Stimulation (TMS) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90882
Adult Crisis Services , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90912
Biofeedback (behavioral health & medical conditions) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
90913
Biofeedback (behavioral health & medical conditions) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
91110
Diagnostics Capsule Endoscopy , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
91111
Diagnostics Capsule Endoscopy , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
91112
Wireless GI transit/pressure measurement All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
91113
Diagnostics Capsule Endoscopy , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92229
Imaging of retina for detection/monitoring of disease; automated point-of-care analysis/report All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92242
Fluorescein/ICG Angiography All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92310
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92314
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92325
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92326
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92512
Rhinomanometry All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92517
Vestibular evoked myogenic potential (VEMP), cervical (cVEMP) with interpretation/report All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92518
Vestibular evoked myogenic potential (VEMP), ocular (oVEMP) with interpretation/report All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92519
Vestibular evoked myogenic potential (VEMP), cervical & ocular (cVEMP + oVEMP) with interpretation/report All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92549
CDP SOT with MCT/ADT All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92601
Rehab Cochlear Implant Analysis GN, GN, GN, GN All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92602
Rehab Cochlear Implant Analysis GN, GN, GN, GN All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92603
Rehab Cochlear Implant Analysis GN, GN, GN, GN All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
92604
Rehab Cochlear Implant Analysis GN, GN, GN, GN All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93260
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93261
Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93264
Remote monitoring – PA pressure sensor (up to 30 days) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93278
Signal averaged ECG All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93799
Fetal magnetic cardiac signal recording (obsolete transition) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
93998
Near infrared spectroscopy for lower extremity wounds All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
95836
Electrocorticogram from implanted brain neurostimulator – up to 30 days All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
95999
Movement disorder continuous recording 6–10 days (obsolete to 1/1/24) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96377
On-body Injector Application (example Neulasta on-body) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96573
Photodynamic Therapy – external light (per day) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96574
Debridement + Photodynamic Therapy (per day) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96931
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96932
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96933
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96934
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96935
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96936
Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
96999
OCT of the skin (obsolete transition) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97014
Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97032
Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97151
Early Intensive Developmental and Behavioral Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit UB, UB, UB, UB SNBC, F&C, and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97153
EIDBI Intervention Individual UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97154
EIDBI Intervention Group UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97155
EIDBI Observation UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97156
EIDBI Caregiving Training and Counseling - Individual UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97157
EIDBI Family Training Group UB SNBC, F&C and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97545
Work Hardening , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97546
Work Hardening , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97610
Low frequency ultrasound wound therapy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97750
Functional Evaluation / Physical Performance Test All except PWSHC and PHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97810
Other Health Services Acupuncture , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97811
Other Health Services Acupuncture , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97813
Other Health Services Acupuncture , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
97814
Other Health Services Acupuncture , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99091
Telemonitoring , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99183
Hyperbaric Oxygen Therapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99184
Hypothermia in Neonate All newborns
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99199
Doula Services , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99453
Telemonitoring , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99454
Telemonitoring , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99456
Work-related or Medical Disability Exam All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99457
Telemonitoring , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
99458
Telemonitoring , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0426
Ground Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0427
Ground Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0428
Ground Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0429
Ground Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0430
Transportation Air Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0431
Transportation Air Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0435
Transportation Air Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A0436
Transportation Air Ambulance , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4221
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4222
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4223
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4239
Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4253
Diabetic test strips All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4453
Anal irrigation / manual enema system & accessories , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4459
Anal irrigation / manual enema system & accessories , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4468
Home ventilator – multifunction device (includes oxygen, neb, aspiration, cough stim) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4541
TENS for trigeminal nerve , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4542
External upper limb tremor stimulator (wrist) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4563
Rectal control system for vaginal insertion (long term use) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4606
Disposable oximeter probes All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A4649
Miscellaneous DME codes , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5500
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5501
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5503
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5507
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5510
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5512
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5513
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A5514
Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A7025
Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A9282
Wig / Hair Prosthesis All (non PAR only; no authorization for PAR)
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A9284
Spirometer (home monitoring post heart/lung transplant) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A9592
Copper Cu-64 Dotatate, diagnostic (1 millicurie) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A9900
Anal irrigation / manual enema system & accessories , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
A9999
Miscellaneous DME codes , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4102
Electrolyte containing fluids , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4103
Electrolyte containing fluids , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4105
Enzyme Cartridge – Enteral Nutrition All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4149
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4150
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4152
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4153
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4154
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4155
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4157
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4158
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4159
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4160
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4161
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
B4162
Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1062
Intravertebral body fracture augmentation with implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1823
Generator, neurostimulator (transvenous) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1826
