Prior authorization codes
The Health Plan
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 11057 | Paring or Cutting - HH or NH Aide Trim skin lesions over 4 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11920 | Cosmetic & Reconstructive Correct skin color 6.0 cm/< | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11950 | Cosmetic & Reconstructive Tx contour defects 1 cc/< | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11951 | Cosmetic & Reconstructive Tx contour defects 1.1-5.0cc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11952 | Cosmetic & Reconstructive Tx contour defects 5.1-10cc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11954 | Cosmetic & Reconstructive Tx contour defects >10.0 cc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11960 | Cosmetic & Reconstructive Insert tissue expander(s) | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11970 | Cosmetic & Reconstructive Replace tissue expander | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 11971 | Cosmetic & Reconstructive Remove tissue expander(s) | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15730 | Cosmetic & Reconstructive Mdfc flap w/prsrv vasc pedcl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15731 | Cosmetic & Reconstructive Forehead flap w/vasc pedicle | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15733 | Cosmetic & Reconstructive Musc myoq/fscq flp h&n pedcl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15756 | Cosmetic & Reconstructive Free myo/skin flap microvasc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15757 | Cosmetic & Reconstructive Free skin flap microvasc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15758 | Cosmetic & Reconstructive Free fascial flap microvasc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15760 | Cosmetic & Reconstructive Composite skin graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15769 | Cosmetic & Reconstructive Grfg autol soft tiss dir exc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15770 | Cosmetic & Reconstructive Derma-fat-fascia graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15771 | Cosmetic & Reconstructive Grfg autol fat lipo 50 cc/< | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15772 | Cosmetic & Reconstructive Grfg autol fat lipo ea addl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15773 | Cosmetic & Reconstructive Grfg autol fat lipo 25 cc/< | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15774 | Cosmetic & Reconstructive Gfrg autol fat lipo ea addl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15820 | Cosmetic & Reconstructive Revision of lower eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15821 | Cosmetic & Reconstructive Revision of lower eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15822 | Cosmetic & Reconstructive Revision of upper eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15823 | Cosmetic & Reconstructive Revision of upper eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15830 | Cosmetic & Reconstructive Exc skin abd | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15832 | Cosmetic & Reconstructive Excise excessive skin thigh | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15833 | Cosmetic & Reconstructive Excise excessive skin leg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15834 | Cosmetic & Reconstructive Excise excessive skin hip | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15835 | Cosmetic & Reconstructive Excise excessive skin buttck | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15836 | Cosmetic & Reconstructive Excise excessive skin arm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15837 | Cosmetic & Reconstructive Excise excess skin arm/hand | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15838 | Cosmetic & Reconstructive Excise excess skin fat pad | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15839 | Cosmetic & Reconstructive Excise excess skin & tissue | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15847 | Cosmetic & Reconstructive Exc skin abd add-on | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15876 | Cosmetic & Reconstructive Suction lipectomy head&neck | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15877 | Cosmetic & Reconstructive Suction lipectomy trunk | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15878 | Cosmetic & Reconstructive Suction lipectomy upr extrem | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 15879 | Cosmetic & Reconstructive Suction lipectomy lwr extrem | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 16036 | Cosmetic & Reconstructive Escharotomy addl incision Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 17999 | Cosmetic & Reconstructive Skin tissue procedure | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 20560 | Chronic Low Back Pain Treatment Ndl insj w/o njx 1 or 2 musc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 20561 | Chronic Low Back Pain Treatment Ndl insj w/o njx 3+ musc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21137 | Cosmetic & Reconstructive Reduction of forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21138 | Cosmetic & Reconstructive Reduction of forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21139 | Cosmetic & Reconstructive Reduction of forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21172 | Cosmetic & Reconstructive Reconstruct orbit/forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21175 | Cosmetic & Reconstructive Reconstruct orbit/forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21179 | Cosmetic & Reconstructive Reconstruct entire forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21180 | Cosmetic & Reconstructive Reconstruct entire forehead | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21181 | Cosmetic & Reconstructive Contour cranial bone lesion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21182 | Cosmetic & Reconstructive Reconstruct cranial bone | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21183 | Cosmetic & Reconstructive Reconstruct cranial bone | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21184 | Cosmetic & Reconstructive Reconstruct cranial bone | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21208 | Cosmetic & Reconstructive Augmentation of facial bones | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21209 | Cosmetic & Reconstructive Reduction of facial bones | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21230 | Cosmetic & Reconstructive Rib cartilage graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21235 | Cosmetic & Reconstructive Ear cartilage graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21256 | Cosmetic & Reconstructive Reconstruction of orbit | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21260 | Cosmetic & Reconstructive Revise eye sockets | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21261 | Cosmetic & Reconstructive Revise eye sockets | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21263 | Cosmetic & Reconstructive Revise eye sockets | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21267 | Cosmetic & Reconstructive Revise eye sockets | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21275 | Cosmetic & Reconstructive Revision orbitofacial bones | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21280 | Cosmetic & Reconstructive Revision of eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21282 | Cosmetic & Reconstructive Revision of eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21299 | Cosmetic & Reconstructive Cranio/maxillofacial surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21742 | Cosmetic & Reconstructive Repair stern/nuss w/o scope | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 21743 | Cosmetic & Reconstructive Repair sternum/nuss w/scope | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22100 | Orthopedic Surgeries Remove part of neck vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22101 | Orthopedic Surgeries Remove part thorax vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22102 | Orthopedic Surgeries Remove part lumbar vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22110 | Orthopedic Surgeries Remove part of neck vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22112 | Orthopedic Surgeries Remove part thorax vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22114 | Orthopedic Surgeries Remove part lumbar vertebra | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22116 | Orthopedic Surgeries Remove extra spine segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22206 | Orthopedic Surgeries Incis spine 3 column thorac | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22207 | Orthopedic Surgeries Incis spine 3 column lumbar | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22208 | Orthopedic Surgeries Incis spine 3 column adl seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22210 | Orthopedic Surgeries Incis 1 vertebral seg cerv | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22212 | Orthopedic Surgeries Incis 1 vertebral seg thorac | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22214 | Orthopedic Surgeries Incis 1 vertebral seg lumbar | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22216 | Orthopedic Surgeries Incis addl spine segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22220 | Orthopedic Surgeries Incis w/discectomy cervical | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22222 | Orthopedic Surgeries Incis w/discectomy thoracic | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22224 | Orthopedic Surgeries Incis w/discectomy lumbar | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22226 | Orthopedic Surgeries Revise extra spine segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22318 | Orthopedic Surgeries Treat odontoid fx w/o graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22319 | Orthopedic Surgeries Treat odontoid fx w/graft | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22325 | Orthopedic Surgeries Treat spine fracture | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22326 | Orthopedic Surgeries Treat neck spine fracture | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22327 | Orthopedic Surgeries Treat thorax spine fracture | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22328 | Orthopedic Surgeries Treat each add spine fx | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22510 | Percutaneous Vertebroplasty Perq cervicothoracic inject | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22511 | Percutaneous Vertebroplasty Perq lumbosacral injection | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22512 | Percutaneous Vertebroplasty Vertebroplasty addl inject | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22513 | Percutaneous Vertebroplasty Perq vertebral augmentation | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22514 | Percutaneous Vertebroplasty Perq vertebral augmentation | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22515 | Percutaneous Vertebroplasty Perq vertebral augmentation | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22532 | Orthopedic Surgeries Lat thorax spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22533 | Orthopedic Surgeries Lat lumbar spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22534 | Orthopedic Surgeries Lat thor/lumb addl seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22548 | Orthopedic Surgeries Neck spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22551 | Orthopedic Surgeries Neck spine fuse&remov bel c2 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22552 | Orthopedic Surgeries Addl neck spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22554 | Orthopedic Surgeries Neck spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22556 | Orthopedic Surgeries Thorax spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22558 | Orthopedic Surgeries Lumbar spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22585 | Orthopedic Surgeries Additional spinal fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22586 | Orthopedic Surgeries Prescrl fuse w/ instr l5-s1 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22590 | Orthopedic Surgeries Spine & skull spinal fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22595 | Orthopedic Surgeries Neck spinal fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22600 | Orthopedic Surgeries Neck spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22610 | Orthopedic Surgeries Thorax spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22612 | Orthopedic Surgeries Lumbar spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22614 | Orthopedic Surgeries Spine fusion extra segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22630 | Orthopedic Surgeries Lumbar spine fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22632 | Orthopedic Surgeries Spine fusion extra segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22633 | Orthopedic Surgeries Lumbar spine fusion combined | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22634 | Orthopedic Surgeries Spine fusion extra segment | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22800 | Orthopedic Surgeries Post fusion </6 vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22802 | Orthopedic Surgeries Post fusion 7-12 vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22804 | Orthopedic Surgeries Post fusion 13/> vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22808 | Orthopedic Surgeries Ant fusion 2-3 vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22810 | Orthopedic Surgeries Ant fusion 4-7 vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22812 | Orthopedic Surgeries Ant fusion 8/> vert seg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22818 | Orthopedic Surgeries Kyphectomy 1-2 segments | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22819 | Orthopedic Surgeries Kyphectomy 3 or more | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22830 | Orthopedic Surgeries Exploration of spinal fusion | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22840 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22841 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22842 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22843 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22844 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22845 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22846 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22847 | Orthopedic Surgeries Insert spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22848 | Orthopedic Surgeries Insert pelv fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22849 | Orthopedic Surgeries Reinsert spinal fixation | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22850 | Orthopedic Surgeries Remove spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22852 | Orthopedic Surgeries Remove spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22855 | Orthopedic Surgeries Remove spine fixation device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22856 | Orthopedic Surgeries Cerv artific diskectomy | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22857 | Orthopedic Surgeries Lumbar artif diskectomy | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22860 | Orthopedic Surgeries Tot disc arthrp 2ntrspc lmbr | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22861 | Orthopedic Surgeries Revise cerv artific disc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22862 | Orthopedic Surgeries Revise lumbar artif disc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22864 | Orthopedic Surgeries Remove cerv artif disc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22865 | Orthopedic Surgeries Remove lumb artif disc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 22899 | Orthopedic Surgeries Spine surgery procedure | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 27445 | Orthopedic Surgeries Revision of knee joint | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 27446 | Orthopedic Surgeries Revision of knee joint Requires Precert Only if IP | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 27447 | Orthopedic Surgeries Total knee arthroplasty Requires Precert Only if IP | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 27486 | Orthopedic Surgeries Revise/replace knee joint | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 27487 | Orthopedic Surgeries Revise/replace knee joint | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 28344 | Cosmetic & Reconstructive Repair extra toe(s) | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30400 | Rhinoplasty Reconstruction of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30410 | Rhinoplasty Reconstruction of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30420 | Rhinoplasty Reconstruction of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30435 | Rhinoplasty Revision of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30450 | Rhinoplasty Revision of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30462 | Rhinoplasty Revision of nose | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30465 | Cosmetic & Reconstructive Repair nasal stenosis | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30545 | Cosmetic & Reconstructive Repair nasal defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30560 | Cosmetic & Reconstructive Release of nasal adhesions | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 30620 | Cosmetic & Reconstructive Intranasal reconstruction | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32850 | Transplant Procedures Donor pneumonectomy Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32851 | Transplant Procedures Lung transplant single Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32852 | Transplant Procedures Lung transplant with bypass Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32853 | Transplant Procedures Lung transplant double Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32854 | Transplant Procedures Lung transplant with bypass Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32855 | Transplant Procedures Prepare donor lung single Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 32856 | Transplant Procedures Prepare donor lung double Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33930 | Transplant Procedures Removal of donor heart/lung Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33933 | Transplant Procedures Prepare donor heart/lung Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33935 | Transplant Procedures Transplantation heart/lung Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33940 | Transplant Procedures Removal of donor heart Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33944 | Transplant Procedures Prepare donor heart Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33945 | Transplant Procedures Transplantation of heart Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33975 | Cardiovascular Surgery Implant ventricular device Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33976 | Cardiovascular Surgery Implant ventricular device Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33979 | Cardiovascular Surgery Insert intracorporeal device Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33981 | Cardiovascular Surgery Replace vad pump ext Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33982 | Cardiovascular Surgery Replace vad intra w/o bp Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 33983 | Cardiovascular Surgery Replace vad intra w/bp Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36465 | Injection Procedures Njx noncmpnd sclrsnt 1 vein | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36466 | Injection Procedures Njx noncmpnd sclrsnt mlt vn | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36468 | Cosmetic & Reconstructive Njx sclrsnt spider veins | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36470 | Cosmetic & Reconstructive Njx sclrsnt 1 incmptnt vein | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36471 | Cosmetic & Reconstructive Njx sclrsnt mlt incmptnt vn | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36473 | Vascular Surgery Endovenous mchnchem 1st vein | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36474 | Vascular Surgery Endovenous mchnchem add-on | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36475 | Vascular Surgery Endovenous rf 1st vein | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36476 | Vascular Surgery Endovenous rf vein add-on | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36478 | Vascular Surgery Endovenous laser 1st vein | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36479 | Vascular Surgery Endovenous laser vein addon | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36482 | Vascular Surgery Endoven ther chem adhes 1st | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 36483 | Vascular Surgery Endoven ther chem adhes sbsq | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43633 | Bariatrics Surgery Removal of stomach partial Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43644 | Bariatrics Surgery Lap gastric bypass/roux-en-y Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43645 | Bariatrics Surgery Lap gastr bypass incl smll i Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43659 | Bariatrics Surgery Laparoscope proc stom | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43770 | Bariatrics Surgery Lap place gastr adj device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43771 | Bariatrics Surgery Lap revise gastr adj device Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43772 | Bariatrics Surgery Lap rmvl gastr adj device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43773 | Bariatrics Surgery Lap replace gastr adj device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43774 | Bariatrics Surgery Lap rmvl gastr adj all parts | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43775 | Bariatrics Surgery Lap sleeve gastrectomy Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43843 | Bariatrics Surgery Gastroplasty w/o v-band Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43845 | Bariatrics Surgery Gastroplasty duodenal switch Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43846 | Bariatrics Surgery Gastric bypass for obesity Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43847 | Bariatrics Surgery Gastric bypass incl small i Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43848 | Bariatrics Surgery Revision gastroplasty Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43860 | Bariatrics Surgery Revise stomach-bowel fusion Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 43865 | Bariatrics Surgery Revise stomach-bowel fusion Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44132 | Transplant Procedures Enterectomy cadaver donor Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44133 | Transplant Procedures Enterectomy live donor Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44135 | Transplant Procedures Intestine transplnt cadaver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44136 | Transplant Procedures Intestine transplant live Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44137 | Transplant Procedures Remove intestinal allograft Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44715 | Transplant Procedures Prepare donor intestine Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44720 | Transplant Procedures Prep donor intestine/venous Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 44721 | Transplant Procedures Prep donor intestine/artery Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47133 | Transplant Procedures Removal of donor liver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47135 | Transplant Procedures Transplantation of liver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47140 | Transplant Procedures Partial removal donor liver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47141 | Transplant Procedures Partial removal donor liver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47142 | Transplant Procedures Partial removal donor liver Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47143 | Transplant Procedures Prep donor liver whole Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47144 | Transplant Procedures Prep donor liver 3-segment Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47145 | Transplant Procedures Prep donor liver lobe split Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47146 | Transplant Procedures Prep donor liver/venous Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 47147 | Transplant Procedures Prep donor liver/arterial Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 48551 | Transplant Procedures Prep donor pancreas Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 48552 | Transplant Procedures Prep donor pancreas/venous Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 48554 | Transplant Procedures Transpl allograft pancreas Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 48556 | Transplant Procedures Removal allograft pancreas Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50300 | Transplant Procedures Remove cadaver donor kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50320 | Transplant Procedures Remove kidney living donor Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50323 | Transplant Procedures Prep cadaver renal allograft Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50325 | Transplant Procedures Prep donor renal graft Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50327 | Transplant Procedures Prep renal graft/venous Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50328 | Transplant Procedures Prep renal graft/arterial Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50329 | Transplant Procedures Prep renal graft/ureteral Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50340 | Transplant Procedures Removal of kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50360 | Transplant Procedures Transplantation of kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50365 | Transplant Procedures Transplantation of kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50370 | Transplant Procedures Remove transplanted kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 50380 | Transplant Procedures Reimplantation of kidney Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54400 | Penile Implant - Cosmetic & Reconstructive Insert semi-rigid prosthesis | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54401 | Penile Implant - Cosmetic & Reconstructive Insert self-contd prosthesis | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54405 | Penile Implant - Cosmetic & Reconstructive Insert Multi-Comp Penis Pros | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54406 | Penile Implant - Cosmetic & Reconstructive Remove Muti-Comp Penis Pros | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54408 | Penile Implant - Cosmetic & Reconstructive Repair Multi-Comp Penis Pros | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54410 | Penile Implant - Cosmetic & Reconstructive Remove/Replace Penis Prosth | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54411 | Penile Implant - Cosmetic & Reconstructive Remov/Replc Penis Pros Comp | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54416 | Penile Implant - Cosmetic & Reconstructive Remv/Repl Penis Contain Pros | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 54417 | Penile Implant - Cosmetic & Reconstructive Remv/Replc Penis Pros Compl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63001 | Spinal Surgeries Remove spine lamina 1/2 crvl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63003 | Spinal Surgeries Remove spine lamina 1/2 thrc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63005 | Spinal Surgeries Remove spine lamina 1/2 lmbr | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63011 | Spinal Surgeries Remove spine lamina 1/2 scrl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63012 | Spinal Surgeries Remove lamina/facets lumbar | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63015 | Spinal Surgeries Remove spine lamina >2 crvcl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63016 | Spinal Surgeries Remove spine lamina >2 thrc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63017 | Spinal Surgeries Remove spine lamina >2 lmbr | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63020 | Spinal Surgeries Neck spine disk surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63030 | Spinal Surgeries Low back disk surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63035 | Spinal Surgeries Spinal disk surgery add-on | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63040 | Spinal Surgeries Laminotomy single cervical | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63042 | Spinal Surgeries Laminotomy single lumbar | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63043 | Spinal Surgeries Laminotomy addl cervical | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63045 | Spinal Surgeries Remove spine lamina 1 crvl | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63046 | Spinal Surgeries Remove spine lamina 1 thrc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63047 | Spinal Surgeries Remove spine lamina 1 lmbr | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63048 | Spinal Surgeries Remove spinal lamina add-on | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63050 | Spinal Surgeries Cervical laminoplsty 2/> seg Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63051 | Spinal Surgeries C-laminoplasty w/graft/plate Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63055 | Spinal Surgeries Decompress spinal cord thrc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63056 | Spinal Surgeries Decompress spinal cord lmbr | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63064 | Spinal Surgeries Decompress spinal cord thrc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63075 | Spinal Surgeries Neck spine disk surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63076 | Spinal Surgeries Neck spine disk surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63077 | Spinal Surgeries Spine disk surgery thorax Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63078 | Spinal Surgeries Spine disk surgery thorax Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63081 | Spinal Surgeries Remove vert body dcmprn crvl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63082 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63085 | Spinal Surgeries Remove vert body dcmprn thrc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63086 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63087 | Spinal Surgeries Remov vertbr dcmprn thrclmbr Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63088 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63090 | Spinal Surgeries Remove vert body dcmprn lmbr Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63091 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63101 | Spinal Surgeries Remove vert body dcmprn thrc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63102 | Spinal Surgeries Remove vert body dcmprn lmbr Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63103 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63170 | Spinal Surgeries Incise spinal cord tract(s) Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63185 | Spinal Surgeries Incise spine nrv half segmnt Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63190 | Spinal Surgeries Incise spine nrv >2 segmnts Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63191 | Spinal Surgeries Incise spine accessory nerve Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63200 | Spinal Surgeries Release spinal cord lumbar Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63250 | Spinal Surgeries Revise spinal cord vsls crvl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63251 | Spinal Surgeries Revise spinal cord vsls thrc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63252 | Spinal Surgeries Revise spine cord vsl thrlmb Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63265 | Spinal Surgeries Excise intraspinl lesion crv | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63270 | Spinal Surgeries Excise intrspinl lesion crvl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63275 | Spinal Surgeries Bx/exc xdrl spine lesn crvl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63280 | Spinal Surgeries Bx/exc idrl spine lesn crvl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63285 | Spinal Surgeries Bx/exc idrl imed lesn cervl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63295 | Spinal Surgeries Repair laminectomy defect Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63300 | Spinal Surgeries Remove vert xdrl body crvcl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63301 | Spinal Surgeries Remove vert xdrl body thrc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63302 | Spinal Surgeries Remove vert xdrl body thrlmb Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63303 | Spinal Surgeries Remov vert xdrl bdy lmbr/sac Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63304 | Spinal Surgeries Remove vert idrl body crvcl Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63305 | Spinal Surgeries Remove vert idrl body thrc Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63306 | Spinal Surgeries Remov vert idrl bdy thrclmbr Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63307 | Spinal Surgeries Remov vert idrl bdy lmbr/sac Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63308 | Spinal Surgeries Remove vertebral body add-on Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63650 | Spinal Stimulator for Pain Management Implant neuroelectrodes | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63655 | Spinal Stimulator for Pain Management Implant neuroelectrodes | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63685 | Spinal Stimulator for Pain Management Insrt/redo spine n generator | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63700 | Nervous System Surgery Repair of spinal herniation Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63702 | Nervous System Surgery Repair of spinal herniation Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63704 | Nervous System Surgery Repair of spinal herniation Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63706 | Nervous System Surgery Repair of spinal herniation Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63707 | Nervous System Surgery Repair spinal fluid leakage Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63709 | Nervous System Surgery Repair spinal fluid leakage Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63710 | Nervous System Surgery Graft repair of spine defect Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 63740 | Nervous System Surgery Install spinal shunt Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 64555 | Nervous System & Orthopedic Procedures Implant neuroelectrodes | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67900 | Cosmetic & Reconstructive Repair brow defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67901 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67902 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67903 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67904 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67906 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67908 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67909 | Cosmetic & Reconstructive Revise eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67911 | Cosmetic & Reconstructive Revise eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67912 | Cosmetic & Reconstructive Correction eyelid w/implant | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67914 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67915 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67916 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67917 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67921 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67922 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67923 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67924 | Cosmetic & Reconstructive Repair eyelid defect | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67950 | Cosmetic & Reconstructive Revision of eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67961 | Cosmetic & Reconstructive Revision of eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 67966 | Cosmetic & Reconstructive Revision of eyelid | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69300 | Otoplasty - Cosmetic & Reconstructive Revise external ear | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69714 | Auditory Implants Implant temple bone w/stimul | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69717 | Auditory Implants Temple bone implant revision | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69799 | Auditory Implants Middle ear surgery procedure | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69930 | Auditory Implants Implant cochlear device | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 69979 | Cochlear Implants and Other Auditory Implants Temporal bone surgery | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 97810 | Chronic Low Back Pain Treatment Acupunct w/o stimul 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 97811 | Chronic Low Back Pain Treatment Acupunct w/o stimul addl 15m | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 97813 | Chronic Low Back Pain Treatment Acupunct w/stimul 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 97814 | Chronic Low Back Pain Treatment Acupunct w/stimul addl 15m | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 99374 | Home Health Nursing & NH Aide Home health care supervision | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| 99509 | Custodial Care Home visit day life activity, 1 hour Licensed caregiver only | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| A0426 | Ambulance Transport Ambulance, ALS-1 non-emergency Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| A0428 | Ambulance Transport Ambulance, BLS non-emergency Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4034 | DMEPOS - PEN Enter Feed Supkit Syr By Day PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4035 | DMEPOS - PEN Enteral Feed Supp Pump Per D PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4036 | DMEPOS - PEN Enteral Feed Sup Kit Grav By PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4081 | DMEPOS - PEN Enteral Ng Tubing w/ Stylet PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4082 | DMEPOS - PEN Enteral Ng Tubing w/o Stylet PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4083 | DMEPOS - PEN Enteral Stomach Tube Levine PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4087 | DMEPOS - PEN Gastro/Jejuno Tube, Std PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4088 | DMEPOS - PEN Gastro/Jejuno Tube, Low-Pro PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4105 | DMEPOS - PEN Enzyme cartridge enteral nut PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4148 | DMEPOS - PEN Enteral feeding supply kit PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4149 | DMEPOS - PEN Ef Blenderized Foods PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4150 | DMEPOS - PEN Ef Complet w/Intact Nutrient PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4152 | DMEPOS - PEN Ef Calorie Dense>/=1.5Kcal PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4153 | DMEPOS - PEN Ef Hydrolyzed/Amino Acids PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4154 | DMEPOS - PEN Ef Spec Metabolic Noninherit PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4155 | DMEPOS - PEN Ef Incomplete/Modular PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4157 | DMEPOS - PEN Ef Special Metabolic Inherit PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4158 | DMEPOS - PEN Ef Ped Complete Intact Nut PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4159 | DMEPOS - PEN Ef Ped Complete Soy Based PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4160 | DMEPOS - PEN Ef Ped Caloric Dense>/=0.7Kc PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4161 | DMEPOS - PEN Ef Ped Hydrolyzed/Amino Acid PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4162 | DMEPOS - PEN Ef Ped Specmetabolic Inherit PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4164 | DMEPOS - PEN Parenteral 50% Dextrose Solu PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4168 | DMEPOS - PEN Parenteral Sol Amino Acid 3. PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4172 | DMEPOS - PEN Parenteral Sol Amino Acid 5. PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4176 | DMEPOS - PEN Parenteral Sol Amino Acid 7- PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4178 | DMEPOS - PEN Parenteral Sol Amino Acid > PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4180 | DMEPOS - PEN Parenteral Sol Carb > 50% PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4185 | DMEPOS - PEN Parenteral Sol 10 Gm Lipids PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4187 | DMEPOS - PEN Omegaven, 10 grams lipids PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4189 | DMEPOS - PEN Parenteral Sol Amino Acid & Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4193 | DMEPOS - PEN Parenteral Sol 52-73 Gm Prot Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4197 | DMEPOS - PEN Parenteral Sol 74-100 Gm Pro Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4199 | DMEPOS - PEN Parenteral Sol > 100Gm Prote Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4216 | DMEPOS - PEN Parenteral Nutrition Additiv PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4220 | DMEPOS - PEN Parenteral Supply Kit Premix PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4222 | DMEPOS - PEN Parenteral Supply Kit Homemi PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B4224 | DMEPOS - PEN Parenteral Administration Ki PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B5000 | DMEPOS - PEN Parenteral Sol Renal-Amirosy PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B5100 | DMEPOS - PEN Parenteral Solution Hepatic PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B5200 | DMEPOS - PEN Parenteral Sol Hepatic Fream PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B9002 | MS DMEPOS - PEN Enter Nutr Inf Pump Any Type PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B9004 | MS DMEPOS - PEN Parenteral Infus Pump Portab Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B9006 | MS DMEPOS - PEN Parenteral Infus Pump Statio Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B9998 | DMEPOS - PEN Enteral Supp Not Otherwise C PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| B9999 | DMEPOS - PEN Parenteral Supp Not Othrws C PEN > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0100 | NU DMEPOS Cane adjust/fixed with tip DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0105 | NU DMEPOS Cane adjust/fixed quad/3 pro DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0110 | NU DMEPOS Crutch forearm pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0111 | NU DMEPOS Crutch forearm each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0112 | NU DMEPOS Crutch underarm pair wood DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0113 | NU DMEPOS Crutch underarm each wood DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0114 | NU DMEPOS Crutch underarm pair no wood DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0116 | NU DMEPOS Crutch underarm each no wood DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0117 | RR DMEPOS Underarm springassist crutch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0130 | NU DMEPOS Walker rigid adjust/fixed ht DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0135 | NU DMEPOS Walker folding adjust/fixed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0140 | RR DMEPOS Walker w trunk support DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0141 | NU DMEPOS Rigid wheeled walker adj/fix DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0143 | NU DMEPOS Walker folding wheeled w/o s DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0144 | RR DMEPOS Enclosed walker w rear seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0147 | NU DMEPOS Walker variable wheel resist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0148 | NU DMEPOS Heavyduty walker no wheels DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0149 | RR DMEPOS Heavy duty wheeled walker DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0150 | DMEPOS Combo walker-transport chair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0153 | NU DMEPOS Forearm crutch platform atta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0154 | NU DMEPOS Walker platform attachment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0155 | NU DMEPOS Walker wheel attachment,pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0156 | NU DMEPOS Walker seat attachment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0157 | NU DMEPOS Walker crutch attachment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0158 | NU DMEPOS Walker leg extenders set of4 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0159 | NU DMEPOS Brake for wheeled walker DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0160 | NU DMEPOS Sitz type bath or equipment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0161 | NU DMEPOS Sitz bath/equipment w/faucet DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0162 | NU DMEPOS Sitz bath chair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0163 | NU DMEPOS Commode chair with fixed arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0165 | RR DMEPOS Commode chair with detacharm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0167 | NU DMEPOS Commode chair pail or pan DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0168 | NU DMEPOS Heavyduty/wide commode chair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0170 | RR DMEPOS Commode chair electric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0171 | RR DMEPOS Commode chair non-electric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0175 | NU DMEPOS Commode chair foot rest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0181 | RR DMEPOS Press pad alternating w/ pum Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0182 | RR DMEPOS Replace pump, alt press pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0183 | RR DMEPOS Powered pres-redu underlay/pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0184 | NU DMEPOS Dry pressure mattress DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0185 | NU DMEPOS Gel pressure mattress pad Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0186 | RR DMEPOS Air pressure mattress Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0187 | RR DMEPOS Water pressure mattress Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0188 | NU DMEPOS Synthetic sheepskin pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0189 | NU DMEPOS Lambswool sheepskin pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0191 | NU DMEPOS Protector heel or elbow DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0193 | RR DMEPOS Powered air flotation bed Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0194 | RR DMEPOS Air fluidized bed Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0196 | RR DMEPOS Gel pressure mattress Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0197 | RR DMEPOS Air pressure pad for mattres Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0198 | RR DMEPOS Water pressure pad for mattr Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0199 | NU DMEPOS Dry pressure pad for mattres DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0200 | NU DMEPOS Heat lamp without stand DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0201 | NU DMEPOS Penile contractur devic manu DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0202 | RR DMEPOS Phototherapy light w/ photom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0205 | NU DMEPOS Heat lamp with stand DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0210 | NU DMEPOS Electric heat pad standard DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0215 | NU DMEPOS Electric heat pad moist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0217 | NU DMEPOS Water circ heat pad w pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0218 | NU DMEPOS Fluid circ cold pad w pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0225 | NU DMEPOS Hydrocollator unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0235 | RR DMEPOS Paraffin bath unit portable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0236 | RR DMEPOS Pump for water circulating p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0239 | NU DMEPOS Hydrocollator unit portable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0249 | NU DMEPOS Pad water circulating heat u DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0250 | RR DMEPOS Hosp bed fixed ht w/ mattres DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0251 | RR DMEPOS Hosp bed fixd ht w/o mattres DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0255 | RR DMEPOS Hospital bed var ht w/ mattr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0256 | RR DMEPOS Hospital bed var ht w/o matt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0260 | RR DMEPOS Hosp bed semi-electr w/ matt Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0261 | RR DMEPOS Hosp bed semi-electr w/o mat Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0265 | RR DMEPOS Hosp bed total electr w/ mat Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0266 | RR DMEPOS Hosp bed total elec w/o matt Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0271 | NU DMEPOS Mattress innerspring DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0272 | NU DMEPOS Mattress foam rubber DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0275 | NU DMEPOS Bed pan standard DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0276 | NU DMEPOS Bed pan fracture DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0277 | RR DMEPOS Powered pres-redu air mattrs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0280 | NU DMEPOS Bed cradle DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0290 | RR DMEPOS Hosp bed fx ht w/o rails w/m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0291 | RR DMEPOS Hosp bed fx ht w/o rail w/o DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0292 | RR DMEPOS Hosp bed var ht no sr w/matt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0293 | RR DMEPOS Hosp bed var ht no sr no mat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0294 | RR DMEPOS Hosp bed semi-elect w/ mattr Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0295 | RR DMEPOS Hosp bed semi-elect w/o matt Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0296 | RR DMEPOS Hosp bed total elect w/ matt Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0297 | RR DMEPOS Hosp bed total elect w/o mat Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0300 | RR DMEPOS Enclosed ped crib hosp grade DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0301 | RR DMEPOS Hd hosp bed, 350-600 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0302 | RR DMEPOS Ex hd hosp bed > 600 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0303 | RR DMEPOS Hosp bed hvy dty xtra wide Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0304 | RR DMEPOS Hosp bed xtra hvy dty x wide Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0305 | RR DMEPOS Rails bed side half length DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0310 | NU DMEPOS Rails bed side full length DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0316 | RR DMEPOS Bed safety enclosure DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0325 | NU DMEPOS Urinal male jug-type DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0326 | NU DMEPOS Urinal female jug-type DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0371 | RR DMEPOS Nonpower mattress overlay DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0372 | RR DMEPOS Powered air mattress overlay Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0373 | RR DMEPOS Nonpowered pressure mattress DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0424 | RR DMEPOS Stationary compressed gas 02 Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0431 | RR DMEPOS Portable gaseous 02 Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0433 | RR DMEPOS Portable liquid oxygen sys Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0434 | RR DMEPOS Portable liquid 02 Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0439 | RR DMEPOS Stationary liquid 02 Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0441 | DMEPOS Stationary o2 contents, gas Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0442 | DMEPOS Stationary o2 contents, liq Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0443 | DMEPOS Portable 02 contents, gas Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0444 | DMEPOS Portable 02 contents, liquid Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0447 | DMEPOS Port o2 cont, liq over 4 lpm Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0462 | RR DMEPOS Rocking bed w/ or w/o side r Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0465 | RR DMEPOS Home vent invasive interface Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0466 | RR DMEPOS Home vent non-invasive inter Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0467 | RR DMEPOS Home vent multi-function Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0468 | RR DMEPOS home vent dual DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0469 | RR DMEPOS Lung expans high oscil neb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0470 | RR DMEPOS Rad w/o backup non-inv intfc Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0471 | RR DMEPOS Rad w/backup non inv intrfc Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0472 | RR DMEPOS Rad w backup invasive intrfc Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0480 | RR DMEPOS Percussor elect/pneum home m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0482 | RR DMEPOS Cough stimulating device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0483 | RR DMEPOS Chest compression gen system Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0484 | NU DMEPOS Non-elec oscillatory pep dvc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0485 | NU DMEPOS Oral device/appliance prefab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0486 | NU DMEPOS Oral device/appliance cusfab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0490 | RR DMEPOS Control unit nm hw remote DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0491 | DMEPOS Oral dv nm mouthpc hw remote DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0500 | RR DMEPOS Ippb all types DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0530 | RR DMEPOS Electronic posa treatment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0550 | RR DMEPOS Humidif extens supple w ippb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0560 | NU DMEPOS Humidifier supplemental w/ i DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0561 | NU DMEPOS Humidifier nonheated w pap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0562 | NU DMEPOS Humidifier heated used w pap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0565 | RR DMEPOS Compressor air power source DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0570 | RR DMEPOS Nebulizer with compression DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0572 | RR DMEPOS Aerosol compressor adjust pr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0574 | RR DMEPOS Ultrasonic generator w svneb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0575 | RR DMEPOS Nebulizer ultrasonic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0580 | NU DMEPOS Nebulizer for use w/ regulat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0585 | RR DMEPOS Nebulizer w/ compressor & he DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0600 | RR DMEPOS Suction pump portab hom modl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0601 | RR DMEPOS Cont airway pressure device Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0602 | NU DMEPOS Manual breast pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0605 | NU DMEPOS Vaporizer room type DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0606 | RR DMEPOS Drainage board postural DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0607 | NU DMEPOS Blood glucose monitor home DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0610 | NU DMEPOS Pacemaker monitr audible/vis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0615 | NU DMEPOS Pacemaker monitr digital/vis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0617 | RR DMEPOS Automatic ext defibrillator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0618 | RR DMEPOS Apnea monitor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0619 | RR DMEPOS Apnea monitor w recorder DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0620 | RR DMEPOS Cap bld skin piercing laser DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0621 | NU DMEPOS Patient lift sling or seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0627 | NU DMEPOS Seat lift mech, electric any DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0629 | NU DMEPOS Seat lift mech, non-electric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0630 | RR DMEPOS Patient lift hydraulic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0635 | RR DMEPOS Patient lift electric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0636 | RR DMEPOS Pt support & positioning sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0639 | RR DMEPOS Moveable patient lift system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0640 | RR DMEPOS Fixed patient lift system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0650 | NU DMEPOS Pneuma compresor non-segment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0651 | NU DMEPOS Pneum compressor segmental DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0652 | NU DMEPOS Pneum compres w/cal pressure DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0655 | NU DMEPOS Pneumatic appliance half arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0656 | RR DMEPOS Segmental pneumatic trunk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0657 | RR DMEPOS Segmental pneumatic chest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0658 | RR DMEPOS Seg pneum comp 2 arm chest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0659 | RR DMEPOS Seg pneum comp head neck che DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0660 | NU DMEPOS Pneumatic appliance full leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0665 | NU DMEPOS Pneumatic appliance full arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0666 | NU DMEPOS Pneumatic appliance half leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0667 | NU DMEPOS Seg pneumatic appl full leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0668 | NU DMEPOS Seg pneumatic appl full arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0669 | NU DMEPOS Seg pneumatic appli half leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0670 | NU DMEPOS Seg pneum int legs/trunk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0671 | NU DMEPOS Pressure pneum appl full leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0672 | NU DMEPOS Pressure pneum appl full arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0673 | NU DMEPOS Pressure pneum appl half leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0675 | RR DMEPOS Pneumatic compression device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0677 | RR DMEPOS Non pneum seq comp trunk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0678 | RR DMEPOS Non pneum seq comp full leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0679 | RR DMEPOS Non pneum seq comp half leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0680 | RR DMEPOS Non pneum comp control cal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0681 | RR DMEPOS Non pneu comp control w/o ca DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0682 | RR DMEPOS Non pneum compress full arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0683 | RR DMEPOS Non pneu peristalic comp pmp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0691 | NU DMEPOS Uvl pnl 2 sq ft or less DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0692 | NU DMEPOS Uvl sys panel 4 ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0693 | NU DMEPOS Uvl sys panel 6 ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0694 | NU DMEPOS Uvl md cabinet sys 6 ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0705 | NU DMEPOS Transfer device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0711 | DMEPOS Ue enclosure restr rom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0720 | NU DMEPOS Tens two lead DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0730 | NU DMEPOS Tens four lead DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0731 | NU DMEPOS Conductive garment for tens/ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0732 | RR DMEPOS Ces system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0733 | RR DMEPOS Trans elec nerv for trigemin DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0734 | RR DMEPOS Ext up limb tremor stim wris DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0735 | RR DMEPOS Non-invasive vagus nerv