Prior authorization codes
PrimeWest
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0001U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0002U | PolypDx All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0003U | Overa (OVA1 Next Generation) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0004U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0005U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0006U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0007U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0008U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0009U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0010U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0011U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0012M | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0012U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0013M | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0013U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0014U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0015M | Adrenal cortical tumor, biochemical assay of 25 steroid markers (24-hr urine specimen) with algorithm (risk All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0015U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0016M | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0016U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 00170 | Anesthesia and facility fees for dental cleaning & restorations , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 00172 | Anesthesia and facility fees for dental cleaning & restorations , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 00174 | Anesthesia and facility fees for dental cleaning & restorations , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 00176 | Anesthesia and facility fees for dental cleaning & restorations , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0017U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0018U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0019U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0020U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0021U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0022U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0023U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0024U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0025U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0026U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0027U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0028U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0029U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0030U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0031U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0032U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0033U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0034U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0035U | Real-time quaking-induced conversion for prion detection All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0036U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0037U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0038U | Sensivea Droplet 25OH vitamin D2/D3 Microvolume LC/MS Assay by InSource Diagnostics All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0039U | Anti-dsDNA, high salt/avidity All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0040U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0041U | Lyme ImmunoBlot IgM and IgG by IGeneX Inc. , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0042U | Lyme ImmunoBlot IgM and IgG by IGeneX Inc. , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0043U | Tick-borne Relapsing Fever (TBRF) Borrelia ImmunoBlots IgM & IgG Test , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0044U | Tick-borne Relapsing Fever (TBRF) Borrelia ImmunoBlots IgM & IgG Test , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0045U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0046U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0047U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0048U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0049U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0050U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0051U | RX MNTR LC-MS/MS UR 31 PNL All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0052U | VAP Cholesterol Test All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0053U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0054U | AssuranceRX Micro Serum RX MNTR TRNSPL 96 DNA Seq All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0055U | myTAIHEART CARD HRT TRNSPL 95 DNA Seq All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0056U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0057U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0058U | Merkel SmT Oncoprotein Antibody Titer ONC MERKEL CLL CARC SRM All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0059U | Merkel Virus VP1 Capsid Antibody ONC MERKEL CLL CARC CRM All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0060U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0061U | Transcutaneous multispectral measurement of tissue oxygenation and hemoglobin using Spatial Frequency All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0062U | AI SLE IGG&IGM ALYS 80 BMRK All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0063U | NEURO AUTISM 32 AMINES ALG All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0064U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0065U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0066U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0067U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0068U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0069U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0070U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0071U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0072U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0073U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0074U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0075U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0076U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0077U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0078U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0079U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0080U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0081U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0082U | Drug test(s), definitive, 90 or more drugs or substances All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0083U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0084U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0085U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0086U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0087U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0088U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0089U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0090U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0091U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0092U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0093U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0094U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0095T | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0095U | EoE biomarker ELISA (eotaxin 3, PRG2) with algorithm All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0096U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0097U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0098T | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0098U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0099U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0100U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0101U | Hereditary colon cancer panel with mRNA analytics (15+ genes) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0102U | Hereditary breast cancer related panel (17 genes) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0103U | Hereditary ovarian cancer panel (24 genes) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0104U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0105U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0106U | Gastric emptying, serial collection of 7 timed breath specimens All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0107U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0108U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0109U | Infectious disease (Aspergillus species) real-time PCR All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0110U | Prescription drug monitoring, one or more oral oncology drugs All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0111U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0112U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0113U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0114U | Gastroenterology (Barrett’s esophagus) VIM & CCNA1 methylation analysis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0115U | Respiratory infectious agent detection by nucleic acid (DNA/RNA), 18 viral types & subtypes, 2 bacterial targets All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0116U | Prescription drug monitoring, enzyme immunoassay of 25+ drugs with LC-MS/MS confirmation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0117U | Pain management, analysis of 11 endogenous analytes with LC-MS/MS, urine (pain-index score) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0118U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0119U | Ceramides LC MS/MS with risk score for MACE All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling of 58 genes (PMBCL, DLBCL) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0121U | Sickle cell disease, microfluidic flow adhesion (VCAM-1), whole blood All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0122U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0123U | Mechanical fragility, RBC, shear stress and spectral analysis profiling All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0124U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0125U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0126U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0127U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0128U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0129U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0130U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0131U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0132U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0133U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0134U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0135U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0136U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0137U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0138U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0139U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0140U | Infectious Disease Labs (bacteria and fungi) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0141U | Infectious Disease Labs (bacteria and fungi) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0142U | Infectious Disease Labs (bacteria and fungi) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0143U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0144U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0145U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0146U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0147U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0148U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0149U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0150U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0151U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0152U | Infectious disease (bacteria, fungi, parasites, DNA viruses), DNA PCR & next-gen sequencing (>1000 potential All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0153U | Oncology (breast), mRNA, next-gen sequencing profiling of 101 genes (triple negative breast cancer subtype) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0154U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0155U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0156U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0157U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0158U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0159U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0160U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0161U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0162U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0163T | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0163U | Oncology (colorectal) screening, ELISA of 3 plasma/serum proteins with algorithm (CRC or advanced adenomas All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0164U | Gastroenterology (IBS) immunoassay for anti-CdtB and anti-vinculin antibodies All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0165U | Peanut allergen-specific IgE (64 epitopes) quantitative ELISA All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0166U | Liver disease, 10 biochemical assays (α2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0167U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0168U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0169U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0170U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0171U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0172U | Oncology (solid tumor), BRCA1/2 mutation & homologous recombination deficiency pathways (HRD), DNA NGS All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0173U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0174U | Oncology (solid tumor), 30 protein targets by mass spectrometry (formalin-fixed paraffin-embedded tissue) with All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0175U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0176U | Cytothelial distending toxin B (CdtB) & vinculin IgG antibodies by immunoassay (ELISA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0177U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0178U | Peanut allergen-specific quantitative ELISA (minimum eliciting exposure for clinical reaction) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0179U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0203U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0204U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0205U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0206U | Neurology (Alzheimer’s disease); cell aggregation (C-PKcε) + ELISA biomarkers; positive/negative classification All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0207U | Neurology (Alzheimer’s disease); quantitative imaging of phosphorylated ERK1/2 with in situ All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0208U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0209U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0210U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0211U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0212U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0213U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0214U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0215U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0216U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0217U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0218U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0219T | Posterior intrafacet implant(s) placement , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0219U | Diagnostics continued Infectious agent (HIV), targeted viral NGS (protease, reverse transcriptase, integrase) with algorithm for antiviral All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0220U | Oncology (breast cancer), AI-based image analysis of 12 histologic & immunohistochemical features (recurrence All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0221T | Posterior intrafacet implant(s) placement , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0221U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0222T | Posterior intrafacet implant(s) placement , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0222U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0223U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0224U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0225U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0226U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0227U | Drug assay, presumptive, ≥30 drugs/metabolites, urine LC-MS/MS with multiple reaction monitoring (MRM) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0228U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0229U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0230U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0231U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0232T | Platelet Rich Plasma (PRP) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0232U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0233U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0234U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0235U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0236U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0237U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0238U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0239U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0240U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0241U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0242U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0243U | Obstetrics (preeclampsia), biochemical assay of placental-growth factor (time-resolved fluorescence All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0244U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0245U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0246U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0247U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0248U | Oncology (brain) – 3D spheroid culture 12 drug response All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0249U | Oncology (breast), semiquantitative analysis of 32 phosphoproteins/proteins, laser capture microdissection + All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0250U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0251U | Hepcidin-25, enzyme-linked immunosorbent assay (ELISA), serum/plasma All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0252U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0253U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0254U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0255U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0256U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0257U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0258U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0286U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0287U | Oncology (thyroid) mRNA gene expression profiling All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0288U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0289U | Pain propensity RNA expression risk score (36 genes) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0290U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0291U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0292U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0293U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0294U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0295U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0296U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0297U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0298U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0299U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0300U | Proprietary tests (U codes/M codes) – General Selected examples: ; ; ; , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0329T | Continuous intraocular pressure monitoring All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0330T | Tear film imaging All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0331T | Myocardial sympathetic innervation imaging , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0332T | Myocardial sympathetic innervation imaging , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0333T | Automated visual screening All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0335T | Subtalar joint implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0338T | Transcatheter renal sympathetic denervation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0339T | Transcatheter renal sympathetic denervation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0342T | Therapeutic apheresis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0345T | Transcatheter mitral valve repair (TMVr) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0353T | OCT – Breast All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0358T | Bioelectrical impedance analysis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0373T | EIDBI Intervention Higher Intensity UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0394T | HDR electronic brachytherapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0395T | HDR electronic brachytherapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0397T | ERCP with optical endomicroscopy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0402T | Corneal Collagen Cross-Linking All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0408T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0409T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0410T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0411T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0412T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0413T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0414T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0415T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0416T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0417T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0418T | Cardiac contractility modulation system (code family) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0419T | Destruction neurofibroma, extensive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0420T | Destruction neurofibroma, extensive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0421T | Transurethral waterjet ablation of prostate All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0422T | Tactile breast imaging All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0437T | Synthetic implant for abdominal wall reinforcement All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0439T | Myocardial contrast perfusion echo All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0440T | Cryoablation of peripheral/truncal nerve(s) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0441T | Cryoablation of peripheral/truncal nerve(s) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0442T | Cryoablation of peripheral/truncal nerve(s) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0443T | Real time spectral analysis of prostate tissue by fluorescence All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0444T | Drug eluting ocular insert placement , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0445T | Drug eluting ocular insert placement , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0446T | Implantable Glucose Sensor (procedures) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0447T | Implantable Glucose Sensor (procedures) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0448T | Implantable Glucose Sensor (procedures) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0449T | Insertion of aqueous drainage device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0450T | Insertion of aqueous drainage device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0464T | VEP testing for glaucoma All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0472T | Retinal prosthesis device evaluation/programming , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0473T | Retinal prosthesis device evaluation/programming , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0474T | Insertion of anterior segment aqueous drainage device All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0479T | Fractional ablative laser fenestration of burn and traumatic scars , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0480T | Fractional ablative laser fenestration of burn and traumatic scars , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0481T | Autologous White Blood Cell Injection All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0483T | TMVI prosthetic valve – percutaneous/transapical , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0484T | TMVI prosthetic valve – percutaneous/transapical , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0485T | OCT of middle ear; unilateral/bilateral , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0486T | OCT of middle ear; unilateral/bilateral , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0489T | Autologous adipose derived regenerative cell therapy for scleroderma (harvest/prep) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0490T | Autologous adipose derived regenerative cell therapy for scleroderma (multiple injections) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0506T | Macular pigment optical density measurement by heterochromatic flicker photometer (HFP) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0507T | Near-infrared dual imaging of meibomian glands All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0509T | Pattern electroretinography (PERG) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0510T | Removal/reinsertion of sinus tarsi implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0511T | Removal/reinsertion of sinus tarsi implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0512T | Extracorporeal shock wave wound healing All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0513T | Extracorporeal shock wave wound healing All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0515T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0516T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0517T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0518T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0519T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0520T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0521T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0522T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0523T | Wireless LV cardiac stimulator – complete system / components / programming / interrogation , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0524T | Endovenous chemical ablation with balloon isolation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0525T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0526T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0527T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0528T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0529T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0530T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0531T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0532T | Intracardiac ischemia monitoring system – implant & programming , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0541T | Magnetocardiography (MCG) – myocardial ischemia , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0542T | Magnetocardiography (MCG) – myocardial ischemia , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0543T | Transapical mitral valve repair with artificial chordae All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0544T | Transcatheter mitral valve annulus reconstruction All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0545T | Transcatheter tricuspid valve annulus reconstruction All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0546T | Intraoperative radiofrequency spectroscopy – breast margin assessment All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0547T | Bone material quality by tibial microindentation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0552T | Low level laser therapy – dynamic photonic/thermokinetic All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0554T | Bone strength & fracture risk by finite element analysis – family , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0555T | Bone strength & fracture risk by finite element analysis – family , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0556T | Bone strength & fracture risk by finite element analysis – family , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0557T | Bone strength & fracture risk by finite element analysis – family , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0558T | Bone strength & fracture risk by finite element analysis – family , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0559T | Anatomic 3D printed model/guide – first & additional , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0560T | Anatomic 3D printed model/guide – first & additional , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0561T | Anatomic 3D printed model/guide – first & additional , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0562T | Anatomic 3D printed model/guide – first & additional , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0563T | Meibomian gland evacuation via wearable heat device with manual expression (bilateral) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0565T | Autologous adipose derived cellular implant for knee OA – harvest/prep All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0566T | Autologous adipose derived cellular implant for knee OA – injection All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0569T | Transcatheter tricuspid valve repair – initial prosthesis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0570T | Transcatheter tricuspid valve repair – each additional prosthesis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0571T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0572T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0573T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0574T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0575T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0576T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0577T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0578T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0579T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0580T | Substernal ICD system – implant/revision/removal/programming/remote , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0581T | Percutaneous cryoablation of malignant breast tumor All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0582T | Transurethral ablation of malignant prostate tissue – water vapor All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0583T | Tympanostomy with automated tube delivery, iontophoresis anesthesia All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0584T | Islet cell transplant – percutaneous All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0585T | Islet cell transplant – laparoscopic All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0586T | Islet cell transplant – open All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0587T | Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0588T | Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0589T | Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0590T | Integrated posterior tibial nerve neurostimulation – implant & revisions , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0594T | Humerus osteotomy with lengthening device All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0596T | Female intraurethral valve-pump (initial & replacement) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0597T | Female intraurethral valve-pump (initial & replacement) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0600T | Irreversible Electroporation Ablation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0601T | Irreversible Electroporation Ablation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0604T | Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0605T | Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0606T | Experimental continued Remote OCT of retina – patient initiated capture/transmission , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0609T | Magnetic resonance spectroscopy for discogenic pain (≥3 discs, biomarkers lactid acid, carbohydrate, collagen, All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0611T | Magnetic resonance spectroscopy for discogenic pain (cervical, thoracic, lumbar); biomarker analysis across ≥3 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0613T | Interatrial Septal Shunt Device All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0615T | Surgery-Procedure continued Eye-movement analysis (no spatial calibration) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0619T | Prostate commissurotomy + drug delivery (endoscopic) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0621T | Trabeculostomy ab interno (laser / with endoscope) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0622T | Trabeculostomy ab interno (laser / with endoscope) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0623T | Automated quantification & characterization of coronary atherosclerotic plaque (CTA data analysis & reporting) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0624T | Automated quantification & characterization of coronary atherosclerotic plaque (CTA data All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0625T | Coronary plaque quantification via CTA (data analysis only) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0626T | Coronary plaque quantification via CTA (data review and reconciliation of discordant data) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0627T | Allogeneic product injection to intervertebral disc , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0628T | Allogeneic product injection to intervertebral disc , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0629T | Allogeneic product injection to intervertebral disc , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0630T | Allogeneic product injection to intervertebral disc , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0631T | Transcutaneous visible light hyperspectral imaging (oxy/deoxyhemoglobin, tissue oxygenation) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0633T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0634T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0635T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0636T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0637T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0638T | CT Breast with 3D rendering , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0640T | Near-infrared spectroscopy wound studies , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0644T | Transcatheter removal/debulking of intracardiac mass All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0646T | Transcatheter tricuspid valve implantation/replacement All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0647T | Percutaneous G-tube with magnetic gastropexy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0648T | Quantitative magnetic resonance for tissue composition (fat, iron, water, etc.), multiparametric data acquisition, , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0649T | Quantitative magnetic resonance for tissue composition (fat, iron, water, etc.), multiparametric data acquisition, , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0651T | Magnetically controlled capsule endoscopy (MCCE), esophagus with interpretation/report All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0652T | Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0653T | Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0654T | Esophagogastroduodenoscopy (EGD), transnasal flexible, diagnostic with brushing/wash/biopsy, intraluminal , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0655T | Transperineal focal laser ablation of prostate (MR-fused) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0658T | Electrical impedance spectroscopy (skin lesions), automated melanoma risk score All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0659T | Supersaturated oxygen intracoronary infusion during PCI for AMI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0662T | Scalp cooling – measurement/calibration/placement/monitoring/removal , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0663T | Scalp cooling – measurement/calibration/placement/monitoring/removal , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0668T | Uterine allograft backbench prep/reconstruction , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0669T | Uterine allograft backbench prep/reconstruction , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0670T | Uterine allograft backbench prep/reconstruction , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 0859T | Near-infrared spectroscopy wound studies , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11920 | Tattooing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11921 | Tattooing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11922 | Tattooing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11950 | SubQ filling (collagen) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11951 | SubQ filling (collagen) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11952 | SubQ filling (collagen) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11954 | SubQ filling (collagen) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 11980 | Subcutaneous hormone pellets , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13100 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13101 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13102 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13120 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13121 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13122 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13131 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13132 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13151 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 13152 | Scar Revisions (incl. keloids) , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15200 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15730 | Midface Flap or Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15733 | Midface Flap or Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15769 | Grafting of autologous soft tissue, fat by liposuction , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15771 | Grafting of autologous soft tissue, fat by liposuction , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15772 | Grafting of autologous soft tissue, fat by liposuction , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15773 | Grafting of autologous soft tissue, fat by liposuction , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15774 | Grafting of autologous soft tissue, fat by liposuction , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15775 | Punch graft for hair transplant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15776 | Punch graft for hair transplant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15780 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15781 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15782 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15783 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15786 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15787 | Dermabrasion , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15788 | Chemical Peel , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15789 | Chemical Peel , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15792 | Chemical Peel , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15793 | Chemical Peel , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15820 | Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15821 | Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15822 | Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15823 | Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15824 | Rhytidectomy , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15825 | Rhytidectomy , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15826 | Rhytidectomy , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15828 | Rhytidectomy , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15829 | Rhytidectomy , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15830 | Gender affirming codes – not covered for diagnosis of Gender Dysphoria); may be covered for other , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15832 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15833 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15834 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15835 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15836 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15837 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15838 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15839 | Excision of excessive SubQ , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15847 | Cosmetic Abdominoplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15876 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15877 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15878 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 15879 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17000 