Neurostimulator generator (closed-loop leads) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1827
Neurostimulator generator (closed-loop leads) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1832
Autograft suspension (incl. processing/components) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C1982
Catheter, pressure generating, intermittently occlusive All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C2596
Experimental Probe, image guided, robotic waterjet ablation (BPH) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9067
Gallium Ga-68 Dotatoc, diagnostic (0.01 mci) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9727
Sleep Apnea – Pillar Palatal Implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9738
Blue light cystoscopy imaging agent All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9739
Cystourethroscopy with transprostatic implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9740
Cystourethroscopy with transprostatic implant , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9751
Bronchoscopy with microwave ablation and full image guided navigation bundle All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9757
Laminotomy + annular closure device All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9758
Transcatheter interatrial shunt IDE trial – blinded procedure including RHC & TEE/ICE All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9759
Transcatheter microinfusion therapy All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9760
Interatrial shunt IDE trial – non randomized/non blinded All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9762
Cardiac MRI for morphology/function with strain imaging (quantification of segmental dysfunction) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9763
Cardiac MRI for morphology/function with strain imaging (quantification of segmental dysfunction) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9764
Endovascular lithotripsy revascularization , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9765
Endovascular lithotripsy revascularization , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9766
Endovascular lithotripsy revascularization , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9767
Endovascular lithotripsy revascularization , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
C9784
Endoscopic sleeve gastroplasty All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D0210
Dental Diagnostics , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D0330
Diagnostics Children under age 6
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D0999
Dental Diagnostics , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D1330
Oral Hygiene Instruction All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2720
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2721
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2722
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2740
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2750
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2751
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2752
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2753
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2780
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2781
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2782
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2783
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2790
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2791
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2792
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2794
Crowns , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2952
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2953
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2960
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2961
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2962
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2971
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2975
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D2999
Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D3460
Endodontics (endosseous implant) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4240
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4241
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4245
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4249
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4260
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4261
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4263
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4264
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4266
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4267
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4268
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4270
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4273
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4274
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4275
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4276
Periodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4341
Other Periodontics – covered for all (scaling and root planing 4+ teeth), (scaling and root planing 1–3 teeth), (Periodontal Maintenance) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4342
Other Periodontics – covered for all (scaling and root planing 4+ teeth), (scaling and root planing 1–3 teeth), (Periodontal Maintenance) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4381
Other Periodontics – covered for all D4341 (scaling and root planing 4+ teeth), D4342 (scaling and root planing 1–3 teeth), D4910 (Periodontal Maintenance) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4910
Other Periodontics – covered for all (scaling and root planing 4+ teeth), (scaling and root planing 1–3 teeth), (Periodontal Maintenance) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D4999
Other Periodontics – covered for all D4341 (scaling and root planing 4+ teeth), D4342 (scaling and root planing 1–3 teeth), D4910 (Periodontal Maintenance) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5110
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5120
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5130
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5140
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5211
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5212
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5213
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5214
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5221
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5222
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5223
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5224
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5225
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5226
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5227
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5228
Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5820
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5821
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5862
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5867
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5899
Dentures – , – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5911
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5912
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5937
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5951
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5952
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5953
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5954
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5958
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5959
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5960
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5982
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5983
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5984
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5985
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5986
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D5987
Maxillofacial Prosthetics , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6010
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6012
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6013
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6040
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6050
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6051
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6055
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6056
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6057
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6058
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6059
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6060
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6061
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6062
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6063
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6064
Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6065
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6066
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6067
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6068
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6069
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6070
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6071
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6072
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6073
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6074
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6075
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6076
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6077
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6080
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6082
