Prior authorization codes
SummaCare
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0256U | Tandem mass spectroscopy (MS/MS) profile of | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0611T | Magnetic resonance spectroscopy, determination and | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0612T | Magnetic resonance spectroscopy, determination and | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0614U | Inborn error of metabolism (primary mitochondrial | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0615U | Borrelia burgdorferi (Lyme disease), antibody detection of | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0617U | Cardiovascular (atherosclerotic cardiovascular disease | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0618U | Psychiatry (bipolar disorder), DNA methylation analysis of | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0619U | Pulmonary (chronic obstructive pulmonary disease | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0620U | Oncology (hepatocellular carcinoma), DNA methylation | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0622U | Psychiatry (major depressive disorder), DNA methylation | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0623T | Automated quantification and characterization of coronary | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0623U | Autoimmune (multiple sclerosis), DNA methylation | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0624T | Automated quantification and characterization of coronary | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0624U | Hepatology (nonalcoholic steatohepatitis [NASH]), DNA | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0625T | Automated quantification and characterization of coronary | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0625U | Endocrinology (osteoporosis), DNA methylation analysis of | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0626T | Automated quantification and characterization of coronary | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0626U | Neurology (Parkinson disease), DNA methylation analysis | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0627U | Psychiatry (schizophrenia), DNA methylation analysis of | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0628U | Nephrology (kidney disease-related genetic conditions) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0629U | Infectious disease (tuberculosis), DNA, analysis of 1 target | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0630U | Oncology (breast), mRNA, gene expression profiling by | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0989T | Revj/rmvl integrated nstimj sys ptn subq & subf | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0990T | Transcrv instlj biod hydrogel matrl intrauterine | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0991T | Cysto lo-nrg lithotrp & acous actuated microsphere | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0992T | N-invas assmt car rsk augmnt sw alys fat w/o ct | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0993T | N-invas assmt car rsk augmnt sw alys fat w/ct | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0994T | Evasc delivery aortic wall stablj drug ther perq | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0995T | Evasc delivery aortic wall stablj drug ther open | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0996T | Insj & scleral fixation capsular bag prosthesis | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0997T | Precuneus magnetic stimulation treatment plng | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0998T | Precuneus magnetic stimulation treatment dlvr | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 0999T | Autologous musc cell ther hrvg musc progen cells | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1000T | Autologous musc cell ther admn musc progen cells | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1001T | Autologous musc cell ther njx musc progen cells | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1002T | Air displacement plethysmograp whl bdy comp asmt | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1003T | Arthrp 1st carp/mtcrpl jt w/mtcrpl prostc rplcmt | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1004T | Elec alys impl s-sclp cont bi eeg sys w/o prgrmg | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1005T | Elec alys impl s-sclp cont bi eeg sys prgrmg 1st | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1006T | Elec alys impl s-sclp cont bi eeg sys prgrmg ea | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1007T | Eeg impl s-sclp cont bi eeg sys phys/qhp w/o vid | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1008T | Rem mntr s-sclp impl cont bi eeg sys fitg set-up | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1009T | Rem mntr s-sclp impl cont bi eeg mntr sys wo vid | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1010T | Cptrizd oph alys monocular eye mvmt rta eye trck | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1011T | Photobiomodulation therapy of oral cavity | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1012T | Motorized ab interno trephination sclera/trab mw | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1013T | Lap srg impl/rplcmt lwr esophgl sphnctr nea & pg/r | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1015T | Revision/removal lower esophageal sphnctr nstim pg/rcvr | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1016T | Elec alys npgs lwr esophgl sphnctr intraop prgrmg | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1017T | Elec alys npgs lwr esophgl sphnctr sbsq wo reprgrmg | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1018T | Elec alys npgs lwr esoph sphnct sbsq w/reprgrmg | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1019T | Lymphovenous bypass w/robotic asst per extremity | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1020T | Raman spectroscopy 1+skin les prob score mal rsk | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1021T | Active thoracic irrigation (separate procedure) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1022T | Perq tiss displacement intra-abdl/pelvic strux | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1023T | Perq tiss displacement intrathoracic structures | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1024T | percutaneous tissue displacement soft tissue | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 1025T | Alternating electric fld dosim&dlvr simulaj mldg | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 27458 | Osteot femur uni insj xtrnl ctrld imed lngth dev | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 27713 | Osteot tibia uni insj xtrnl ctrld imed lngth dev | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 33884 | add-on code used to describe the placement of an | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 35602 | Bpg oth/thn vein carotid-contralateral carotid | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 37296 | Revascularization evasc imvt angiop uni sf les 1st vsl | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 37297 | Revascularization evasc imvt angiop uni sf