stim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0736 | RR DMEPOS Transcut tibial nerv stimula DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0738 | RR DMEPOS Tc tibial ns, control ph app DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0739 | RR DMEPOS Tc tibial ns, control ph app DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0740 | RR DMEPOS Non-implant pelv flr e-stim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0743 | RR DMEPOS Ext low ext nerve stimu rls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0744 | RR DMEPOS Neuromuscular stim for scoli DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0745 | RR DMEPOS Neuromuscular stim for shock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0747 | NU DMEPOS Elec osteogen stim not spine DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0748 | NU DMEPOS Elec osteogen stim spinal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0749 | RR DMEPOS Elec osteogen stim implanted DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0760 | NU DMEPOS Osteogen ultrasound stimltor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0762 | RR DMEPOS Trans elec jt stim dev sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0764 | RR DMEPOS Functional neuromuscularstim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0766 | RR DMEPOS Elec Stim Cancer Treatment Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0776 | NU DMEPOS IV pole DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0779 | RR DMEPOS Amb infusion pump mechanical Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0780 | NU DMEPOS Mech amb infusion pump <8hrs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0781 | RR DMEPOS External ambulatory infus pu Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0782 | NU DMEPOS Non-programble infusion pump Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0783 | NU DMEPOS Programmable infusion pump Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0784 | RR DMEPOS Ext amb infusn pump insulin Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0785 | KF DMEPOS Replacement impl pump cathet Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0786 | NU DMEPOS Implantable pump replacement Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0791 | RR DMEPOS Parenteral infusion pump sta Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0840 | NU DMEPOS Tract frame attach headboard DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0849 | RR DMEPOS Cervical pneum trac equip DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0850 | NU DMEPOS Traction stand free standing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0855 | RR DMEPOS Cervical traction equipment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0856 | RR DMEPOS Cervic collar w air bladders DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0860 | NU DMEPOS Tract equip cervical tract DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0870 | NU DMEPOS Tract frame attach footboard DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0880 | NU DMEPOS Trac stand free stand extrem DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0890 | NU DMEPOS Traction frame attach pelvic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0900 | NU DMEPOS Trac stand free stand pelvic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0910 | RR DMEPOS Trapeze bar attached to bed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0911 | RR DMEPOS Hd trapeze bar attach to bed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0912 | RR DMEPOS Hd trapeze bar free standing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0920 | RR DMEPOS Fracture frame attached to b DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0930 | RR DMEPOS Fracture frame free standing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0940 | RR DMEPOS Trapeze bar free standing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0941 | RR DMEPOS Gravity assisted traction de DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0942 | NU DMEPOS Cervical head harness/halter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0944 | NU DMEPOS Pelvic belt/harness/boot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0945 | NU DMEPOS Belt/harness extremity DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0946 | RR DMEPOS Fracture frame dual w cross DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0947 | NU DMEPOS Fracture frame attachmnts pe DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0948 | NU DMEPOS Fracture frame attachmnts ce DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0950 | NU DMEPOS Tray DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0951 | NU DMEPOS Loop heel DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0952 | NU DMEPOS Toe loop/holder, each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0953 | NU DMEPOS W/c Lateral Thigh/Knee Sup DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0954 | NU DMEPOS Foot Box, Any Type Each Foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0955 | RR DMEPOS Cushioned headrest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0956 | NU DMEPOS W/c lateral trunk/hip suppor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0957 | NU DMEPOS W/c medial thigh support DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0958 | RR DMEPOS Whlchr att- conv 1 arm drive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0959 | NU DMEPOS Amputee adapter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0960 | NU DMEPOS W/c shoulder harness/straps DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0961 | NU DMEPOS Wheelchair brake extension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0966 | NU DMEPOS Wheelchair head rest extensi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0967 | NU DMEPOS Man wc rim/projection rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0968 | RR DMEPOS Wheelchair commode seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0969 | NU DMEPOS Wheelchair narrowing device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0971 | NU DMEPOS Wheelchair anti-tipping devi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0973 | NU DMEPOS W/ch access det adj armrest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0974 | NU DMEPOS W/ch access anti-rollback DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0978 | NU DMEPOS W/c acc,saf belt pelv strap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0980 | NU DMEPOS Wheelchair safety vest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0981 | NU DMEPOS Seat upholstery, replacement DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0982 | NU DMEPOS Back upholstery, replacement DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0983 | RR DMEPOS Add pwr joystick DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0984 | RR DMEPOS Add pwr tiller DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0985 | RR DMEPOS W/c seat lift mechanism DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0986 | RR DMEPOS Man w/c push-rim powr system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0988 | RR DMEPOS Lever-activated wheel drive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0990 | NU DMEPOS Wheelchair elevating leg res DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0992 | NU DMEPOS Wheelchair solid seat insert DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0994 | NU DMEPOS Wheelchair arm rest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E0995 | NU DMEPOS Wc calf rest, pad replacemnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1002 | RR DMEPOS Pwr seat tilt Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1003 | RR DMEPOS Pwr seat recline Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1004 | RR DMEPOS Pwr seat recline mech Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1005 | RR DMEPOS Pwr seat recline pwr Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1006 | RR DMEPOS Pwr seat combo w/o shear Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1007 | RR DMEPOS Pwr seat combo w/shear Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1008 | RR DMEPOS Pwr seat combo pwr shear Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1009 | NU DMEPOS Add mech leg elevation DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1010 | RR DMEPOS Add pwr leg elevation Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1011 | NU DMEPOS Ped wc modify width adjustm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1012 | RR DMEPOS Ctr mount pwr elev leg rest Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1014 | RR DMEPOS Reclining back add ped w/c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1015 | NU DMEPOS Shock absorber for man w/c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1016 | NU DMEPOS Shock absorber for power w/c Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1017 | NU DMEPOS Hd shck absrbr for hd man wc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1018 | NU DMEPOS Hd shck absrber for hd powwc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1020 | RR DMEPOS Residual limb support system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1028 | RR DMEPOS W/c manual swingaway DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1029 | RR DMEPOS W/c vent tray fixed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1030 | RR DMEPOS W/c vent tray gimbaled DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1031 | RR DMEPOS Rollabout chair with casters DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1032 | RR DMEPOS Wheelchair joystick drive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1033 | RR DMEPOS Wheelchair hardware headrest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1034 | RR DMEPOS Wheelchair trunk hip support DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1035 | RR DMEPOS Patient transfer system <300 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1036 | RR DMEPOS Patient transfer system >300 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1037 | RR DMEPOS Transport chair, ped size DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1038 | RR DMEPOS Transport chair pt wt<=300lb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1039 | RR DMEPOS Transport chair pt wt >300lb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1050 | RR DMEPOS Whelchr fxd full length arms DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1060 | RR DMEPOS Wheelchair detachable arms DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1070 | RR DMEPOS Wheelchair detachable foot r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1083 | RR DMEPOS Hemi-wheelchair fixed arms DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1084 | RR DMEPOS Hemi-wheelchair detachable a DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1087 | RR DMEPOS Wheelchair lightwt fixed arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1088 | RR DMEPOS Wheelchair lightweight det a DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1092 | RR DMEPOS Wheelchair wide w/ leg rests DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1093 | RR DMEPOS Wheelchair wide w/ foot rest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1100 | RR DMEPOS Whchr s-recl fxd arm leg res DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1110 | RR DMEPOS Wheelchair semi-recl detach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1150 | RR DMEPOS Wheelchair standard w/ leg r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1160 | RR DMEPOS Wheelchair fixed arms DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1161 | RR DMEPOS Manual adult wc w tiltinspac DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1170 | RR DMEPOS Whlchr ampu fxd arm leg rest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1171 | RR DMEPOS Wheelchair amputee w/o leg r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1172 | RR DMEPOS Wheelchair amputee detach ar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1180 | RR DMEPOS Wheelchair amputee w/ foot r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1190 | RR DMEPOS Wheelchair amputee w/ leg re DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1195 | RR DMEPOS Wheelchair amputee heavy dut DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1200 | RR DMEPOS Wheelchair amputee fixed arm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1221 | RR DMEPOS Wheelchair spec size w foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1222 | RR DMEPOS Wheelchair spec size w/ leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1223 | RR DMEPOS Wheelchair spec size w foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1224 | RR DMEPOS Wheelchair spec size w/ leg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1225 | RR DMEPOS Manual semi-reclining back DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1226 | NU DMEPOS Manual fully reclining back DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1230 | NU DMEPOS Power operated vehicle Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1231 | NU DMEPOS Rigid ped w/c tilt-in-space DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1232 | RR DMEPOS Folding ped wc tilt-in-space DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1233 | RR DMEPOS Rig ped wc tltnspc w/o seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1234 | RR DMEPOS Fld ped wc tltnspc w/o seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1235 | RR DMEPOS Rigid ped wc adjustable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1236 | RR DMEPOS Folding ped wc adjustable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1237 | RR DMEPOS Rgd ped wc adjstabl w/o seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1238 | RR DMEPOS Fld ped wc adjstabl w/o seat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1240 | RR DMEPOS Whchr litwt det arm leg rest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1270 | RR DMEPOS Wheelchair lightweight leg r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1280 | RR DMEPOS Whchr h-duty det arm leg res DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1295 | RR DMEPOS Wheelchair heavy duty fixed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1310 | NU DMEPOS Whirlpool non-portable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1353 | DMEPOS Oxygen supplies regulator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1355 | DMEPOS Oxygen supplies stand/rack DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1372 | NU DMEPOS Oxy suppl heater for nebuliz DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1390 | RR DMEPOS Oxygen concentrator Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1391 | RR DMEPOS Oxygen concentrator, dual Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1392 | RR DMEPOS Portable oxygen concentrator Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1405 | RR DMEPOS O2/water vapor enrich w/heat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1406 | RR DMEPOS O2/water vapor enrich w/o he DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1700 | RR DMEPOS Jaw motion rehab system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1701 | DMEPOS Repl cushions for jaw motion DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1702 | DMEPOS Repl measr scales jaw motion DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1800 | RR DMEPOS Adjust elbow ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1801 | RR DMEPOS Sps elbow device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1802 | RR DMEPOS Adjst forearm pro/sup device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1803 | RR DMEPOS Adjust elbow extension dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1804 | RR DMEPOS Adjust elbow flexion dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1805 | RR DMEPOS Adjust wrist ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1806 | RR DMEPOS Sps wrist device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1807 | RR DMEPOS Adjust wrist extension dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1808 | RR DMEPOS Adjust elbow flexion dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1810 | RR DMEPOS Adjust knee ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1811 | RR DMEPOS Sps knee device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1812 | RR DMEPOS Knee ext/flex w act res ctrl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1813 | RR DMEPOS Adjust knee extension device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1814 | RR DMEPOS Adjust knee flexion device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1815 | RR DMEPOS Adjust ankle ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1816 | RR DMEPOS Sps ankle device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1818 | RR DMEPOS Sps forearm device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1820 | NU DMEPOS Soft interface material DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1821 | NU DMEPOS Replacement interface spsd DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1822 | RR DMEPOS Adjust ankle extension dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1823 | RR DMEPOS Adjust ankle flexion device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1825 | RR DMEPOS Adjust finger ext/flex devc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1826 | RR DMEPOS Adjust finger extension dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1827 | RR DMEPOS Adjust finger flexion device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1828 | RR DMEPOS Adjust toe extension device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1829 | RR DMEPOS Adjust toe flexion device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1830 | RR DMEPOS Adjust toe ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1831 | RR DMEPOS Static str toe dev ext/flex DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1832 | RR DMEPOS Sps finger device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1840 | RR DMEPOS Adj shoulder ext/flex device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1841 | RR DMEPOS Static str shldr dev rom adj DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E1905 | RR DMEPOS Vr cbt therapy DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2000 | RR DMEPOS Gastric suction pump hme mdl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2001 | RR DMEPOS Suct pum ext urine mgmt sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2100 | NU DMEPOS Bld glucose monitor w voice DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2101 | NU DMEPOS Bld glucose monitor w lance DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2102 | NU DMEPOS Adju cgm receiver/monitor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2103 | NU DMEPOS Non-adju cgm receiver/mon DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2104 | NU DMEPOS Glucose monitor w cartridge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2120 | RR DMEPOS Pulse gen sys tx endolymp fl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2201 | NU DMEPOS Man w/ch acc seat w>=20"<24" DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2202 | NU DMEPOS Seat width 24-27 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2203 | NU DMEPOS Frame depth less than 22 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2204 | NU DMEPOS Frame depth 22 to 25 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2205 | NU DMEPOS Manual wc accessory, handrim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2206 | NU DMEPOS Man wc whl lock comp repl ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2207 | NU DMEPOS Crutch and cane holder DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2208 | NU DMEPOS Cylinder tank carrier DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2209 | NU DMEPOS Arm trough each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2210 | NU DMEPOS Wheelchair bearings DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2211 | NU DMEPOS Pneumatic propulsion tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2212 | NU DMEPOS Pneumatic prop tire tube DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2213 | NU DMEPOS Pneumatic prop tire insert DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2214 | NU DMEPOS Pneumatic caster tire each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2215 | NU DMEPOS Pneumatic caster tire tube DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2216 | NU DMEPOS Foam filled propulsion tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2217 | NU DMEPOS Foam filled caster tire each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2218 | NU DMEPOS Foam propulsion tire each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2219 | NU DMEPOS Foam caster tire any size ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2220 | NU DMEPOS Solid propuls tire, repl, ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2221 | NU DMEPOS Solid caster tire repl, each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2222 | NU DMEPOS Solid caster integ whl, repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2224 | NU DMEPOS Propulsion whl excl tire rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2225 | NU DMEPOS Caster wheel excludes tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2226 | NU DMEPOS Caster fork replacement only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2227 | RR DMEPOS Gear reduction drive wheel DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2228 | RR DMEPOS Mwc acc, wheelchair brake DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2231 | NU DMEPOS Solid seat support base DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2298 | RR DMEPOS Pwr seat elev sys for crt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2310 | RR DMEPOS Electro connect btw control DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2311 | RR DMEPOS Electro connect btw 2 sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2312 | RR DMEPOS Mini-prop remote joystick DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2313 | RR DMEPOS Pwc harness, expand control DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2321 | RR DMEPOS Hand interface joystick DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2322 | RR DMEPOS Mult mech switches DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2323 | NU DMEPOS Special joystick handle DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2324 | NU DMEPOS Chin cup interface DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2325 | RR DMEPOS Sip and puff interface DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2326 | RR DMEPOS Breath tube kit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2327 | RR DMEPOS Head control interface mech DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2328 | RR DMEPOS Head/extremity control inter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2329 | RR DMEPOS Head control nonproportional DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2330 | RR DMEPOS Head control proximity switc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2340 | NU DMEPOS W/c wdth 20-23 in seat frame DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2341 | NU DMEPOS W/c wdth 24-27 in seat frame DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2342 | NU DMEPOS W/c dpth 20-21 in seat frame DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2343 | NU DMEPOS W/c dpth 22-25 in seat frame DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2351 | NU DMEPOS Electronic sgd interface DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2359 | NU DMEPOS Gr34 sealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2360 | NU DMEPOS 22nf nonsealed leadacid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2361 | NU DMEPOS 22nf sealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2362 | NU DMEPOS Gr24 nonsealed leadacid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2363 | NU DMEPOS Gr24 sealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2364 | NU DMEPOS U1nonsealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2365 | NU DMEPOS U1 sealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2366 | NU DMEPOS Battery charger, single mode DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2367 | NU DMEPOS Battery charger, dual mode DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2368 | RR DMEPOS Pwr wc drivewheel motor repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2369 | RR DMEPOS Pwr wc drivewheel gear repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2370 | RR DMEPOS Pwr wc dr wh motor/gear comb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2371 | NU DMEPOS Gr27 sealed leadacid battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2372 | NU DMEPOS Gr27 non-sealed leadacid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2373 | RR DMEPOS Hand/chin ctrl spec joystick DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2374 | RR DMEPOS Hand/chin ctrl std joystick DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2375 | RR DMEPOS Non-expandable controller DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2376 | RR DMEPOS Expandable controller, repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2377 | RR DMEPOS Expandable controller, initl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2378 | RR DMEPOS Pw actuator replacement DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2381 | NU DMEPOS Pneum drive wheel tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2382 | NU DMEPOS Tube, pneum wheel drive tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2383 | NU DMEPOS Insert, pneum wheel drive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2384 | NU DMEPOS Pneumatic caster tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2385 | NU DMEPOS Tube, pneumatic caster tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2386 | NU DMEPOS Foam filled drive wheel tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2387 | NU DMEPOS Foam filled caster tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2388 | NU DMEPOS Foam drive wheel tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2389 | NU DMEPOS Foam caster tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2390 | NU DMEPOS Solid drive wheel tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2391 | NU DMEPOS Solid caster tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2392 | NU DMEPOS Solid caster tire, integrate DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2394 | NU DMEPOS Drive wheel excludes tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2395 | NU DMEPOS Caster wheel excludes tire DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2396 | NU DMEPOS Caster fork DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2397 | NU DMEPOS Pwc acc, lith-based battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2398 | NU DMEPOS Wc dynamic pos back hardware DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2402 | RR DMEPOS Neg press wound therapy pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2500 | NU DMEPOS Sgd digitized pre-rec <=8min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2502 | NU DMEPOS Sgd prerec msg >8min <=20min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2504 | NU DMEPOS Sgd prerec msg>20min <=40min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2506 | NU DMEPOS Sgd prerec msg > 40 min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2508 | NU DMEPOS Sgd spelling phys contact DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2510 | NU DMEPOS Sgd w multi methods msg/accs DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2511 | NU DMEPOS Sgd sftwre prgrm for pc/pda DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2512 | NU DMEPOS Sgd accessory, mounting sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2513 | NU DMEPOS Sgd accessory, emg sensor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2601 | NU DMEPOS Gen w/c cushion wdth < 22 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2602 | NU DMEPOS Gen w/c cushion wdth >=22 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2603 | NU DMEPOS Skin protect wc cus wd <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2604 | NU DMEPOS Skin protect wc cus wd>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2605 | NU DMEPOS Position wc cush wdth <22 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2606 | NU DMEPOS Position wc cush wdth>=22 in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2607 | NU DMEPOS Skin pro/pos wc cus wd <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2608 | NU DMEPOS Skin pro/pos wc cus wd>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2611 | NU DMEPOS Gen use back cush wdth <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2612 | NU DMEPOS Gen use back cush wdth>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2613 | NU DMEPOS Position back cush wd <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2614 | NU DMEPOS Position back cush wd>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2615 | NU DMEPOS Pos back post/lat wdth <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2616 | NU DMEPOS Pos back post/lat wdth>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2619 | NU DMEPOS Replace cover w/c seat cush DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2620 | NU DMEPOS Wc planar back cush wd <22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2621 | NU DMEPOS Wc planar back cush wd>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2622 | NU DMEPOS Adj skin pro w/c cus wd<22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2623 | NU DMEPOS Adj skin pro wc cus wd>=22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2624 | NU DMEPOS Adj skin pro/pos cus<22in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2625 | NU DMEPOS Adj skin pro/pos wc cus>=22 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2626 | NU DMEPOS Seo mobile arm sup att to wc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2627 | NU DMEPOS Arm supp att to wc rancho ty DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2628 | NU DMEPOS Mobile arm supports reclinin DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2629 | NU DMEPOS Friction dampening arm supp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2630 | NU DMEPOS Monosuspension arm/hand supp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2631 | NU DMEPOS Elevat proximal arm support DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2632 | NU DMEPOS Offset/lat rocker arm w/ela DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E2633 | NU DMEPOS Mobile arm support supinator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E3000 | RR DMEPOS Speech volume modulation sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| E3200 | RR DMEPOS Gait modul sys, ras, px only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0068 | Home Health Nursing & NH Aide Adm IV infusion drug in home | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0069 | Home Health Nursing & NH Aide Adm SQ infusion drug in home | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0070 | Home Health Nursing & NH Aide Adm of IV chemo drug in home | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0088 | Home Health Nursing & NH Aide Adm IV drug 1st home visit | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0089 | Home Health Nursing & NH Aide Adm SubQ drug 1st home visit | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0090 | Home Health Nursing & NH Aide Adm IV chemo 1st home visit | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0151 | Home Health Therapy PT/OT/ST Hhcp-serv of PT,ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0152 | Home Health Therapy PT/OT/ST Hhcp-serv of OT,ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0153 | Home Health Therapy PT/OT/ST Hhcp-svs of S/L path,ea 15mn | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0155 | Home Health Nursing & NH Aide Hhcp-svs of CSW,ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0156 | Home Health Nursing & NH Aide Hhcp-svs of aide,ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0157 | Home Health Therapy PT/OT/ST Hhc PT assistant ea 15 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0158 | Home Health Therapy PT/OT/ST Hhc OT assistant ea 15 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0159 | Home Health Therapy PT/OT/ST Hhc PT maint ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0160 | Home Health Therapy PT/OT/ST Hhc occup therapy ea 15 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0161 | Home Health Therapy PT/OT/ST Hhc S/L path ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0237 | Home Health Therapy PT/OT/ST Therapeutic procd strg endur | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0299 | Home Health Nursing & NH Aide Hhs/hospice of RN ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0300 | Home Health Nursing & NH Aide Hhs/hospice of LPN ea 15 min | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0341 | Diagnostic & Therapeutic Percutaneous islet celltrans Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0342 | Diagnostic & Therapeutic Laparoscopy islet cell trans Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0343 | Diagnostic & Therapeutic Laparotomy islet cell transp Only Performed Inpatient | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0412 | Diagnostic & Therapeutic Open tx iliac spine uni/bil | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0414 | Diagnostic & Therapeutic Pelvic ring fx treat int fix | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0415 | Diagnostic & Therapeutic Open tx post pelvic fxcture | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| G0454 | Diagnostic & Therapeutic MD document visit by npp | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J0637 | Drugs & Injections Caspofungin acetate inj, 5 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J0695 | Drugs & Injections Ceftolozane & tazobactam inj, 50/25 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J0712 | Drugs & Injections Ceftaroline fosamil inj, 10 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J0878 | Drugs & Injections Daptomycin injection, 1 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J1335 | Drugs & Injections Ertapenem sodium inj, 500 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J1833 | Drugs & Injections Isavuconazonium inj, 1 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J2020 | Drugs & Injections Linezolid injection, 200 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J2186 | Drugs & Injections Meropenem & vaborbactam inj, 20 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J2248 | Drugs & Injections Micafungin sodium inj, 1 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J2407 | Drugs & Injections Oritavancin injection, 10 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J2770 | Drugs & Injections Quinupristin/dalfopristin inj, 500 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J3090 | Drugs & Injections Tedizolid phosphate inj, 1 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J3095 | Drugs & Injections Telavancin injection, 10 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J3243 | Drugs & Injections Tigecycline injection, 1 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| J8499 | Drugs & Injections Posaconazole tab, 100 mg SNF Drug Carve-out | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0001 | RR DMEPOS Standard wheelchair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0002 | RR DMEPOS Stnd hemi (low seat) whlchr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0003 | RR DMEPOS Lightweight wheelchair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0004 | RR DMEPOS High strength ltwt whlchr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0005 | NU DMEPOS Ultralightweight wheelchair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0006 | RR DMEPOS Heavy duty wheelchair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0007 | RR DMEPOS Extra heavy duty wheelchair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0009 | RR DMEPOS Other manual wheelchair/base DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0010 | RR DMEPOS Stnd wt frame power whlchr Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0011 | RR DMEPOS Stnd wt pwr whlchr w control Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0012 | RR DMEPOS Ltwt portbl power whlchr Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0015 | RR DMEPOS Detach non-adj ht armrst rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0017 | NU DMEPOS Detach adjust armrest base DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0018 | NU DMEPOS Detach adjust armrst upper DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0019 | NU DMEPOS Arm pad repl, each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0020 | NU DMEPOS Fixed adjust armrest pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0037 | NU DMEPOS Hi mount flip-up ftrest repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0038 | NU DMEPOS Leg strap each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0039 | NU DMEPOS Leg strap h style each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0040 | NU DMEPOS Adjustable angle footplate DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0041 | NU DMEPOS Large size footplate each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0042 | NU DMEPOS Standard size ftplate rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0043 | NU DMEPOS Ftrst lowr exten tube rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0044 | NU DMEPOS Ftrst upr hanger brac rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0045 | NU DMEPOS Ftrst compl assembly repl ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0046 | NU DMEPOS Elev lgrst lwr exten repl ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0047 | NU DMEPOS Elev legrst upr hangr rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0050 | NU DMEPOS Ratchet assembly replacement DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0051 | NU DMEPOS Cam rel asm ft/legrst rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0052 | NU DMEPOS Swingaway detach ftrest repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0053 | NU DMEPOS Elevate footrest articulate DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0056 | NU DMEPOS Seat ht <17 or >=21 ltwt wc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0065 | NU DMEPOS Spoke protectors DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0069 | NU DMEPOS Rr whl compl sol tire rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0070 | RR DMEPOS Rr whl compl pne tire rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0071 | NU DMEPOS Fr cstr comp pne tire rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0072 | NU DMEPOS Fr cstr semi-pne tire rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0073 | NU DMEPOS Caster pin lock each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0077 | NU DMEPOS Fr cstr asmb sol tire rep ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0098 | NU DMEPOS Drive belt for pwc, repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0105 | NU DMEPOS IV hanger DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0195 | RR DMEPOS Elevating whlchair leg rests DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0455 | RR DMEPOS Pump uninterrupted infusion Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0552 | DMEPOS Sup/ext non-ins inf pump syr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0601 | NU DMEPOS Repl batt silver oxide 1.5 v DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0602 | NU DMEPOS Repl batt silver oxide 3 v DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0603 | NU DMEPOS Repl batt alkaline 1.5 v DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0604 | NU DMEPOS Repl batt lithium 3.6 v DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0605 | NU DMEPOS Repl batt lithium 4.5 v DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0606 | RR DMEPOS Aed garment w elec analysis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0607 | RR DMEPOS Repl batt for aed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0608 | NU DMEPOS Repl garment for aed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0609 | DMEPOS Repl electrode for aed DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0672 | DMEPOS Removable soft interface le DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0730 | RR DMEPOS Ctrl dose inh drug deliv sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0733 | NU DMEPOS 12-24hr sealed lead acid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0738 | RR DMEPOS Portable gas oxygen system Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0739 | DMEPOS Repair/svc dme non-oxygen eq DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0800 | NU DMEPOS Pov group 1 std up to 300lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0801 | NU DMEPOS Pov group 1 hd 301-450 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0802 | NU DMEPOS Pov group 1 vhd 451-600 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0806 | NU DMEPOS Pov group 2 std up to 300lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0807 | NU DMEPOS Pov group 2 hd 301-450 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0808 | NU DMEPOS Pov group 2 vhd 451-600 lbs Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0813 | RR DMEPOS Pwc gp 1 std port seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0814 | RR DMEPOS Pwc gp 1 std port cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0815 | RR DMEPOS Pwc gp 1 std seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0816 | RR DMEPOS Pwc gp 1 std cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0820 | RR DMEPOS Pwc gp 2 std port seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0821 | RR DMEPOS Pwc gp 2 std port cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0822 | RR DMEPOS Pwc gp 2 std seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0823 | RR DMEPOS Pwc gp 2 std cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0824 | RR DMEPOS Pwc gp 2 hd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0825 | RR DMEPOS Pwc gp 2 hd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0826 | RR DMEPOS Pwc gp 2 vhd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0827 | RR DMEPOS Pwc gp vhd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0828 | RR DMEPOS Pwc gp 2 xtra hd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0829 | RR DMEPOS Pwc gp 2 xtra hd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0835 | RR DMEPOS Pwc gp2 std sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0836 | RR DMEPOS Pwc gp2 std sing pow opt cap Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0837 | RR DMEPOS Pwc gp 2 hd sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0838 | RR DMEPOS Pwc gp 2 hd sing pow opt cap Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0839 | RR DMEPOS Pwc gp2 vhd sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0840 | RR DMEPOS Pwc gp2 xhd sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0841 | RR DMEPOS Pwc gp2 std mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0842 | RR DMEPOS Pwc gp2 std mult pow opt cap Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0843 | RR DMEPOS Pwc gp2 hd mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0848 | RR DMEPOS Pwc gp 3 std seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0849 | RR DMEPOS Pwc gp 3 std cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0850 | RR DMEPOS Pwc gp 3 hd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0851 | RR DMEPOS Pwc gp 3 hd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0852 | RR DMEPOS Pwc gp 3 vhd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0853 | RR DMEPOS Pwc gp 3 vhd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0854 | RR DMEPOS Pwc gp 3 xhd seat/back Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0855 | RR DMEPOS Pwc gp 3 xhd cap chair Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0856 | RR DMEPOS Pwc gp3 std sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0857 | RR DMEPOS Pwc gp3 std sing pow opt cap Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0858 | RR DMEPOS Pwc gp3 hd sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0859 | RR DMEPOS Pwc gp3 hd sing pow opt cap Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0860 | RR DMEPOS Pwc gp3 vhd sing pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0861 | RR DMEPOS Pwc gp3 std mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0862 | RR DMEPOS Pwc gp3 hd mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0863 | RR DMEPOS Pwc gp3 vhd mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K0864 | RR DMEPOS Pwc gp3 xhd mult pow opt s/b Always requires Prior Authorization | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| K1007 | DMEPOS Bil hkaf pc s/d micro sensor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0112 | DMEPOS Cranial cervical orthosis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0113 | DMEPOS Cranial cervical torticollis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0120 | DMEPOS Cerv flex n/adj foam pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0130 | DMEPOS Flex thermoplastic collar mo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0140 | DMEPOS Cervical semi-rigid adjustab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0150 | DMEPOS Cerv semi-rig adj molded chn DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0160 | DMEPOS Cerv sr wire occ/man pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0170 | DMEPOS Cervical collar molded to pt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0172 | DMEPOS Cerv col sr foam 2pc pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0174 | DMEPOS Cerv sr 2pc thor ext pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0180 | DMEPOS Cer post col occ/man sup adj DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0190 | DMEPOS Cerv collar supp adj cerv ba DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0200 | DMEPOS Cerv col supp adj bar & thor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0220 | DMEPOS Thor rib belt custom fabrica DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0450 | DMEPOS Tlso flex trunk/thor pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0452 | DMEPOS Tlso flex custom fab thoraci DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0454 | DMEPOS Tlso trnk sj-t9 pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0455 | DMEPOS Tlso flex trnk sj-t9 pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0456 | DMEPOS Tlso flex trnk sj-ss pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0457 | DMEPOS Tlso flex trnk sj-ss pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0458 | DMEPOS Tlso 2mod symphis-xipho pre DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0460 | DMEPOS Tlso 2 shl symphys-stern cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0462 | DMEPOS Tlso 3mod sacro-scap pre DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0464 | DMEPOS Tlso 4mod sacro-scap pre DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0466 | DMEPOS Tlso r fram soft ant pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0467 | DMEPOS Tlso r fram soft pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0468 | DMEPOS Tlso rig fram pelvic pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0469 | DMEPOS Tlso rig fram pelvic pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0470 | DMEPOS Tlso rigid frame pre subclav DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0472 | DMEPOS Tlso rigid frame hyperex pre DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0480 | DMEPOS Tlso rigid plastic custom fa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0482 | DMEPOS Tlso rigid lined custom fab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0484 | DMEPOS Tlso rigid plastic cust fab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0486 | DMEPOS Tlso rigidlined cust fab two DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0488 | DMEPOS Tlso rigid lined pre one pie DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0490 | DMEPOS Tlso rigid plastic pre one DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0491 | DMEPOS Tlso 2 piece rigid shell DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0492 | DMEPOS Tlso 3 piece rigid shell DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0621 | DMEPOS Sio flex pelvic/sacr pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0622 | DMEPOS Sio flex pelvisacral custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0623 | DMEPOS Sio rig pnl pelv/sac pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0624 | DMEPOS Sio panel custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0625 | DMEPOS Lo flex l1-below l5 pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0626 | DMEPOS Lo sag rig pnl stays pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0627 | DMEPOS Lo sag ri an/pos pnl pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0628 | DMEPOS Lso flex no ri stays pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0629 | DMEPOS Lso flex w/rigid stays cust DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0630 | DMEPOS Lso r post pnl sj-t9 pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0631 | DMEPOS Lso sag r an/pos pnl pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0632 | DMEPOS Lso sag rigid frame cust DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0633 | DMEPOS Lso sc r pos/lat pnl pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0634 | DMEPOS Lso flexion control custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0635 | DMEPOS Lso sagit rigid panel prefab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0636 | DMEPOS Lso sagittal rigid panel cus DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0637 | DMEPOS Lso sc r ant/pos pnl pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0638 | DMEPOS Lso sag-coronal panel custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0639 | DMEPOS Lso s/c shell/panel prefab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0640 | DMEPOS Lso s/c shell/panel custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0641 | DMEPOS Lo rig pos pnl l1-l5 pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0642 | DMEPOS Lo sag ri an/pos pnl pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0643 | DMEPOS Lso sag ctr rigi pos pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0648 | DMEPOS Lso sag r an/pos pnl pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0649 | DMEPOS Lso sc r pos/lat pnl pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0650 | DMEPOS Lso sc r ant/pos pnl pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0651 | DMEPOS Lso sag-co shell pnl pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0700 | DMEPOS Ctlso a-p-l control molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0710 | DMEPOS Ctlso a-p-l control w/ inter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0720 | DMEPOS Ctlso a-p-l control custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0810 | DMEPOS Halo cervical into jckt vest DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0820 | DMEPOS Halo cervical into body jack DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0830 | DMEPOS Halo cerv into milwaukee typ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0859 | DMEPOS Mri compatible system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0861 | DMEPOS Halo repl liner/interface DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0970 | DMEPOS Tlso corset front DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0972 | DMEPOS Lso corset front DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0974 | DMEPOS Tlso full corset DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0976 | DMEPOS Lso full corset DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0978 | DMEPOS Axillary crutch extension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0980 | DMEPOS Peroneal straps pair pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0982 | DMEPOS Stocking sup grips 4 pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L0984 | DMEPOS Protect body sock ea pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1000 | DMEPOS Ctlso milwauke initial model DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1001 | DMEPOS Ctlso infant immobilizer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1005 | DMEPOS Tension based scoliosis orth DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1006 | DMEPOS Scoliosis orth sag/ cor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1007 | DMEPOS Scoliosis orth s-c custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1010 | DMEPOS Ctlso axilla sling DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1020 | DMEPOS Kyphosis pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1025 | DMEPOS Kyphosis pad floating DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1030 | DMEPOS Lumbar bolster pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1040 | DMEPOS Lumbar or lumbar rib pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1050 | DMEPOS Sternal pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1060 | DMEPOS Thoracic pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1070 | DMEPOS Trapezius sling DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1080 | DMEPOS Outrigger DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1085 | DMEPOS Outrigger bil w/ vert extens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1090 | DMEPOS Lumbar sling DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1100 | DMEPOS Ring flange plastic/leather DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1110 | DMEPOS Ring flange plas/leather mol DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1120 | DMEPOS Covers for upright each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1200 | DMEPOS Furnsh initial orthosis only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1210 | DMEPOS Lateral thoracic extension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1220 | DMEPOS Anterior thoracic extension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1230 | DMEPOS Milwaukee type superstructur DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1240 | DMEPOS Lumbar derotation pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1250 | DMEPOS Anterior asis pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1260 | DMEPOS Anterior thoracic derotation DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1270 | DMEPOS Abdominal pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1280 | DMEPOS Rib gusset (elastic) each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1290 | DMEPOS Lateral trochanteric pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1300 | DMEPOS Body jacket mold to patient DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1310 | DMEPOS Post-operative body jacket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1600 | DMEPOS Ho flex frejka w/cov pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1610 | DMEPOS Ho frejka cov only pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1620 | DMEPOS Ho flex pavlik harns pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1630 | DMEPOS Abduct control hip semi-flex DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1640 | DMEPOS Pelv band/spread bar thigh c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1650 | DMEPOS Ho abduction hip adjustable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1652 | DMEPOS Ho bi thighcuffs w sprdr bar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1653 | DMEPOS Ho abduction static ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1660 | DMEPOS Ho abduction static plastic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1680 | DMEPOS Pelvic & hip control thigh c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1681 | DMEPOS Ho bilateral hip abduction DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1685 | DMEPOS Post-op hip abduct custom fa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1686 | DMEPOS Ho post-op hip abduction DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1690 | DMEPOS Combination bilateral ho DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1700 | DMEPOS Leg perthes orth toronto typ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1710 | DMEPOS Legg perthes orth newington DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1720 | DMEPOS Legg perthes orthosis trilat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1730 | DMEPOS Legg perthes orth scottish r DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1755 | DMEPOS Legg perthes patten bottom t DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1810 | DMEPOS Ko elastic with joints DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1812 | DMEPOS Ko elastic w/joints pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1820 | DMEPOS Ko elas w/ condyle pads & jo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1821 | DMEPOS Ko elas w/ condyle pads otf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1830 | DMEPOS Ko immob canvas long pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1831 | DMEPOS Knee orth pos locking joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1832 | DMEPOS Ko adj jnt pos r sup pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1833 | DMEPOS Ko adj jnt pos r sup pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1834 | DMEPOS Ko w/0 joint rigid molded to DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1836 | DMEPOS Ko rigid w/o joints pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1840 | DMEPOS Ko derot ant cruciate custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1843 | DMEPOS Ko single upright pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1844 | DMEPOS Ko w/adj jt rot cntrl molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1845 | DMEPOS Ko double upright pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1846 | DMEPOS Ko w adj flex/ext rotat mold DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1847 | DMEPOS Ko dbl upright w/air pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1848 | DMEPOS Ko dbl upright w/air pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1850 | DMEPOS Ko swedish type pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1851 | DMEPOS Ko single upright prefab ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1852 | DMEPOS Ko double upright prefab ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1860 | DMEPOS Ko supracondylar socket mold DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1900 | DMEPOS Afo sprng wir drsflx calf bd DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1902 | DMEPOS Afo ankle gauntlet pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1904 | DMEPOS Afo molded ankle gauntlet DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1906 | DMEPOS Afo multilig ank sup pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1907 | DMEPOS Afo supramalleolar custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1910 | DMEPOS Afo sing bar clasp attach sh DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1920 | DMEPOS Afo sing upright w/ adjust s DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1930 | DMEPOS Afo plastic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1932 | DMEPOS Afo rig ant tib prefab tcf/= DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1933 | DMEPOS Afo rig ant tib tcf/= ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1940 | DMEPOS Afo molded to patient plasti DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1945 | DMEPOS Afo molded plas rig ant tib DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1950 | DMEPOS Afo spiral molded to pt plas DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1951 | DMEPOS Afo spiral prefabricated DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1952 | DMEPOS Afo spiral prefab ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1960 | DMEPOS Afo pos solid ank plastic mo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1970 | DMEPOS Afo plastic molded w/ankle j DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1971 | DMEPOS Afo w/ankle joint, prefab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1980 | DMEPOS Afo sing solid stirrup calf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L1990 | DMEPOS Afo doub solid stirrup calf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2000 | DMEPOS Kafo sing fre stirr thi/calf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2005 | DMEPOS Kafo sng/dbl mechanical act DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2006 | DMEPOS Kaf sng/dbl swg/stn mcpr cus DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2010 | DMEPOS Kafo sng solid stirrup w/o j DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2020 | DMEPOS Kafo dbl solid stirrup band/ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2030 | DMEPOS Kafo dbl solid stirrup w/o j DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2034 | DMEPOS Kafo pla sin up w/wo k/a cus DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2035 | DMEPOS Kafo plastic pediatric size DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2036 | DMEPOS Kafo plas doub free knee mol DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2037 | DMEPOS Kafo plas sing free knee mol DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2038 | DMEPOS Kafo w/o joint multi-axis an DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2040 | DMEPOS Hkafo torsion bil rot straps DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2050 | DMEPOS Hkafo torsion cable hip pelv DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2060 | DMEPOS Hkafo torsion ball bearing j DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2070 | DMEPOS Hkafo torsion unilat rot str DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2080 | DMEPOS Hkafo unilat torsion cable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2090 | DMEPOS Hkafo unilat torsion ball br DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2106 | DMEPOS Afo tib fx cast plaster mold DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2108 | DMEPOS Afo tib fx cast molded to pt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2112 | DMEPOS Afo tibial fracture soft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2114 | DMEPOS Afo tib fx semi-rigid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2116 | DMEPOS Afo tibial fracture rigid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2126 | DMEPOS Kafo fem fx cast thermoplas DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2128 | DMEPOS Kafo fem fx cast molded to p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2132 | DMEPOS Kafo femoral fx cast soft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2134 | DMEPOS Kafo fem fx cast semi-rigid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2136 | DMEPOS Kafo femoral fx cast rigid DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2180 | DMEPOS Plas shoe insert w ank joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2182 | DMEPOS Drop lock knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2184 | DMEPOS Limited motion knee joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2186 | DMEPOS Adj motion knee jnt lerman t DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2188 | DMEPOS Quadrilateral brim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2190 | DMEPOS Waist belt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2192 | DMEPOS Pelvic band & belt thigh fla DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2200 | DMEPOS Limited ankle motion ea jnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2210 | DMEPOS Dorsiflexion assist each joi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2220 | DMEPOS Dorsi & plantar flex ass/res DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2230 | DMEPOS Split flat caliper stirr & p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2232 | DMEPOS Rocker bottom, contact afo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2240 | DMEPOS Round caliper and plate atta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2250 | DMEPOS Foot plate molded stirrup at DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2260 | DMEPOS Reinforced solid stirrup DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2265 | DMEPOS Long tongue stirrup DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2270 | DMEPOS Varus/valgus strap padded/li DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2275 | DMEPOS Plastic mod low ext pad/line DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2280 | DMEPOS Molded inner boot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2300 | DMEPOS Abduction bar jointed adjust DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2310 | DMEPOS Abduction bar-straight DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2320 | DMEPOS Non-molded lacer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2330 | DMEPOS Lacer molded to patient mode DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2335 | DMEPOS Anterior swing band DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2340 | DMEPOS Pre-tibial shell molded to p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2350 | DMEPOS Prosthetic type socket molde DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2360 | DMEPOS Extended steel shank DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2370 | DMEPOS Patten bottom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2375 | DMEPOS Torsion ank & half solid sti DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2380 | DMEPOS Torsion straight knee joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2385 | DMEPOS Straight knee joint heavy du DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2387 | DMEPOS Add le poly knee custom kafo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2390 | DMEPOS Offset knee joint each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2395 | DMEPOS Offset knee joint heavy duty DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2397 | DMEPOS Suspension sleeve lower ext DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2405 | DMEPOS Knee joint drop lock ea jnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2415 | DMEPOS Knee joint cam lock each joi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2425 | DMEPOS Knee disc/dial lock/adj flex DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2430 | DMEPOS Knee jnt ratchet lock ea jnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2492 | DMEPOS Knee lift loop drop lock rin DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2500 | DMEPOS Thi/glut/ischia wgt bearing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2510 | DMEPOS Th/wght bear quad-lat brim m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2520 | DMEPOS Th/wght bear quad-lat brim c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2525 | DMEPOS Th/wght bear nar m-l brim mo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2526 | DMEPOS Th/wght bear nar m-l brim cu DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2530 | DMEPOS Thigh/wght bear lacer non-mo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2540 | DMEPOS Thigh/wght bear lacer molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2550 | DMEPOS Thigh/wght bear high roll cu DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2570 | DMEPOS Hip clevis type 2 posit jnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2580 | DMEPOS Pelvic control pelvic sling DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2600 | DMEPOS Hip clevis/thrust bearing fr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2610 | DMEPOS Hip clevis/thrust bearing lo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2620 | DMEPOS Pelvic control hip heavy dut DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2622 | DMEPOS Hip joint adjustable flexion DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2624 | DMEPOS Hip adj flex ext abduct cont DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2627 | DMEPOS Plastic mold recipro hip & c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2628 | DMEPOS Metal frame recipro hip & ca DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2630 | DMEPOS Pelvic control band & belt u DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2640 | DMEPOS Pelvic control band & belt b DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2650 | DMEPOS Pelv & thor control gluteal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2660 | DMEPOS Thoracic control thoracic ba DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2670 | DMEPOS Thorac cont paraspinal uprig DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2680 | DMEPOS Thorac cont lat support upri DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2750 | DMEPOS Plating chrome/nickel pr bar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2755 | DMEPOS Carbon graphite lamination DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2760 | DMEPOS Extension per extension per DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2768 | DMEPOS Ortho sidebar disconnect DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2780 | DMEPOS Non-corrosive finish DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2785 | DMEPOS Drop lock retainer each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2795 | DMEPOS Knee control full kneecap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2800 | DMEPOS Knee cap medial or lateral p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2810 | DMEPOS Knee control condylar pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2820 | DMEPOS Soft interface below knee se DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2830 | DMEPOS Soft interface above knee se DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2840 | DMEPOS Tibial length sock fx or equ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L2850 | DMEPOS Femoral lgth sock fx or equa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3000 | DMEPOS Ft insert ucb berkeley shell DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3001 | DMEPOS Foot insert remov molded spe DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3002 | DMEPOS Foot insert plastazote or eq DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3003 | DMEPOS Foot insert silicone gel eac DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3010 | DMEPOS Foot longitudinal arch suppo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3020 | DMEPOS Foot longitud/metatarsal sup DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3030 | DMEPOS Foot arch support remov prem DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3031 | DMEPOS Foot lamin/prepreg composite DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3040 | DMEPOS Ft arch suprt premold longit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3050 | DMEPOS Foot arch supp premold metat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3060 | DMEPOS Foot arch supp longitud/meta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3070 | DMEPOS Arch suprt att to sho longit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3080 | DMEPOS Arch supp att to shoe metata DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3090 | DMEPOS Arch supp att to shoe long/m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3100 | DMEPOS Hallus-valgus nt dyn pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3140 | DMEPOS Abduction rotation bar shoe DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3150 | DMEPOS Abduct rotation bar w/o shoe DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3170 | DMEPOS Foot plas heel stabi pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3224 | DMEPOS Woman's shoe oxford brace DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3225 | DMEPOS Man's shoe oxford brace DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3300 | DMEPOS Sho lift taper to metatarsal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3310 | DMEPOS Shoe lift elev heel/sole neo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3330 | DMEPOS Lifts elevation metal extens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3332 | DMEPOS Shoe lifts tapered to one-ha DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3334 | DMEPOS Shoe lifts elevation heel /i DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3340 | DMEPOS Shoe wedge sach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3350 | DMEPOS Shoe heel wedge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3360 | DMEPOS Shoe sole wedge outside sole DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3370 | DMEPOS Shoe sole wedge between sole DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3380 | DMEPOS Shoe clubfoot wedge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3390 | DMEPOS Shoe outflare wedge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3400 | DMEPOS Shoe metatarsal bar wedge ro DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3410 | DMEPOS Shoe metatarsal bar between DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3420 | DMEPOS Full sole/heel wedge btween DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3430 | DMEPOS Sho heel count plast reinfor DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3440 | DMEPOS Heel leather reinforced DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3450 | DMEPOS Shoe heel sach cushion type DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3455 | DMEPOS Shoe heel new leather standa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3460 | DMEPOS Shoe heel new rubber standar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3465 | DMEPOS Shoe heel thomas with wedge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3470 | DMEPOS Shoe heel thomas extend to b DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3480 | DMEPOS Shoe heel pad & depress for DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3500 | DMEPOS Ortho shoe add leather insol DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3510 | DMEPOS Orthopedic shoe add rub insl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3520 | DMEPOS O shoe add felt w leath insl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3530 | DMEPOS Ortho shoe add half sole DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3540 | DMEPOS Ortho shoe add full sole DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3550 | DMEPOS O shoe add standard toe tap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3560 | DMEPOS O shoe add horseshoe toe tap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3570 | DMEPOS O shoe add instep extension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3580 | DMEPOS O shoe add instep velcro clo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3590 | DMEPOS O shoe convert to sof counte DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3595 | DMEPOS Ortho shoe add march bar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3600 | DMEPOS Trans shoe calip plate exist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3610 | DMEPOS Trans shoe caliper plate new DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3620 | DMEPOS Trans shoe solid stirrup exi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3630 | DMEPOS Trans shoe solid stirrup new DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3640 | DMEPOS Shoe dennis browne splint bo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3650 | DMEPOS So 8 abd restraint pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3660 | DMEPOS So 8 ab rstr can/web pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3670 | DMEPOS So acro/clav can web pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3671 | DMEPOS So cap design w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3674 | DMEPOS So airplane w/wo joint cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3675 | DMEPOS So vest canvas/web pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3702 | DMEPOS Eo w/o joints cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3710 | DMEPOS Eo elas w/metal jnts pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3720 | DMEPOS Forearm/arm cuffs free motio DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3730 | DMEPOS Forearm/arm cuffs ext/flex a DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3740 | DMEPOS Cuffs adj lock w/ active con DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3760 | DMEPOS Eo adj jt prefab custom fit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3761 | DMEPOS Eo, adj lock joint prefab ot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3762 | DMEPOS Eo rigid w/o joints pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3763 | DMEPOS Ewho rigid w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3764 | DMEPOS Ewho w/joint(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3765 | DMEPOS Ewhfo rigid w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3766 | DMEPOS Ewhfo w/joint(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3806 | DMEPOS Whfo w/joint(s) custom fab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3807 | DMEPOS Whfo w/o joints pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3808 | DMEPOS Whfo, rigid w/o joints DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3809 | DMEPOS Whfo w/o joints pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3900 | DMEPOS Hinge extension/flex wrist/f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3901 | DMEPOS Hinge ext/flex wrist finger DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3904 | DMEPOS Whfo electric custom fitted DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3905 | DMEPOS Who w/nontorsion jnt(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3906 | DMEPOS Who w/o joints cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3908 | DMEPOS Who cock-up nonmolde pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3912 | DMEPOS Hfo flexion glove pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3913 | DMEPOS Hfo w/o joints cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3915 | DMEPOS Who nontorsion jnts pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3916 | DMEPOS Who nontorsion jnts pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3917 | DMEPOS Metacarp fx orthosis pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3918 | DMEPOS Metacarp fx orthosis pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3919 | DMEPOS Ho w/o joints cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3921 | DMEPOS Hfo w/joint(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3923 | DMEPOS Hfo without joints pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3924 | DMEPOS Hfo without joints pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3925 | DMEPOS Fo pip dip jnt/sprng pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3927 | DMEPOS Fo pip dip no jt spr pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3929 | DMEPOS Hfo nontorsion jnts pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3930 | DMEPOS Hfo nontorsion jnts pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3931 | DMEPOS Whfo nontorsion joint prefab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3933 | DMEPOS Fo w/o joints cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3935 | DMEPOS Fo nontorsion joint cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3956 | DMEPOS Add joint upper ext orthosis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3960 | DMEPOS Sewho airplan desig abdu pos DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3961 | DMEPOS Sewho cap design w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3962 | DMEPOS Sewho erbs palsey design abd DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3967 | DMEPOS Sewho airplane w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3971 | DMEPOS Sewho cap design w/jnt(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3973 | DMEPOS Sewho airplane w/jnt(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3975 | DMEPOS Sewhfo cap design w/o jnt cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3976 | DMEPOS Sewhfo airplane w/o jnts cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3977 | DMEPOS Sewhfo cap desgn w/jnt(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3978 | DMEPOS Sewhfo airplane w/jnt(s) cf DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3980 | DMEPOS Up ext fx orthos humeral nos DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3981 | DMEPOS Ue fx orth shoul cap forearm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3982 | DMEPOS Upper ext fx orthosis rad/ul DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3984 | DMEPOS Upper ext fx orthosis wrist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L3995 | DMEPOS Sock fracture or equal each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4000 | DMEPOS Repl girdle milwaukee orth DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4002 | DMEPOS Replace strap, any orthosis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4010 | DMEPOS Replace trilateral socket br DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4020 | DMEPOS Replace quadlat socket brim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4030 | DMEPOS Replace socket brim cust fit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4040 | DMEPOS Replace molded thigh lacer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4045 | DMEPOS Replace non-molded thigh lac DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4050 | DMEPOS Replace molded calf lacer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4055 | DMEPOS Replace non-molded calf lace DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4060 | DMEPOS Replace high roll cuff DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4070 | DMEPOS Replace prox & dist upright DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4080 | DMEPOS Repl met band kafo-afo prox DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4090 | DMEPOS Repl met band kafo-afo calf/ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4100 | DMEPOS Repl leath cuff kafo prox th DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4110 | DMEPOS Repl leath cuff kafo-afo