Prior Auth Required

30450 - service/diagnosis

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / Serviceservice/diagnosis
Procedure / Service Description

Service Category Benefit/Description Codes Requiring Authorization Member Program* - 58552, 58553, 58554, 58570, 58571, 58572, 58573, 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 service/diagnosis 19340, 19342, 19350, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 30400, 30410, 30420, 30430, 30435, 30450, 53400, 53405, 53410, 53415, 58661, 58700, 58953, 58956, 15772, 15773, S9128, 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

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.