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6083
D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6084
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6086
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6087
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6088
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6094
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6097
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6098
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6099
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6120
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6121
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6122
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6123
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6190
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6194
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6195
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6205
D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624,
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6210
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6211
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6212
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6214
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6240
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6241
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6242
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6243
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6245
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6250
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6251
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6252
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6253
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6545
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6548
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6624
D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6634
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6710
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6720
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6721
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6792
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6793
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6794
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6795
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6797
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6799
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6920
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6940
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6950
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D6985
Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7220
Removal of Impacted tooth , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7230
Removal of Impacted tooth , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7240
Removal of Impacted tooth , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7241
Removal of Impacted tooth , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7251
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7252
Removal of Impacted tooth , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7272
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7290
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7291
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7490
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7880
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7899
Mandibular Ortho Repositioning device 21499, 21089 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D7953
Oral Surgery , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8010
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8020
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8030
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8040
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8070
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8080
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8090
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8091
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8210
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8220
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8670
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8671
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8680
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8681
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D8999
Orthodontia (No age restriction) , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9941
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9952
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9971
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9972
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9973
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9974
Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
D9999
(unspecified adjunctive procedure)
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0170
Wheelchair accessory – seat lift mechanism & crutch tips , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0171
Wheelchair accessory – seat lift mechanism & crutch tips , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0172
Wheelchair accessory – seat lift mechanism & crutch tips , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0193
Mattress Group 2 (low air/powered/advanced) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0194
Mattress Group 3 (air fluidized) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0202
Bililights – after 1 month rental All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0260
Hospital Bed – Semi Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0261
Hospital Bed – Semi Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0265
Hospital Bed – Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0266
Hospital Bed – Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0277
Mattress Group 2 (low air/powered/advanced) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0294
Hospital Bed – Semi Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0295
Hospital Bed – Semi Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0296
Hospital Bed – Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0297
Hospital Bed – Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0300
Enclosed Crib / Bed Enclosure , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0301
Hospital Bed – Heavy Duty , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0302
Hospital Bed – Heavy Duty , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0303
Hospital Bed – Heavy Duty , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0304
Hospital Bed – Heavy Duty , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0316
Enclosed Crib / Bed Enclosure , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0329
Hospital Bed – Semi Electric , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0371
Mattress Group 2 (low air/powered/advanced) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0372
Mattress Group 2 (low air/powered/advanced) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0373
Mattress Group 2 (low air/powered/advanced) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0445
Continuous oximeter devices & probes All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0462
Hospital Bed – Rocking All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0465
Ventilators – invasive/noninvasive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0466
Ventilators – invasive/noninvasive , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0467
Home ventilator – multifunction device (includes oxygen, neb, aspiration, cough stim) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0468
Home ventilator – dual function device (adds cough stimulation) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0480
Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0482
Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0483
Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0485
Oral appliances for sleep disorder , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0486
Oral appliances for sleep disorder , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0487
Spirometer (home monitoring post heart/lung transplant) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0500
IPPB – Intermittent positive pressure breathing All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0530
Electronic positional OSA treatment (includes components) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0575
Nebulizer – ultrasonic All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0604
Breast Pump – heavy duty (rental only) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0617
External defibrillators (AED) , (wearable) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0618
Durable Medical Equipment (DME) Apnea monitor – after 6 month rental , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0619
Durable Medical Equipment (DME) Apnea monitor – after 6 month rental , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0620
Piercing device, skin All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0625
Patient lift – bathroom/toilet (NOC) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0627
Lift Chair Mechanism , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0629
Lift Chair Mechanism , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0630
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0635
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0636
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0637
Standers , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0638
Standers , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0639
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0640
Patient lift – fixed system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0641
Standers , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0642
Standers , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0652