les ea addl vsl | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 37298 | Revascularization evasc imvt angiop uni cplx les 1st vsl | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 37299 | Revascularization evasc imvt angiop uni cplx les ea addl | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 43889 | Gstr rstcv px trnsorl esg w/argon plasma coagj | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 44305 | 1200 E. Market Street, Suite 400, Akron, Ohio | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 52443 | Cysto 1st trurl ant prostate comis nonrx balo cath | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 52597 | Trurl robotic-assisted waterjet resection prostate | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55707 | Biopsy, prostate, transrectal, ultrasound-guided | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55708 | Biopsy, prostate, transrectal, ultrasound-guided with mri | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55709 | Biopsy, prostate, transperineal, ultrasound-guided | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55710 | Biopsy, prostate, transperineal, ultrasound-guided with | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55711 | Bx prostate transrectal mri-us gid trgt les 1st | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55712 | Bx prostate tprnl mri-us gid trgt les 1st | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55713 | Bx prostate in-bore ct/mri bx addl trgt les 1st | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55714 | Bx prostate in-bore ct/mri trgt les only 1st | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55715 | Bx prostate ea addl mri-us fusion/in-bore ct/mri | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55868 | Laps surg prstect rpbic radical w/lymph node bx | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55869 | Laps surg prstect rpbic rad w/bi pel lymphadec | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 55877 | Ablation ire prostate 1 or more tumors percutaneous | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 63032 | Lamot dcmprn nrv rt rpr anulr dfct 1ntrspc lmbr | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64567 | Perq elec nrv field stimj cranial nrv w/o impltj | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64643 | Injection of chemical for paralysis of nerve muscles on arm | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64644 | Injection of chemical for paralysis of nerve muscles on arm | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64654 | Initial open implantation bat modulation system | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64655 | Revision/rplcmt bat modulation system lead only | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64656 | Revision/rplcmt bat modulation system pg only | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64657 | Removal bat modulation system total system | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64658 | Removal bat modulation system lead only | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64659 | Removal bat modulation system pg only | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 64728 | Dcmprn median nrv at carpl tunl perq balo dilat | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70471 | Cta head & neck c+ w/noncontrast img & post-pxessing | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70472 | Ct cere prfuj alys c+ w/ct/cta same anatomy | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70473 | Ct cere prfuj alys c+ w/o ct/cta same anatomy | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70486 | Ct maxillofacial area including paranasal sinuses w/o | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70487 | Ct maxillofacial area including paranasal sinuses w/ | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 70488 | Ct maxillofacial area including paranasal sinuses w/o and | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 75577 | Quan & charac c atherosclerotc plaq asses sev c ds | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 76873 | Ultrasound, transrectal; prostate volume study for | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 76942 | US Guidance Needle Placement IMG S&I | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 77385 | Intensity modulated radiation treatment delivery (IMRT) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 77386 | Intensity modulated radiation treatment delivery (IMRT) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 77401 | Radiation treatment delivery, superficial and/or ortho | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 77425 | Intraoperative radiation treatment delivery, electrons | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78102 | Bone marrow imaging, limited | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78185 | Spleen imaging w/or wo vascular flow | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78195 | Lymph system imaging (lymphoscintigraphy) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78230 | Salivary gland nuclear imaging | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78231 | Salivary gland nuclear imaging with serial imaging | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78232 | Salivary gland function study | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78258 | Esophagus motility study | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78261 | Gastric mucosa imaging | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78265 | Gastric emptying imaging study (e.g. solid, liquid, both) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78266 | Gastric emptying imaging study (e.g. solid, liquid, both) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78278 | Gi bleeding scintigraphy | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78290 | Intestinal imaging | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78291 | Peritoneal-venous shunt patency | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78428 | Cardiac shunt detection | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78445 | Non-cardiac vascular flow imaging | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78459 | Myocardial imaging, positron emission tomography (pet) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78494 | Spect equilibrium cardiac radionuclide angiography | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78597 | Quantitative differential pulmonary perfusion, including | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78598 | Quantitative differential pulmonary perfusion and | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78610 | Brain imaging vascular flow | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78630 | Csternogram | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78635 | Cerebrospinal ventriculography | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78645 | Shunt evaluation | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78650 | Csf leakage detection | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78660 | Radiopharmaceutical dacryocystorgraphy | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78730 | Urinary bladder residual study | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78740 | Ureteral reflux study (radiopharmaceutical voiding | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 78761 | Testicular scan-vascular flow and delayed images | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 91124 | Rectal sensation, tone and compliance study | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 91125 | Anrct mano rct sensation & rct balo expulsion test | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92628 | Evaluation hearing aid candidacy 1st 30 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92629 | Evaluation hearing aid candidacy ea addl 15 min | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92631 | Hearing aid selection services 1st 30 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92632 | Hearing aid selection services ea addl 15 min | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92634 | Hearing aid fitting services 1st 60 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92635 | Hearing aid fitting services ea addl 15 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92636 | Hearing aid post-fitting f-up svc 1st 30 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92637 | Hearing aid post-fitting f-up svc ea addl 15 min | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92638 | Behavioral verification of amplification | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92639 | Hearing aid meas verif w/probe microphone | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92641 | Hearing device verificaiton, electroacoustic analysis | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92642 | Hearing assistive device suppl tech fitting svc | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92930 | Perq tcat plmt ntrac st 2+les 2+st 2+c segments | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 92945 | Perq trluml revsc chrnc tot occls 1 antgrd & rtrgr | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 93145 | Interrog eval crtd sins bat modulj sys ip wo | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 93146 | Interrog eval crtd sins bat modulj sys ip w/ | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 97007 | Mchnl sclp cool cap sply head meas fitg & education | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 97008 | Mchnl sclp cool hair prepj cap plmt ther & precool | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 97009 | Mchnl sclp cool after chemo each 30 minutes | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 98979 | Rtm tx mgmt 1 r-t ia comunicaj cal mo 1st 10 min | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 98984 | Rtm dev sply data respir sys 2-15 days in 30d pd | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 98985 | Rtm dev sply data muscskel sys 2-15 d in 30d pd | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 98986 | Rtm dev sply data cbt 2-15 days in 30 d pd | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 99445 | Rem mntr physiol param dev sply w/rec 2-15 days | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| 99470 | Rpm tx mgmt 1 r-t ia comunicaj cal mo 1st 10 min | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| A9543 | Yttrium 90 Ibritumomab Tiuxetan (Zevalin) | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| A9590 | Iodine i-131, iobenguane, 1 millicurie | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| A9609 | Injection, of fluorodeoxyglucose F18 FDG therapeutic, up | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| C8001 | 3d anat seg imaging preop planning, data prep and | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6003 | Radiation treatment delivery, single treatment area, single | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6004 | Radiation treatment delivery, single treatment area, single | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6005 | Radiation treatment delivery, single treatment area, single | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6006 | Radiation treatment delivery, single treatment area, single | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6008 | Radiation treatment delivery, 2 separate treatment areas | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6009 | Radiation treatment delivery, 2 separate treatment areas | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6010 | Radiation treatment delivery, 2 separate treatment areas | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6011 | Radiation treatment delivery, 3 or more separate treatment | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6012 | Radiation treatment delivery, 3 or more separate treatment | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6013 | Radiation treatment delivery, 3 or more separate treatment | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6014 | Radiation treatment delivery, 3 or more separate treatment | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6015 | Intensity modulated treatment delivery, single or multiple | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6016 | Compensator-based beam modulation treatment delivery | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| G6017 | Intra-fraction localization and tracking of target or patient | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4398 | Summit ac, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4399 | Summit fx, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4400 | Polygon3 membrane, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4401 | Absolv3 membrane, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4402 | Xwrap 2.0, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4403 | Xwrap dual plus, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4404 | Xwrap hydro plus, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4405 | Xwrap fenestra plus, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4406 | Xwrap fenestra, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4407 | Xwrap tribus, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4408 | Xwrap hydro, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4409 | Xmniomatrixf3x, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4410 | Amchomatrixdl, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4411 | Amniomatrixf4x, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4413 | Cygnus solo, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4414 | Simplichor, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4415 | Alexiguard sl-t, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4416 | Alexiguard tl-t, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4417 | alexiguard dl-t, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4420 | Nuform, per square centimeter | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4431 | Pma skin substitute product, not otherwise specified (list in | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4432 | 510(k) skin substitute product, not otherwise specified (list | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |
| Q4433 | 361 hct/p skin substitute product, not otherwise specified | 2026-04-15 | Not listed | 97% | [PDF] Prior Authorization Requirements Effective 4.15.26 - SummaCare |