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17003 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17004 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17106 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17107 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17108 | Lesion Destruction , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17340 | Cryotherapy for acne All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17360 | Chemical exfoliation for acne All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17380 | Electrolysis epilation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 17999 | Ablative laser treatment (non-contact, full field and fractional ablation, open wound, per day, total treatment All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19294 | IORT applicator placement (add-on) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19300 | Mastectomy, SubQ , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19302 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19303 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19316 | Mastopexy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19318 | Mastectomy, SubQ , All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19328 | Removal of mammary implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19330 | Breast Implant Removal , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19340 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19342 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19350 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19355 | Correction of inverted nipples All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19357 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19361 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19364 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19367 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19368 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 19369 | Breast Reconstruction (post-cancer) , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 20932 | Allograft add on codes for osteoarticular/hemicortical/intercalary , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 20933 | Allograft add on codes for osteoarticular/hemicortical/intercalary , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 20934 | Allograft add on codes for osteoarticular/hemicortical/intercalary , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 20975 | Electrical stimulation to aid bone healing – invasive (operative) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21010 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21025 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21026 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21050 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21060 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21070 | Mandible – Coronoidectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21073 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21079 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21080 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21081 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21085 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21087 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21089 | Mandibular Ortho Repositioning device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21110 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21120 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21121 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21122 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21123 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21125 | Mandibular augmentation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21127 | Mandibular augmentation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21141 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21142 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21143 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21145 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21146 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21147 | Lefort I , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21150 | Lefort II , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21151 | Lefort II , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21188 | Midface Reconstruction (other) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21193 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21194 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21195 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21196 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21198 | With Osteotomy Segmental All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21206 | Maxilla – Osteotomy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21208 | Facial Osteoplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21209 | Facial bones reduction All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21210 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21240 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21242 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21243 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21244 | With Transosteal Bone Plate All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21245 | Subperiosteal Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21246 | Subperiosteal Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21247 | With Autografts All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21248 | Endosteal Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21249 | Endosteal Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21255 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21270 | Malar augmentation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21299 | Maxilla – Osteotomy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21480 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21485 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21490 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21497 | TMJ related services and TMJ surgery , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21499 | Mandibular Ortho Repositioning device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21685 | Sleep Apnea – Hyoid Myotomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 21899 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22532 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22533 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22534 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22548 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22551 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22552 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22554 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22556 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22558 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22585 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22586 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22590 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22595 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22600 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22610 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22612 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22614 | Spinal Fusions , , , , , , , , , , , , ; , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22630 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22632 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22633 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22634 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22800 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22802 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22804 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22808 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22810 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22812 | Blue light cystoscopy imaging agent C9738 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22856 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22857 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22858 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22860 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22861 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22862 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22864 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22865 | Disc Replacement – Artificial , , (obsolete 1/1/23), , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22867 | Interspinous/interlaminar stabilization without fusion , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22868 | Interspinous/interlaminar stabilization without fusion , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22869 | Interspinous/interlaminar stabilization without fusion , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 22870 | Interspinous/interlaminar stabilization without fusion , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 27198 | Posterior Pelvic Ring Fx – Closed treatment with manipulation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 27279 | Sacroiliac Joint Stabilization (Fusion) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 27280 | Sacroiliac Joint Stabilization (Fusion) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 29800 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 29804 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30120 | Planing of skin of nose All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30400 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30410 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30420 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30430 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30435 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30450 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 30468 | Nasal valve collapse repair with implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31243 | Nasal/sinus endoscopy, cryoablation nasal tissues/nerves All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31591 | Laryngoplasty, medialization, unilateral All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31592 | Cricotracheal resection All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31647 | Bronchial valve insertion/removal , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31648 | Bronchial valve insertion/removal , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31649 | Bronchial valve insertion/removal , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31651 | Bronchial valve insertion/removal , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 31899 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32491 | Lung Volume Reduction Surgery All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32851 | Lung , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32852 | Lung , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32853 | Lung , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32854 | Lung , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 32994 | Pulmonary tumor cryoablation (percutaneous) – chest wall/pleura included All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33140 | Transmyocardial laser revascularization , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33141 | Transmyocardial laser revascularization , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33240 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33241 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33270 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33271 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33272 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33273 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33274 | Leadless pacemaker , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33275 | Leadless pacemaker , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33289 | Wireless PA pressure sensor implantation (CardioMEMS) – complete All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33340 | Left atrial appendage closure All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33361 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33362 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33363 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33364 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33365 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33366 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33367 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33368 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33369 | TAVR/TAVI All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33390 | Valvuloplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33391 | Valvuloplasty, aortic valve, complex All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33418 | Transcatheter mitral valve repair (TMVr) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33419 | Transcatheter mitral valve repair (TMVr) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33440 | Ross Konno procedure (aortic valve replacement with pulmonary autograft) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33741 | Transcatheter atrial septostomy (congenital) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33745 | Transcatheter intracardiac shunt (congenital) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33746 | Transcatheter intracardiac shunt (congenital) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33927 | Artificial Heart Procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33928 | Artificial Heart Procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33929 | Artificial Heart Procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33935 | Heart-Lung All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33945 | Heart All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33975 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33976 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33979 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33981 | LVAD/VAD – part 2 , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33982 | LVAD/VAD – part 2 , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33983 | LVAD/VAD – part 2 , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33995 | Percutaneous VAD (right heart – venous only) insertion All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 33997 | Removal of percutaneous right heart VAD cannula All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34717 | Endovascular repair of iliac artery bifurcation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34718 | Endovascular repair of iliac artery bifurcation , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34841 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34842 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34843 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34844 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34845 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34846 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34847 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 34848 | Endoprosthesis for Aorta Repair All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 35400 | Angioscopy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36456 | Partial exchange transfusion, newborn All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36465 | Sclerotherapy – Varicose Veins , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36466 | Sclerotherapy – Varicose Veins , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36468 | Sclerotherapy – Spider Veins All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36470 | Sclerotherapy – Varicose Veins , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36471 | Sclerotherapy – Varicose Veins , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36473 | Endovenous Ablation Therapy of Incompetent Vein , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36474 | Endovenous Ablation Therapy of Incompetent Vein , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36475 | Endovenous Radiofrequency Ablation , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36476 | Endovenous Radiofrequency Ablation , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36478 | Endovenous Radiofrequency Ablation , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36479 | Endovenous Radiofrequency Ablation , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36482 | Endovenous ablation with chemical adhesive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 36483 | Endovenous ablation with chemical adhesive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37246 | Transluminal Balloon Angioplasty (non-dialysis) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37247 | Transluminal Balloon Angioplasty (non-dialysis) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37248 | Transluminal Balloon Angioplasty (non-dialysis) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37249 | Transluminal Balloon Angioplasty (non-dialysis) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37788 | Penile revascularization All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 37790 | Penile venous occlusive procedure All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38225 | CAR T support services (prep/transport/cryopreservation) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38226 | CAR T support services (prep/transport/cryopreservation) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38227 | CAR T support services (prep/transport/cryopreservation) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38228 | CAR T support services (prep/transport/cryopreservation) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38240 | Transplants Bone Marrow/Stem Cell , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38241 | Transplants Bone Marrow/Stem Cell , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 38242 | Bone Marrow/Stem Cell All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 40799 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 41512 | Sleep Apnea – Tongue Base Suspension All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 41530 | Tongue ablation, radiofrequency All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 41899 | Miscellaneous dental code All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 42140 | Sleep Apnea – Uvulectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 42145 | Sleep Apnea – UPPP All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 42975 | Drug induced sleep endoscopy (DISE) for sleep disordered breathing All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43284 | LINX – esophageal sphincter augmentation device (Fact 4), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43285 | LINX – esophageal sphincter augmentation device (Fact 4), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43644 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43645 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43647 | Gastric Neurostimulator Electrodes , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43648 | Gastric Neurostimulator Electrodes , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43659 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43770 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43771 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43772 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43773 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43774 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43775 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43842 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43843 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43845 | Bariatrics – Gastric restriction w/limited absorption All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43846 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43847 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43848 | Bariatrics – Gastric Bypass Revision , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43860 | Bariatrics – Gastric Bypass Revision , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43865 | Bariatrics – Gastric Bypass Revision , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43881 | Gastric Neurostimulator Electrodes , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43882 | Gastric Neurostimulator Electrodes , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43886 | Bariatrics – Gastric restriction with port , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43887 | Bariatrics – Gastric restriction with port , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43888 | Bariatrics – Gastric restriction with port , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 43999 | Bariatrics – Gastric Bypass/Bariatric Surgery , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44135 | Intestine , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44136 | Intestine , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44388 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44389 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44390 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44391 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44392 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44394 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44401 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44402 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44403 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44404 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44405 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44406 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44407 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 44408 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45378 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45379 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45380 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45381 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45382 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45383 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45384 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45385 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45386 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45388 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45389 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45390 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45391 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45392 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45393 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 45398 | Real-time quaking-induced conversion for prion detection 0035U All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 47135 | Liver , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 47399 | Liver , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 47620 | Cholecystectomy w/ transduodenal sphincterotomy/sphincteroplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 48160 | Pancreas , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 48554 | Pancreas , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 50360 | Kidney , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 50365 | Kidney , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 50380 | Kidney Autotransplantation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 51715 | Endoscopic urethral implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 52284 | Cystourethroscopy w/drug delivery for urethral stricture All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53400 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53420 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53425 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53430 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53451 | Periurethral balloon continence device – unilateral/bilateral , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53452 | Periurethral balloon continence device – unilateral/bilateral , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 53854 | Transurethral RF water vapor therapy (Rezūm) – malignant tissue All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54125 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54150 | Circumcision , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54160 | Circumcision , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54161 | Circumcision , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54163 | Circumcision , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54400 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54401 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54405 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54520 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54660 | Insertion of testicular prosthesis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 54690 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55175 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55180 | Gender affirming surgery – Female to Male , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55866 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55874 | Transperineal peri prostatic biodegradable material placement All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55899 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55970 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 55980 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 56625 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 56800 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 56805 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57106 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57110 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57291 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57292 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57295 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57296 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57335 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 57426 | Gender Affirming Surgery Gender affirming surgery – Male to Female , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58150 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58180 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58260 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58262 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58275 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58290 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58291 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58345 | Transcervical introduction of catheter to fallopian tube All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58541 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58542 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58543 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58544 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58550 | 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58674 | Uterine fibroid ablation, radiofrequency All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 58999 | Biomechanical mapping, transvaginal (obsolete/replace) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61850 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61860 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61863 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61864 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61867 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61868 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61885 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 61886 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 62380 | Endoscopic decompression of spinal nerve roots All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63001 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63002 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63003 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63004 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63005 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63006 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63007 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63008 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63009 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63010 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63011 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63012 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63013 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63014 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63015 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63016 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63017 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63018 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63019 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63020 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63021 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63022 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63023 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63024 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63025 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63026 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63027 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63028 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63029 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63030 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63031 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63032 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63033 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63034 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63035 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63036 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63037 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63038 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63039 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63040 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63041 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63042 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63043 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63044 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63045 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63046 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63047 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63048 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63049 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63050 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63051 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63052 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63053 | Laminectomy/Hemilaminectomy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63650 | SCS (Spinal Cord Stimulator) Insertion , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63655 | SCS (Spinal Cord Stimulator) Insertion , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63685 | SCS (Spinal Cord Stimulator) Insertion , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 63688 | Spinal Neurostimulator PG revision/removal All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64553 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64555 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64561 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64566 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64568 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64569 | Revision/replacement cranial nerve (e.g., vagus) neurostimulator electrode array All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64575 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64580 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64581 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64582 | Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64583 | Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64584 | Hypoglossal nerve stimulator – resp. sensor electrode procedures , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64585 | Revision/removal peripheral neurostimulator electrode array All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64590 | Neurostimulator implants – cranial/peripheral/gastric (code set) , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64595 | Revision/removal peripheral or gastric neurostimulator pulse generator/receiver All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64620 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64624 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64625 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64628 | Basivertebral nerve ablation – destruction CPT , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64629 | Basivertebral nerve ablation – destruction CPT , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64632 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64633 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64634 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 64640 | Radiofrequency denervation/neurolysis – facet or SI joint (thoracic/SI require authorization) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65760 | Corneal shape altering procedures , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65765 | Corneal shape altering procedures , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65767 | Corneal shape altering procedures , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65770 | Corneal shape altering procedures , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65771 | Refractive Surgery (LASIK/RK/LRI/CLR) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65772 | Correction of surgically induced astigmatism , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 65775 | Correction of surgically induced astigmatism , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67516 | Experimental continued Suprachoroidal injection of pharmacologic agent All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67900 | service/diagnosis | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67901 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67902 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67903 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67904 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67906 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67908 | Ptosis Repair , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67909 | Reduction of Overcorrection All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67911 | Correction of lid retraction All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 67912 | Correction of lagophthalmos All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 68841 | Drug eluting punctal implant (lacrimal canaliculus) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69300 | Otoplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69710 | Hearing Device Implant/Removal , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69711 | Hearing Device Implant/Removal , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69714 | Temporal Bone Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69716 | Osseointegrated skull implant – magnetic transcutaneous (implant) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69717 | Temporal Bone Implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69719 | Osseointegrated skull implant – magnetic transcutaneous (revision/replacement) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69726 | Osseointegrated skull implant – removal (percutaneous) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69727 | Osseointegrated skull implant – removal (magnetic transcutaneous) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69728 | Removal of Hearing Device Implant with ≥100 sq mm bone removal All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69729 | Implantation of Hearing Device Implant with ≥100 sq mm bone removal All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 69930 | Cochlear Implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 74261 | Diagnostics continued CT Colonography , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 74262 | Diagnostics continued CT Colonography , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 74263 | Diagnostics continued CT Colonography , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 75580 | Noninvasive CT FFR (new code 1/1/24) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 76391 | MR elastography All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 76999 | Pulse-echo ultrasound bone density measurement, tibia All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77046 | Breast MRI , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77047 | Breast MRI , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77048 | Breast MRI , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77049 | Breast MRI , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77061 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77062 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77063 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77065 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77066 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 77067 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81105 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81106 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81107 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81108 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81109 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81110 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81111 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81112 | Platelet antigen genotyping (HPA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81120 | Selected pharmacogenetic/hematology genes (condensed) , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81121 | Selected pharmacogenetic/hematology genes (condensed) , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81162 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81163 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81164 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81165 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81166 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81167 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81168 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81169 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81170 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81171 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81172 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81173 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81174 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81175 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81176 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81177 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81178 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81179 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81180 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81181 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81182 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81183 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81184 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81185 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81186 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81187 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81188 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81189 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81190 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81191 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81192 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81193 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81194 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81195 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81196 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81197 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81198 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81199 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81200 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81201 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81202 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81203 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81204 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81205 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81206 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81207 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81208 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81209 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81210 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81211 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81212 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81213 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81214 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81215 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81216 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81217 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81218 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81219 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81220 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81221 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81222 