Pneumatic compression device , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0670
Pneumatic compression device , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0675
Pneumatic compression device , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0691
Ultraviolet Light Therapy , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0692
Ultraviolet Light Therapy , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0693
Ultraviolet Light Therapy , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0694
Ultraviolet Light Therapy , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0715
Transvaginal Mechanotherapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0716
Transvaginal Mechanotherapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0720
TENS Units ( / / ) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0730
TENS Units ( / / ) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0731
TENS Units ( / / ) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0732
Cranial electrotherapy stimulation (CES) system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0733
TENS for trigeminal nerve , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0734
External upper limb tremor stimulator (wrist) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0735
Non-invasive vagus nerve stimulator All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0736
Transcutaneous tibial nerve stimulator – home All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0740
Pelvic floor/Urinary incontinence device All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0744
Neuromuscular stimulator for scoliosis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0745
Functional & electric stimulators for muscle atrophy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0746
Biofeedback machine All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0747
Bone growth stimulator (osteogenesis) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0748
Spinal—external stimulator All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0749
Bone growth stimulator (osteogenesis) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0760
Bone growth stimulator (osteogenesis) , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0762
Durable Medical Equipment (DME) continued Transcutaneous electrical joint stimulation system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0764
FNS for spinal cord injury / nerve stimulator for nausea & vomiting , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0765
FNS for spinal cord injury / nerve stimulator for nausea & vomiting , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0766
Electrotherapy stimulator All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0769
Electric stimulator for wound treatment All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0770
Functional & electric stimulators for muscle atrophy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0782
Infusion Pump – Implantable , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0783
Infusion Pump – Implantable , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0784
Insulin Pump All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0786
Infusion Pump – Implantable , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0787
Infusion Pump – Implantable , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0935
Continuous Passive Motion (CPM) machine , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0936
Continuous Passive Motion (CPM) machine , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0985
Wheelchair accessory – seat lift mechanism & crutch tips , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E0986
Wheelchair accessory – power assist for manual w/c All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1002
Wheelchair accessory – seating tilt/recline (manual/power) – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1008
Wheelchair accessory – seating tilt/recline (manual/power) – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1012
Wheelchair accessory – center mount power elevating leg rest/platform All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1014
Wheelchair accessory – reclining back , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1035
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1036
Patient lift – hydraulic/mechanical , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1037
Transport Chair – authorization timing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1038
Transport Chair – authorization timing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1039
Transport Chair – authorization timing , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1161
Manual – Tilt/Recliner All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1225
Wheelchair accessory – reclining back , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1226
Wheelchair accessory – reclining back , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1227
Wheelchair accessory – special height arms/back height , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1228
Wheelchair accessory – special height arms/back height , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1229
Manual Wheelchairs – standard ( – , ) , **, **, **, ** All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1230
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1231
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1232
Adaptive Stroller , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1233
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1234
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1235
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1236
Adaptive Stroller , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1237
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1238
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1239
Power Wheelchairs – Group 5 Pediatric , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1310
Whirlpool – non portable (built in) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1399
Female prosthetic (EROS) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1800
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1802
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1805
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1807
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1808
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1810
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1812
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1815
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1820
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1822
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1823
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1825
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1830
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E1840
Dynamic Splinting Devices , – , – , , – , , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2001
Suction pump for external urine management system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2100
Blood glucose monitor – special features , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2101
Blood glucose monitor – special features , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2102
Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2103
Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2227
Wheelchair accessory – gear reduction drive wheels All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2230
Wheelchair accessory – manual or power standing system , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2298
Wheelchair accessory – seat elevation feature All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2301
Wheelchair accessory – manual or power standing system , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2398
Wheelchair accessory – dynamic positioning hardware for back All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2402
Pump or Wound Vac All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2500
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2502
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2504
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2506
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2508
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2510
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2511
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2512
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2599
Augmentative Communication (AC) Devices , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2609
Custom wheelchair cushion , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2610
Powered seat cushion All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E2617
Custom wheelchair cushion , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E3000
Speech volume modulation system (incl. all components) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E8000
Gait Trainer , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E8001
Gait Trainer , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
E8002
Gait Trainer , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0068
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0069
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0070
Home Infusion Codes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0105
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0121
Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0153
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0166
External counterpulsation All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0277
Hyperbaric Oxygen Therapy , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0279
Mammogram or Mammography , , , , , , Female members under age 40 (exception
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0283
Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0327
Colorectal cancer screening; blood-based biomarker All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0429
Dermal filler injection All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0480