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81223 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81224 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81225 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81226 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81227 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81228 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81229 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81230 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81231 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81232 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81233 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81234 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81235 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81236 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81237 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81238 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81239 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81240 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81241 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81242 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81243 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81244 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81245 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81246 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81247 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81248 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81249 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81250 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81251 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81252 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81253 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81254 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81255 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81256 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81257 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81258 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81259 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81260 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81261 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81262 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81263 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81264 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81265 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81266 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81267 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81268 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81269 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81270 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81271 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81272 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81273 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81274 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81275 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81276 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81277 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81278 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81279 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81280 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81281 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81282 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81283 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81284 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81285 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81286 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81287 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81288 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81289 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81290 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81291 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81292 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81293 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81294 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81295 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81296 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81297 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81298 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81299 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81300 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81301 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81302 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81303 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81304 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81305 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81306 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81307 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81308 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81309 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81310 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81311 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81312 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81313 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81314 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81315 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81316 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81317 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81318 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81319 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81320 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81321 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81322 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81323 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81324 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81325 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81326 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81327 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81328 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81329 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81330 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81331 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81332 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81333 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81334 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81335 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81336 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81337 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81338 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81339 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81340 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81341 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81342 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81343 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81344 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81345 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81346 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81347 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81348 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81349 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81350 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81351 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81352 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81353 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81354 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81355 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81356 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81357 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81358 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81359 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81360 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81361 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81362 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81363 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81364 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81365 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81366 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81367 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81368 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81369 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81370 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81371 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81372 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81373 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81374 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81375 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81376 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81377 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81378 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81379 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81380 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81381 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81382 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81383 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81384 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81385 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81386 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81387 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81388 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81389 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81390 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81391 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81392 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81393 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81394 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81395 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81396 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81397 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81398 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81399 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81400 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81401 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81402 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81403 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81404 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81405 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81406 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81407 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81408 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81409 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81410 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81411 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81412 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81413 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81414 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81415 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81416 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81417 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81418 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81419 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81420 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81421 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81422 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81423 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81424 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81425 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81426 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81427 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81428 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81429 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81430 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81431 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81432 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81433 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81434 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81435 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81436 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81437 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81438 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81439 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81440 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81441 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81442 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81443 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81444 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81445 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81446 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81447 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81448 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81449 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81450 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
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| 81463 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81464 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81465 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81466 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81467 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81468 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81469 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81470 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81471 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81472 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81473 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81474 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81475 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81476 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81477 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81478 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81479 | Gene Analysis & Molecular Pathology (except ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81490 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81491 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81492 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81493 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81494 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81495 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81496 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81497 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81498 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81499 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81500 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81501 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81502 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81503 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81504 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81505 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81506 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81507 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81508 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81509 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81510 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81511 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81512 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81513 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81514 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81515 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81516 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81517 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81518 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81519 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81520 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81521 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81522 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81523 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81524 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81525 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81526 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81527 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81528 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81529 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81530 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81531 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81532 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81533 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81534 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81535 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81536 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81537 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81538 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81539 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81540 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81541 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81542 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81543 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81544 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81545 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81546 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81547 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81548 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81549 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81550 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81551 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81552 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81553 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81554 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81555 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81556 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81557 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81558 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81559 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81560 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81561 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81562 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81563 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81564 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81565 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81566 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81567 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81568 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81569 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81570 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81571 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81572 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81573 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81574 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81575 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81576 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81577 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81578 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81579 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81580 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81581 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81582 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81583 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81584 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81585 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81586 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81587 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81588 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81589 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81590 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81591 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81592 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81593 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81594 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81595 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81596 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81597 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81598 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 81599 | Multianalyte Assays (MAAA) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 82013 | Acetylcholinesterase All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 84433 | Thiopurine S methyltransferase (enzyme) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 86849 | Unlisted Immunology Procedure All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 87467 | Hepatitis B surface antigen (HBsAg), quantitative All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88120 | Urinary tract FISH (cytopathology) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88121 | Urinary tract FISH (cytopathology) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88245 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88248 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88249 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88267 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88269 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88271 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88272 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88273 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88274 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88275 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88280 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88283 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88285 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88289 | Chromosome analysis , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88299 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88364 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88365 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88366 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88367 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88368 | Chimerism testing (post transplant follow up) , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88369 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88373 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88374 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 88377 | Cytogenetics / In situ hybridization , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90867 | Transcranial Magnetic Stimulation (TMS) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90868 | Transcranial Magnetic Stimulation (TMS) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90869 | Transcranial Magnetic Stimulation (TMS) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90882 | Adult Crisis Services , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90912 | Biofeedback (behavioral health & medical conditions) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 90913 | Biofeedback (behavioral health & medical conditions) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 91110 | Diagnostics Capsule Endoscopy , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 91111 | Diagnostics Capsule Endoscopy , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 91112 | Wireless GI transit/pressure measurement All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 91113 | Diagnostics Capsule Endoscopy , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92229 | Imaging of retina for detection/monitoring of disease; automated point-of-care analysis/report All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92242 | Fluorescein/ICG Angiography All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92310 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92314 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92325 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92326 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92512 | Rhinomanometry All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92517 | Vestibular evoked myogenic potential (VEMP), cervical (cVEMP) with interpretation/report All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92518 | Vestibular evoked myogenic potential (VEMP), ocular (oVEMP) with interpretation/report All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92519 | Vestibular evoked myogenic potential (VEMP), cervical & ocular (cVEMP + oVEMP) with interpretation/report All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92549 | CDP SOT with MCT/ADT All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92601 | Rehab Cochlear Implant Analysis GN, GN, GN, GN All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92602 | Rehab Cochlear Implant Analysis GN, GN, GN, GN All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92603 | Rehab Cochlear Implant Analysis GN, GN, GN, GN All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 92604 | Rehab Cochlear Implant Analysis GN, GN, GN, GN All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93260 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93261 | Subcutaneous implantable defibrillator (set incl. monitoring) , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93264 | Remote monitoring – PA pressure sensor (up to 30 days) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93278 | Signal averaged ECG All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93799 | Fetal magnetic cardiac signal recording (obsolete transition) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 93998 | Near infrared spectroscopy for lower extremity wounds All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 95836 | Electrocorticogram from implanted brain neurostimulator – up to 30 days All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 95999 | Movement disorder continuous recording 6–10 days (obsolete to 1/1/24) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96377 | On-body Injector Application (example Neulasta on-body) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96573 | Photodynamic Therapy – external light (per day) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96574 | Debridement + Photodynamic Therapy (per day) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96931 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96932 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96933 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96934 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96935 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96936 | Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 96999 | OCT of the skin (obsolete transition) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97014 | Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97032 | Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97153 | EIDBI Intervention Individual UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97154 | EIDBI Intervention Group UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97155 | EIDBI Observation UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97156 | EIDBI Caregiving Training and Counseling - Individual UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97157 | EIDBI Family Training Group UB SNBC, F&C and MnCare under age 21 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97545 | Work Hardening , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97546 | Work Hardening , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97610 | Low frequency ultrasound wound therapy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97750 | Functional Evaluation / Physical Performance Test All except PWSHC and PHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97810 | Other Health Services Acupuncture , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97811 | Other Health Services Acupuncture , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97813 | Other Health Services Acupuncture , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 97814 | Other Health Services Acupuncture , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99091 | Telemonitoring , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99183 | Hyperbaric Oxygen Therapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99184 | Hypothermia in Neonate All newborns | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99199 | Doula Services , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99453 | Telemonitoring , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99454 | Telemonitoring , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99456 | Work-related or Medical Disability Exam All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99457 | Telemonitoring , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| 99458 | Telemonitoring , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0426 | Ground Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0427 | Ground Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0428 | Ground Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0429 | Ground Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0430 | Transportation Air Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0431 | Transportation Air Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0435 | Transportation Air Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A0436 | Transportation Air Ambulance , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4221 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4222 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4223 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4239 | Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4253 | Diabetic test strips All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4453 | Anal irrigation / manual enema system & accessories , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4459 | Anal irrigation / manual enema system & accessories , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4468 | Home ventilator – multifunction device (includes oxygen, neb, aspiration, cough stim) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4541 | TENS for trigeminal nerve , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4542 | External upper limb tremor stimulator (wrist) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4563 | Rectal control system for vaginal insertion (long term use) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4606 | Disposable oximeter probes All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A4649 | Miscellaneous DME codes , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5500 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5501 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5503 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5507 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5510 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5512 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5513 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A5514 | Therapeutic shoes/modifications/inserts (diabetes) , , – , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A7025 | Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A9282 | Wig / Hair Prosthesis All (non PAR only; no authorization for PAR) | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A9284 | Spirometer (home monitoring post heart/lung transplant) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A9592 | Copper Cu-64 Dotatate, diagnostic (1 millicurie) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A9900 | Anal irrigation / manual enema system & accessories , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| A9999 | Miscellaneous DME codes , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4102 | Electrolyte containing fluids , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4103 | Electrolyte containing fluids , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4105 | Enzyme Cartridge – Enteral Nutrition All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4149 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4150 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4152 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4153 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4154 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4155 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4157 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4158 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4159 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4160 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4161 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| B4162 | Enteral Nutrition (oral or tube) – see code list , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1062 | Intravertebral body fracture augmentation with implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1823 | Generator, neurostimulator (transvenous) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1826 | Neurostimulator generator (closed-loop leads) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1827 | Neurostimulator generator (closed-loop leads) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1832 | Autograft suspension (incl. processing/components) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C1982 | Catheter, pressure generating, intermittently occlusive All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C2596 | Experimental Probe, image guided, robotic waterjet ablation (BPH) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9067 | Gallium Ga-68 Dotatoc, diagnostic (0.01 mci) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9727 | Sleep Apnea – Pillar Palatal Implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9738 | Blue light cystoscopy imaging agent All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9739 | Cystourethroscopy with transprostatic implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9740 | Cystourethroscopy with transprostatic implant , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9751 | Bronchoscopy with microwave ablation and full image guided navigation bundle All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9757 | Laminotomy + annular closure device All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9758 | Transcatheter interatrial shunt IDE trial – blinded procedure including RHC & TEE/ICE All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9759 | Transcatheter microinfusion therapy All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9760 | Interatrial shunt IDE trial – non randomized/non blinded All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9762 | Cardiac MRI for morphology/function with strain imaging (quantification of segmental dysfunction) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9763 | Cardiac MRI for morphology/function with strain imaging (quantification of segmental dysfunction) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9764 | Endovascular lithotripsy revascularization , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9765 | Endovascular lithotripsy revascularization , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9766 | Endovascular lithotripsy revascularization , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9767 | Endovascular lithotripsy revascularization , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| C9784 | Endoscopic sleeve gastroplasty All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D0210 | Dental Diagnostics , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D0330 | Diagnostics Children under age 6 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D0999 | Dental Diagnostics , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D1330 | Oral Hygiene Instruction All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2720 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2721 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2722 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2740 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2750 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2751 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2752 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2753 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2780 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2781 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2782 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2783 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2790 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2791 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2792 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2794 | Crowns , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2952 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2953 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2960 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2961 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2962 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2971 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2975 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D2999 | Dentures D5110–D5140, D5211–D5214, D5221–D5226, D5820–D5821, D5862–D5867, D5899 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D3460 | Endodontics (endosseous implant) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4240 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4241 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4245 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4249 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4260 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4261 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4263 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4264 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4266 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4267 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4268 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4270 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4273 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4274 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4275 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D4276 | Periodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5110 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5120 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5130 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5140 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5211 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5212 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5213 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5214 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5221 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5222 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5223 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5224 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5225 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5226 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5227 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5228 | Dentures – PrimeWest Senior Health Complete (MSHO) members only , , , , , , , , , , , , , , , , PWSHC | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5820 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5821 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5862 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5867 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5899 | Dentures – , – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5911 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5912 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5937 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5951 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5952 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5953 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5954 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5958 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5959 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5960 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5982 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5983 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5984 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5985 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5986 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D5987 | Maxillofacial Prosthetics , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6010 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6012 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6013 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6040 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6050 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6051 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6055 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6056 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6057 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6058 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6059 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6060 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6061 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6062 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6063 