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0483
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G0659
Substance Use Disorder Urine Drug Screens – Over the limits for screening/presumptive/definitive require authorization or if provider is out
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9873
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9874
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9875
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9876
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9877
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9878
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9879
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9880
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9881
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9882
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9883
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9884
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9885
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9890
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
G9891
Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0004
Behavioral Health Counseling All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0018
Adult Crisis Services , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0019
CMHRTS (Children's MH Residential Treatment) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0031
CTSS (Children’s Therapeutic Services and Supports) Multiple ( UA, UA, etc.) Children and young adults
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0032
Early Intensive Developmental and Behavioral Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit UB, UB, UB, UB SNBC, F&C, and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H0046
Early Intensive Developmental and Behavioral Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit UB, UB, UB, UB SNBC, F&C, and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
H2011
Adult Crisis Services , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
J3490
Subcutaneous hormone pellets , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
J7330
CARTICEL (autologous cultured chondrocytes) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
J7402
Sinuva sinus implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0001
Manual Wheelchairs – standard ( – , ) , **, **, **, ** All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0002
Manual Wheelchairs – standard ( – , ) , **, **, **, ** All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0003
Manual Wheelchairs – standard ( – , ) , **, **, **, ** All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0004
Manual Wheelchairs – standard ( – , ) , **, **, **, ** All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0005
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0006
Other Manual Wheelchairs , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0007
Other Manual Wheelchairs , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0008
Customized Durable Medical Equipment , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0009
Manual – Special , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0013
Customized Durable Medical Equipment , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0014
Power/Electric ( / ) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0462
Repairs & Maintenance RB modifier, , , (>1 month) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0606
External defibrillators (AED) , (wearable) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0739
Repairs & Maintenance RB modifier, , , (>1 month) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0740
Repairs & Maintenance RB modifier, , , (>1 month) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0743
Pump or Wound Vac All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0800
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0801
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0802
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0806
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0807
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0808
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0812
POV/Scooter , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0813
Power Wheelchairs – Group 1 , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0814
Power Wheelchairs – Group 1 , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0815
Power Wheelchairs – Group 1 , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0816
Power Wheelchairs – Group 1 , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0820
Power Wheelchairs – Group 2 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0831
Power Wheelchairs – Group 2 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0835
Power Wheelchairs – Group 2 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0840
Power Wheelchairs – Group 2 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0841
Power Wheelchairs – Group 2 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0843
Power Wheelchairs – Group 2 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0848
Power Wheelchairs – Group 3 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0855
Power Wheelchairs – Group 3 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0856
Power Wheelchairs – Group 3 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0860
Power Wheelchairs – Group 3 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0861
Power Wheelchairs – Group 3 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0864
Power Wheelchairs – Group 3 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0868
Power Wheelchairs – Group 4 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0871
Power Wheelchairs – Group 4 Standard – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0877
Power Wheelchairs – Group 4 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0880
Power Wheelchairs – Group 4 Single Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0884
Power Wheelchairs – Group 4 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0886
Power Wheelchairs – Group 4 Multiple Power – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0890
Power Wheelchairs – Group 5 Pediatric , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0891
Power Wheelchairs – Group 5 Pediatric , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0898
Power/Electric ( / ) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K0900
Customized Durable Medical Equipment , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K1007
Powered bilateral HKAFO system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
K1027
Oral device to reduce upper airway collapsibility (custom) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L0648
Lumbar sacral orthosis (LSO) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L0650
Lumbar sacral orthosis (LSO) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L1006
Scoliosis Orthosis All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L1600
Hip Orthotics – limit & threshold – , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L1755
Hip Orthotics – limit & threshold – , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L1810
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2006
KAFO microprocessor control (custom fabricated) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2038
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2040
Hip Orthotics – limit & threshold – , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2090
Hip Orthotics – limit & threshold – , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2106
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L2999
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3000
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3001
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3002
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3003
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3010
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3020
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3030
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3031
Orthopedic Shoe Inserts , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3161
Foot adductus positioning device (adjustable) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3201
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3202
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3203
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3204
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3206
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3207
Orthopedic Shoes , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3224
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3225
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3230
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3250
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3251
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3252
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3253
Orthopedic Shoes , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3650
Upper Extremity Orthotics – limit – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L3999
Upper Extremity Orthotics – limit – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L4350
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L4631
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5615
Prosthetic addition – 4 bar linkage knee system All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5827
Endoskeletal knee shin system, single axis electromechanical All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5856
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5857
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5858
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5973
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5980
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L5987
Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L6700
UE prosthetic addition – myoelectric control/pattern recognition module All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L7900
Male prosthetic – vacuum erection (tension ring replacement only) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L7902
Male prosthetic – vacuum erection (tension ring replacement only) , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8608
Argus II retinal prosthesis – misc external component/accessory (>$3,000) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8609
Artificial Cornea All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8614
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8619
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8627
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8628
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8629
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8679
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8680
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8681
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8682
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8683
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8684
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8685
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8686
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8687
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8688
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8689
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8690
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8691
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8692
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8693
Cochlear Device and BAHA , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8695
Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8698
Total artificial heart – misc component/accessory All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8701
Powered UE ROM assist device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
L8702
Powered UE ROM assist device , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0478
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0484
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0488
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0491
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0495
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0496
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0502
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0504
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q0506
LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4100
Wound Care Skin substitutes - All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4226
Wound Care Skin substitutes - All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4227
Amniocore All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4232
Corplex All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4234
Xcellerate All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4235
Amniorepair/altiply All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4238
Derm-maxx All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4239
Amnio-maxx/lite All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4248
Dermacyte amniotic membrane allograft All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4249
Amniply (topical) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4250
Amnioamp-mp All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4253
Zenith Amniotic membrane All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4254
Wound Care continued Novafix dl All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
Q4259
Celera dual layer/membrane All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
R0651
Routine Home Care Day (<8 hours) Non-dual
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
R0652
Hospice Continuous Home Care Day (≥8 hours) Non-dual
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
R0655
Inpatient Respite Day Non-dual
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
R0656
Hospice continued General Inpatient Day Non-dual
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0189
Subcutaneous hormone pellets , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0500
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0504
Industrial/Sport/Computer Glasses , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0506
Industrial/Sport/Computer Glasses , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0508
Industrial/Sport/Computer Glasses , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0581
Industrial/Sport/Computer Glasses , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S0800
Refractive Surgery (LASIK/RK/LRI/CLR) , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S1040
Cranial Remodeling Orthotic – limit under age 2 Members under age 2
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2053
Intestine-Liver All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2400
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2401
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2402
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2403
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2404
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2405
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2409
In utero fetal surgeries (set) , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S2411
Fetoscopic laser treatment All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S5100
Home Care Adult Day Care Services All who do not have EW
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S5560
Durable Medical Equipment (DME) continued Insulin Pen , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S5561
Durable Medical Equipment (DME) continued Insulin Pen , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S9001
Uterine Monitor – home All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S9128
Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other 11950, 11951, 11952, 11954, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15826, 15828, All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S9445
Doula Services , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
S9484
Adult Crisis Services , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T1016
Community Paramedic Services U3 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T1024
Early Intensive Developmental and Behavioral Early Intensive Developmental and Behavioral Intervention (EIDBI) Benefit UB, UB, UB, UB SNBC, F&C, and MnCare under age 21
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T2023
Mental Health Targeted Case Management All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4521
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4529
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4530
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4535
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4538
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4541
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
T4545
Incontinent products (see code list) – , , – , , – All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2020
Glasses + all replacement codes All (except children under age 21)
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2500
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2599
Vision Contact Lenses - , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2744
Tints & Polarized Lenses , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2745
Tints & Polarized Lenses , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V2762
Tints & Polarized Lenses , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5030
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5040
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5050
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5060
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5070
Hearing Aid in glasses - Air conductive All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5080
Hearing Aid in glasses - Bone conductive All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5090
Assistive Listening Device, NOS (includes vibrotactile & pocket talkers) (dispensing fee: ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5100
Pocket Talker All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5110
Pocket Talker Dispensing Fee All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5120
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5130
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5140
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5150
Hearing Aid in glasses - Binaural All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5171
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5181
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5190
CROS in glasses All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5211
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5213
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5221
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5230
BICROS in glasses All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5246
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5247
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5252
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5253
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5256
Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5257
Hearing Aid in glasses - Air conductive V5070 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5260
Hearing Aid in glasses - Air conductive V5070 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5261
Hearing Aid in glasses - Air conductive V5070 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5273
Assistive Listening Device for cochlear implant All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5274
Assistive Listening Device, NOS (includes vibrotactile & pocket talkers) (dispensing fee: ) All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest
V5298
Hearing Aid in glasses - Air conductive V5070 All
2026-07-062026-02-2497%
[PDF] Services Requiring Prior Authorization - PrimeWest