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6064 | Implants / Implant services / Prosthodontics , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6065 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6066 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6067 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6068 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6069 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6070 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6071 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6072 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6073 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6074 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6075 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6076 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6077 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6080 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6082 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6083 | D6084, D6086, D6087, D6088, D6094, D6097, D6098, D6099, D6120, D6121, D6122, D6123, D6190, D6194, D6195, D6205, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6084 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6086 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6087 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6088 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6094 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6097 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6098 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6099 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6120 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6121 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6122 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6123 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6190 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6194 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6195 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6205 | D6210, D6211, D6212, D6214, D6240, D6241, D6242, D6243, D6245, D6250, D6251, D6252, D6253, D6545, D6548, D6624, | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6210 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6211 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6212 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6214 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6240 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6241 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6242 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6243 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6245 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6250 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6251 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6252 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6253 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6545 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6548 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6624 | D6634, D6710, D6720, D6721, D6792, D6793, D6794, D6795, D6797, D6799, D6920, D6940, D6950, D6985 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6634 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6710 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6720 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6721 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6792 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6793 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6794 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6795 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6797 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6799 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6920 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6940 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6950 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D6985 | Removal of Impacted tooth D7220, D7230, D7240, D7241, D7252 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7220 | Removal of Impacted tooth , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7230 | Removal of Impacted tooth , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7240 | Removal of Impacted tooth , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7241 | Removal of Impacted tooth , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7251 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7252 | Removal of Impacted tooth , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7272 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7290 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7291 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7490 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7880 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7899 | Mandibular Ortho Repositioning device 21499, 21089 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D7953 | Oral Surgery , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8010 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8020 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8030 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8040 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8070 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8080 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8090 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8091 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8210 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8220 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8670 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8671 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8680 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8681 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D8999 | Orthodontia (No age restriction) , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9941 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9952 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9971 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9972 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9973 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9974 | Other Dental services (athletic mouthguard), (complete occlusal adjustment), (odontoplasty), , , (bleaching), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| D9999 | (unspecified adjunctive procedure) | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0170 | Wheelchair accessory – seat lift mechanism & crutch tips , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0171 | Wheelchair accessory – seat lift mechanism & crutch tips , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0172 | Wheelchair accessory – seat lift mechanism & crutch tips , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0193 | Mattress Group 2 (low air/powered/advanced) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0194 | Mattress Group 3 (air fluidized) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0202 | Bililights – after 1 month rental All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0260 | Hospital Bed – Semi Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0261 | Hospital Bed – Semi Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0265 | Hospital Bed – Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0266 | Hospital Bed – Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0277 | Mattress Group 2 (low air/powered/advanced) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0294 | Hospital Bed – Semi Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0295 | Hospital Bed – Semi Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0296 | Hospital Bed – Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0297 | Hospital Bed – Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0300 | Enclosed Crib / Bed Enclosure , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0301 | Hospital Bed – Heavy Duty , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0302 | Hospital Bed – Heavy Duty , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0303 | Hospital Bed – Heavy Duty , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0304 | Hospital Bed – Heavy Duty , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0316 | Enclosed Crib / Bed Enclosure , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0329 | Hospital Bed – Semi Electric , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0371 | Mattress Group 2 (low air/powered/advanced) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0372 | Mattress Group 2 (low air/powered/advanced) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0373 | Mattress Group 2 (low air/powered/advanced) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0445 | Continuous oximeter devices & probes All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0462 | Hospital Bed – Rocking All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0465 | Ventilators – invasive/noninvasive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0466 | Ventilators – invasive/noninvasive , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0467 | Home ventilator – multifunction device (includes oxygen, neb, aspiration, cough stim) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0468 | Home ventilator – dual function device (adds cough stimulation) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0480 | Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0482 | Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0483 | Airway Clearance Devices (Chest Compression Vest, Vest Replacement, Cough Stimulator, Percussor) , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0485 | Oral appliances for sleep disorder , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0486 | Oral appliances for sleep disorder , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0487 | Spirometer (home monitoring post heart/lung transplant) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0500 | IPPB – Intermittent positive pressure breathing All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0530 | Electronic positional OSA treatment (includes components) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0575 | Nebulizer – ultrasonic All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0604 | Breast Pump – heavy duty (rental only) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0617 | External defibrillators (AED) , (wearable) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0618 | Durable Medical Equipment (DME) Apnea monitor – after 6 month rental , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0619 | Durable Medical Equipment (DME) Apnea monitor – after 6 month rental , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0620 | Piercing device, skin All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0625 | Patient lift – bathroom/toilet (NOC) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0627 | Lift Chair Mechanism , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0629 | Lift Chair Mechanism , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0630 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0635 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0636 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0637 | Standers , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0638 | Standers , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0639 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0640 | Patient lift – fixed system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0641 | Standers , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0642 | Standers , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0652 | Pneumatic compression device , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0670 | Pneumatic compression device , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0675 | Pneumatic compression device , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0691 | Ultraviolet Light Therapy , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0692 | Ultraviolet Light Therapy , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0693 | Ultraviolet Light Therapy , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0694 | Ultraviolet Light Therapy , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0715 | Transvaginal Mechanotherapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0716 | Transvaginal Mechanotherapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0720 | TENS Units ( / / ) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0730 | TENS Units ( / / ) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0731 | TENS Units ( / / ) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0732 | Cranial electrotherapy stimulation (CES) system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0733 | TENS for trigeminal nerve , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0734 | External upper limb tremor stimulator (wrist) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0735 | Non-invasive vagus nerve stimulator All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0736 | Transcutaneous tibial nerve stimulator – home All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0740 | Pelvic floor/Urinary incontinence device All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0744 | Neuromuscular stimulator for scoliosis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0745 | Functional & electric stimulators for muscle atrophy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0746 | Biofeedback machine All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0747 | Bone growth stimulator (osteogenesis) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0748 | Spinal—external stimulator All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0749 | Bone growth stimulator (osteogenesis) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0760 | Bone growth stimulator (osteogenesis) , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0762 | Durable Medical Equipment (DME) continued Transcutaneous electrical joint stimulation system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0764 | FNS for spinal cord injury / nerve stimulator for nausea & vomiting , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0765 | FNS for spinal cord injury / nerve stimulator for nausea & vomiting , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0766 | Electrotherapy stimulator All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0769 | Electric stimulator for wound treatment All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0770 | Functional & electric stimulators for muscle atrophy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0782 | Infusion Pump – Implantable , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0783 | Infusion Pump – Implantable , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0784 | Insulin Pump All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0786 | Infusion Pump – Implantable , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0787 | Infusion Pump – Implantable , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0935 | Continuous Passive Motion (CPM) machine , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0936 | Continuous Passive Motion (CPM) machine , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0985 | Wheelchair accessory – seat lift mechanism & crutch tips , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E0986 | Wheelchair accessory – power assist for manual w/c All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1002 | Wheelchair accessory – seating tilt/recline (manual/power) – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1008 | Wheelchair accessory – seating tilt/recline (manual/power) – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1012 | Wheelchair accessory – center mount power elevating leg rest/platform All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1014 | Wheelchair accessory – reclining back , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1035 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1036 | Patient lift – hydraulic/mechanical , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1037 | Transport Chair – authorization timing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1038 | Transport Chair – authorization timing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1039 | Transport Chair – authorization timing , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1161 | Manual – Tilt/Recliner All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1225 | Wheelchair accessory – reclining back , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1226 | Wheelchair accessory – reclining back , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1227 | Wheelchair accessory – special height arms/back height , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1228 | Wheelchair accessory – special height arms/back height , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1229 | Manual Wheelchairs – standard ( – , ) , **, **, **, ** All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1230 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1231 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1232 | Adaptive Stroller , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1233 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1234 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1235 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1236 | Adaptive Stroller , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1237 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1238 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1239 | Power Wheelchairs – Group 5 Pediatric , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1310 | Whirlpool – non portable (built in) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1399 | Female prosthetic (EROS) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1800 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1802 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1805 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1807 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1808 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1810 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1812 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1815 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1820 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1822 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1823 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1825 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1830 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E1840 | Dynamic Splinting Devices , – , – , , – , , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2001 | Suction pump for external urine management system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2100 | Blood glucose monitor – special features , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2101 | Blood glucose monitor – special features , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2102 | Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2103 | Continuous Glucose Monitoring (adjunctive/non adjunctive) & supplies (Adjunctive), (Non adjunctive), All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2227 | Wheelchair accessory – gear reduction drive wheels All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2230 | Wheelchair accessory – manual or power standing system , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2298 | Wheelchair accessory – seat elevation feature All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2301 | Wheelchair accessory – manual or power standing system , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2398 | Wheelchair accessory – dynamic positioning hardware for back All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2402 | Pump or Wound Vac All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2500 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2502 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2504 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2506 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2508 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2510 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2511 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2512 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2599 | Augmentative Communication (AC) Devices , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2609 | Custom wheelchair cushion , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2610 | Powered seat cushion All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E2617 | Custom wheelchair cushion , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E3000 | Speech volume modulation system (incl. all components) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E8000 | Gait Trainer , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E8001 | Gait Trainer , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| E8002 | Gait Trainer , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0068 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0069 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0070 | Home Infusion Codes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0105 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0121 | Colonoscopy , , , , , , , , , , , , , , , Members ages 18–44 require authorization | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0166 | External counterpulsation All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0277 | Hyperbaric Oxygen Therapy , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0279 | Mammogram or Mammography , , , , , , Female members under age 40 (exception | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0283 | Cranial Electrotherapy Stimulation (CES) vs other e stim , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0327 | Colorectal cancer screening; blood-based biomarker All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G0429 | Dermal filler injection All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9873 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9874 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9875 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9876 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9877 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9878 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9879 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9880 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9881 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9882 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9883 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9884 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9885 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9890 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| G9891 | Medicare Diabetes Prevention Program (MDPP) , , , , , , , , , , , , , , Medicare members only | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| H0004 | Behavioral Health Counseling All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| H0018 | Adult Crisis Services , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| H0019 | CMHRTS (Children's MH Residential Treatment) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| H0031 | CTSS (Children’s Therapeutic Services and Supports) Multiple ( UA, UA, etc.) Children and young adults | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| H2011 | Adult Crisis Services , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| J3490 | Subcutaneous hormone pellets , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| J7330 | CARTICEL (autologous cultured chondrocytes) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| J7402 | Sinuva sinus implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0001 | Manual Wheelchairs – standard ( – , ) , **, **, **, ** All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0002 | Manual Wheelchairs – standard ( – , ) , **, **, **, ** All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0003 | Manual Wheelchairs – standard ( – , ) , **, **, **, ** All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0004 | Manual Wheelchairs – standard ( – , ) , **, **, **, ** All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0005 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0006 | Other Manual Wheelchairs , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0007 | Other Manual Wheelchairs , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0008 | Customized Durable Medical Equipment , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0009 | Manual – Special , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0013 | Customized Durable Medical Equipment , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0014 | Power/Electric ( / ) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0462 | Repairs & Maintenance RB modifier, , , (>1 month) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0606 | External defibrillators (AED) , (wearable) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0739 | Repairs & Maintenance RB modifier, , , (>1 month) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0740 | Repairs & Maintenance RB modifier, , , (>1 month) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0743 | Pump or Wound Vac All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0800 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0801 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0802 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0806 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0807 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0808 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0812 | POV/Scooter , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0813 | Power Wheelchairs – Group 1 , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0814 | Power Wheelchairs – Group 1 , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0815 | Power Wheelchairs – Group 1 , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0816 | Power Wheelchairs – Group 1 , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0820 | Power Wheelchairs – Group 2 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0831 | Power Wheelchairs – Group 2 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0835 | Power Wheelchairs – Group 2 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0840 | Power Wheelchairs – Group 2 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0841 | Power Wheelchairs – Group 2 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0843 | Power Wheelchairs – Group 2 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0848 | Power Wheelchairs – Group 3 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0855 | Power Wheelchairs – Group 3 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0856 | Power Wheelchairs – Group 3 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0860 | Power Wheelchairs – Group 3 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0861 | Power Wheelchairs – Group 3 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0864 | Power Wheelchairs – Group 3 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0868 | Power Wheelchairs – Group 4 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0871 | Power Wheelchairs – Group 4 Standard – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0877 | Power Wheelchairs – Group 4 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0880 | Power Wheelchairs – Group 4 Single Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0884 | Power Wheelchairs – Group 4 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0886 | Power Wheelchairs – Group 4 Multiple Power – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0890 | Power Wheelchairs – Group 5 Pediatric , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0891 | Power Wheelchairs – Group 5 Pediatric , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0898 | Power/Electric ( / ) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K0900 | Customized Durable Medical Equipment , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K1007 | Powered bilateral HKAFO system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| K1027 | Oral device to reduce upper airway collapsibility (custom) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L0648 | Lumbar sacral orthosis (LSO) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L0650 | Lumbar sacral orthosis (LSO) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L1006 | Scoliosis Orthosis All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L1600 | Hip Orthotics – limit & threshold – , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L1755 | Hip Orthotics – limit & threshold – , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L1810 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2006 | KAFO microprocessor control (custom fabricated) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2038 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2040 | Hip Orthotics – limit & threshold – , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2090 | Hip Orthotics – limit & threshold – , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2106 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L2999 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3000 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3001 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3002 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3003 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3010 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3020 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3030 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3031 | Orthopedic Shoe Inserts , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3161 | Foot adductus positioning device (adjustable) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3201 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3202 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3203 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3204 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3206 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3207 | Orthopedic Shoes , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3224 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3225 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3230 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3250 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3251 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3252 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3253 | Orthopedic Shoes , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3650 | Upper Extremity Orthotics – limit – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L3999 | Upper Extremity Orthotics – limit – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L4350 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L4631 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5615 | Prosthetic addition – 4 bar linkage knee system All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5827 | Endoskeletal knee shin system, single axis electromechanical All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5856 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5857 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5858 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5973 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5980 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L5987 | Lower Limb Orthotics – limits & always authorization list – , – ; , , , , , ; – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L6700 | UE prosthetic addition – myoelectric control/pattern recognition module All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L7900 | Male prosthetic – vacuum erection (tension ring replacement only) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L7902 | Male prosthetic – vacuum erection (tension ring replacement only) , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8608 | Argus II retinal prosthesis – misc external component/accessory (>$3,000) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8609 | Artificial Cornea All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8614 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8619 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8627 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8628 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8629 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8679 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8680 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8681 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8682 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8683 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8684 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8685 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8686 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8687 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8688 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8689 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8690 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8691 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8692 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8693 | Cochlear Device and BAHA , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8695 | Neurostimulator additions (electrodes, generators, etc.) , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8698 | Total artificial heart – misc component/accessory All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8701 | Powered UE ROM assist device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| L8702 | Powered UE ROM assist device , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0478 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0484 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0488 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0491 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0495 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0496 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0502 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0504 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q0506 | LVAD/VAD (implants/devices) – part 1 , , ; – , – , – , – , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4100 | Wound Care Skin substitutes - All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4226 | Wound Care Skin substitutes - All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4227 | Amniocore All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4232 | Corplex All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4234 | Xcellerate All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4235 | Amniorepair/altiply All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4238 | Derm-maxx All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4239 | Amnio-maxx/lite All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4248 | Dermacyte amniotic membrane allograft All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4249 | Amniply (topical) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4250 | Amnioamp-mp All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4253 | Zenith Amniotic membrane All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4254 | Wound Care continued Novafix dl All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| Q4259 | Celera dual layer/membrane All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| R0651 | Routine Home Care Day (<8 hours) Non-dual | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| R0652 | Hospice Continuous Home Care Day (≥8 hours) Non-dual | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| R0655 | Inpatient Respite Day Non-dual | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| R0656 | Hospice continued General Inpatient Day Non-dual | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0189 | Subcutaneous hormone pellets , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0500 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0504 | Industrial/Sport/Computer Glasses , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0506 | Industrial/Sport/Computer Glasses , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0508 | Industrial/Sport/Computer Glasses , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0581 | Industrial/Sport/Computer Glasses , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S0800 | Refractive Surgery (LASIK/RK/LRI/CLR) , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S1040 | Cranial Remodeling Orthotic – limit under age 2 Members under age 2 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2053 | Intestine-Liver All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2400 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2401 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2402 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2403 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2404 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2405 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2409 | In utero fetal surgeries (set) , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S2411 | Fetoscopic laser treatment All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S5100 | Home Care Adult Day Care Services All who do not have EW | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S5560 | Durable Medical Equipment (DME) continued Insulin Pen , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S5561 | Durable Medical Equipment (DME) continued Insulin Pen , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S9001 | Uterine Monitor – home All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S9445 | Doula Services , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| S9484 | Adult Crisis Services , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T1016 | Community Paramedic Services U3 All | 2026-07-06 | 2026-02-24 | 97% | [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 | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T2023 | Mental Health Targeted Case Management All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4521 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4529 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4530 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4535 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4538 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4541 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| T4545 | Incontinent products (see code list) – , , – , , – All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2020 | Glasses + all replacement codes All (except children under age 21) | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2500 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2599 | Vision Contact Lenses - , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2744 | Tints & Polarized Lenses , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2745 | Tints & Polarized Lenses , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V2762 | Tints & Polarized Lenses , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5030 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5040 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5050 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5060 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5070 | Hearing Aid in glasses - Air conductive All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5080 | Hearing Aid in glasses - Bone conductive All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5090 | Assistive Listening Device, NOS (includes vibrotactile & pocket talkers) (dispensing fee: ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5100 | Pocket Talker All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5110 | Pocket Talker Dispensing Fee All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5120 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5130 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5140 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5150 | Hearing Aid in glasses - Binaural All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5171 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5181 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5190 | CROS in glasses All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5211 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5213 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5221 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5230 | BICROS in glasses All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5246 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5247 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5252 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5253 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5256 | Hearing Hearing Aids - Personal , , , , , , , , , , , , , , , , , All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5257 | Hearing Aid in glasses - Air conductive V5070 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5260 | Hearing Aid in glasses - Air conductive V5070 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5261 | Hearing Aid in glasses - Air conductive V5070 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5273 | Assistive Listening Device for cochlear implant All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5274 | Assistive Listening Device, NOS (includes vibrotactile & pocket talkers) (dispensing fee: ) All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |
| V5298 | Hearing Aid in glasses - Air conductive V5070 All | 2026-07-06 | 2026-02-24 | 97% | [PDF] Services Requiring Prior Authorization - PrimeWest |