cal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4130 | DMEPOS Replace pretibial shell DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4205 | DMEPOS Ortho dvc repair per 15 min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4350 | DMEPOS Ankle control ortho pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4360 | DMEPOS Pneumat walking boot pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4361 | DMEPOS Pneuma/vac walk boot pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4370 | DMEPOS Pneum full leg splnt pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4387 | DMEPOS Non-pneum walk boot pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4392 | DMEPOS Replace afo soft interface DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4394 | DMEPOS Replace foot drop spint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4396 | DMEPOS Static or dynami afo pre cst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4397 | DMEPOS Static or dynami afo pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4398 | DMEPOS Foot drop splint pre ots DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L4631 | DMEPOS Afo, walk boot type, cus fab DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5000 | DMEPOS Sho insert w arch toe filler DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5010 | DMEPOS Mold socket ank hgt w/ toe f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5020 | DMEPOS Tibial tubercle hgt w/ toe f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5050 | DMEPOS Ank symes mold sckt sach ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5060 | DMEPOS Symes met fr leath socket ar DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5100 | DMEPOS Molded socket shin sach foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5105 | DMEPOS Plast socket jts/thgh lacer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5150 | DMEPOS Mold sckt ext knee shin sach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5160 | DMEPOS Mold socket bent knee shin s DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5200 | DMEPOS Kne sing axis fric shin sach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5210 | DMEPOS No knee/ankle joints w/ ft b DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5220 | DMEPOS No knee joint with artic ali DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5230 | DMEPOS Fem focal defic constant fri DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5250 | DMEPOS Hip canad sing axi cons fric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5270 | DMEPOS Tilt table locking hip sing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5280 | DMEPOS Hemipelvect canad sing axis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5301 | DMEPOS Bk mold socket sach ft endo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5312 | DMEPOS Knee disart, sach ft, endo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5321 | DMEPOS Ak open end sach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5331 | DMEPOS Hip disart canadian sach ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5341 | DMEPOS Hemipelvectomy canadian sach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5400 | DMEPOS Postop dress & 1 cast chg bk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5410 | DMEPOS Postop dsg bk ea add cast ch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5420 | DMEPOS Postop dsg & 1 cast chg ak/d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5430 | DMEPOS Postop dsg ak ea add cast ch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5450 | DMEPOS Postop app non-wgt bear dsg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5460 | DMEPOS Postop app non-wgt bear dsg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5500 | DMEPOS Init bk ptb plaster direct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5505 | DMEPOS Init ak ischal plstr direct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5510 | DMEPOS Prep bk ptb plaster molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5520 | DMEPOS Perp bk ptb thermopls direct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5530 | DMEPOS Prep bk ptb thermopls molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5535 | DMEPOS Prep bk ptb open end socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5540 | DMEPOS Prep bk ptb laminated socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5560 | DMEPOS Prep ak ischial plast molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5570 | DMEPOS Prep ak ischial direct form DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5580 | DMEPOS Prep ak ischial thermo mold DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5585 | DMEPOS Prep ak ischial open end DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5590 | DMEPOS Prep ak ischial laminated DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5595 | DMEPOS Hip disartic sach thermopls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5600 | DMEPOS Hip disart sach laminat mold DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5610 | DMEPOS Above knee hydracadence DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5611 | DMEPOS Ak 4 bar link w/fric swing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5613 | DMEPOS Ak 4 bar ling w/hydraul swig DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5614 | DMEPOS 4-bar link above knee w/swng DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5615 | DMEPOS Ak 4 bar link hydl swg/stanc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5616 | DMEPOS Ak univ multiplex sys frict DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5617 | DMEPOS Ak/bk self-aligning unit ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5618 | DMEPOS Test socket symes DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5620 | DMEPOS Test socket below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5622 | DMEPOS Test socket knee disarticula DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5624 | DMEPOS Test socket above knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5626 | DMEPOS Test socket hip disarticulat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5628 | DMEPOS Test socket hemipelvectomy DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5629 | DMEPOS Below knee acrylic socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5630 | DMEPOS Syme typ expandabl wall sckt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5631 | DMEPOS Ak/knee disartic acrylic soc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5632 | DMEPOS Symes type ptb brim design s DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5634 | DMEPOS Symes type poster opening so DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5636 | DMEPOS Symes type medial opening so DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5637 | DMEPOS Below knee total contact DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5638 | DMEPOS Below knee leather socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5639 | DMEPOS Below knee wood socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5640 | DMEPOS Knee disarticulat leather so DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5642 | DMEPOS Above knee leather socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5643 | DMEPOS Hip flex inner socket ext fr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5644 | DMEPOS Above knee wood socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5645 | DMEPOS Bk flex inner socket ext fra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5646 | DMEPOS Below knee cushion socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5647 | DMEPOS Below knee suction socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5648 | DMEPOS Above knee cushion socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5649 | DMEPOS Isch containmt/narrow m-l so DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5650 | DMEPOS Tot contact ak/knee disart s DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5651 | DMEPOS Ak flex inner socket ext fra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5652 | DMEPOS Suction susp ak/knee disart DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5653 | DMEPOS Knee disart expand wall sock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5654 | DMEPOS Socket insert symes DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5655 | DMEPOS Socket insert below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5656 | DMEPOS Socket insert knee articulat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5657 | DMEPOS Add low ext man aut vol any DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5658 | DMEPOS Socket insert above knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5661 | DMEPOS Multi-durometer symes DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5665 | DMEPOS Multi-durometer below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5666 | DMEPOS Below knee cuff suspension DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5668 | DMEPOS Bk molded distal cushion DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5670 | DMEPOS Bk molded supracondylar susp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5671 | DMEPOS Bk/ak locking mechanism DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5672 | DMEPOS Bk removable medial brim sus DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5673 | DMEPOS Socket insert w lock mech DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5676 | DMEPOS Bk knee joints single axis p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5677 | DMEPOS Bk knee joints polycentric p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5678 | DMEPOS Bk joint covers pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5679 | DMEPOS Socket insert w/o lock mech DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5680 | DMEPOS Bk thigh lacer non-molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5681 | DMEPOS Intl custm cong/latyp insert DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5682 | DMEPOS Bk thigh lacer glut/ischia m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5683 | DMEPOS Initial custom socket insert DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5684 | DMEPOS Bk fork strap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5685 | DMEPOS Below knee sus/seal sleeve DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5686 | DMEPOS Bk back check DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5688 | DMEPOS Bk waist belt webbing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5690 | DMEPOS Bk waist belt padded and lin DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5692 | DMEPOS Ak pelvic control belt light DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5694 | DMEPOS Ak pelvic control belt pad/l DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5695 | DMEPOS Ak sleeve susp neoprene/equa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5696 | DMEPOS Ak/knee disartic pelvic join DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5697 | DMEPOS Ak/knee disartic pelvic band DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5698 | DMEPOS Ak/knee disartic silesian ba DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5699 | DMEPOS Shoulder harness DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5700 | DMEPOS Replace socket below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5701 | DMEPOS Replace socket above knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5702 | DMEPOS Replace socket hip DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5703 | DMEPOS Symes ankle w/o (sach) foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5704 | DMEPOS Custom shape cover bk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5705 | DMEPOS Custom shape cover ak DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5706 | DMEPOS Custom shape cvr knee disart DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5707 | DMEPOS Custom shape cvr hip disart DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5710 | DMEPOS Kne-shin exo sng axi mnl loc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5711 | DMEPOS Knee-shin exo mnl lock ultra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5712 | DMEPOS Knee-shin exo frict swg & st DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5714 | DMEPOS Knee-shin exo variable frict DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5716 | DMEPOS Knee-shin exo mech stance ph DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5718 | DMEPOS Knee-shin exo frct swg & sta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5722 | DMEPOS Knee-shin pneum swg frct exo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5724 | DMEPOS Knee-shin exo fluid swing ph DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5726 | DMEPOS Knee-shin ext jnts fld swg e DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5728 | DMEPOS Knee-shin fluid swg & stance DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5780 | DMEPOS Knee-shin pneum/hydra pneum DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5781 | DMEPOS Lower limb pros vacuum pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5782 | DMEPOS Hd low limb pros vacuum pump DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5783 | DMEPOS Add low ext mec limb vol sys DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5785 | DMEPOS Exoskeletal bk ultralt mater DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5790 | DMEPOS Exoskeletal ak ultra-light m DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5795 | DMEPOS Exoskel hip ultra-light mate DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5810 | DMEPOS Endoskel knee-shin mnl lock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5811 | DMEPOS Endo knee-shin mnl lck ultra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5812 | DMEPOS Endo knee-shin frct swg & st DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5814 | DMEPOS Endo knee-shin hydral swg ph DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5816 | DMEPOS Endo knee-shin polyc mch sta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5818 | DMEPOS Endo knee-shin frct swg & st DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5822 | DMEPOS Endo knee-shin pneum swg frc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5824 | DMEPOS Endo knee-shin fluid swing p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5826 | DMEPOS Miniature knee joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5827 | DMEPOS Endo knee shin single axis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5828 | DMEPOS Endo knee-shin fluid swg/sta DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5830 | DMEPOS Endo knee-shin pneum/swg pha DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5840 | DMEPOS Multi-axial knee/shin system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5841 | DMEPOS Addition endoskletl knee-shi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5845 | DMEPOS Knee-shin sys stance flexion DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5848 | DMEPOS Knee-shin sys hydraul stance DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5850 | DMEPOS Endo ak/hip knee extens assi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5855 | DMEPOS Mech hip extension assist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5856 | DMEPOS Elec knee-shin swing/stance DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5857 | DMEPOS Elec knee-shin swing only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5858 | DMEPOS Stance phase only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5859 | DMEPOS Knee-shin pro flex/ext cont DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5910 | DMEPOS Endo below knee alignable sy DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5920 | DMEPOS Endo ak/hip alignable system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5925 | DMEPOS Above knee manual lock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5926 | DMEPOS Endoskel posit rotat unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5930 | DMEPOS High activity knee frame DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5940 | DMEPOS Endo bk ultra-light material DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5950 | DMEPOS Endo ak ultra-light material DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5960 | DMEPOS Endo hip ultra-light materia DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5961 | DMEPOS Endo poly hip, pneu/hyd/rot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5962 | DMEPOS Below knee flex cover system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5964 | DMEPOS Above knee flex cover system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5966 | DMEPOS Hip flexible cover system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5968 | DMEPOS Multiaxial ankle w dorsiflex DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5970 | DMEPOS Foot external keel sach foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5971 | DMEPOS Sach foot, replacement DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5972 | DMEPOS Flexible keel foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5973 | DMEPOS Ank-foot sys dors-plant flex DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5974 | DMEPOS Foot single axis ankle/foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5975 | DMEPOS Combo ankle/foot prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5976 | DMEPOS Energy storing foot DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5978 | DMEPOS Ft prosth multiaxial ankl/ft DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5979 | DMEPOS Multi-axial ankle/ft prosth DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5980 | DMEPOS Flex foot system DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5981 | DMEPOS Flex-walk sys low ext prosth DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5982 | DMEPOS Exoskeletal axial rotation u DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5984 | DMEPOS Endoskeletal axial rotation DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5985 | DMEPOS Lwr ext dynamic prosth pylon DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5986 | DMEPOS Multi-axial rotation unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5987 | DMEPOS Shank ft w vert load pylon DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5988 | DMEPOS Vertical shock reducing pylo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5990 | DMEPOS User adjustable heel height DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L5991 | DMEPOS User adjustable heel height DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6000 | DMEPOS Part hand thumb rem DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6010 | DMEPOS Part hand little/ring DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6020 | DMEPOS Part hand no fingers DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6026 | DMEPOS Part hand myo exclu term dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6034 | DMEPOS Part hand finger distal amp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6035 | DMEPOS Prosthetic digit mechanical DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6036 | DMEPOS Prosthetic thumb mechanical DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6038 | DMEPOS Multiax rotation attachment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6039 | DMEPOS Passive custom digit/thumb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6050 | DMEPOS Wrst mld sck flx hng tri pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6055 | DMEPOS Wrst mold sock w/exp interfa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6100 | DMEPOS Elb mold sock flex hinge pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6110 | DMEPOS Elbow mold sock suspension t DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6120 | DMEPOS Elbow mold doub splt soc ste DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6130 | DMEPOS Elbow stump activated lock h DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6200 | DMEPOS Elbow mold outsid lock hinge DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6205 | DMEPOS Elbow molded w/ expand inter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6250 | DMEPOS Elbow inter loc elbow forarm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6300 | DMEPOS Shlder disart int lock elbow DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6310 | DMEPOS Shoulder passive restor comp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6320 | DMEPOS Shoulder passive restor cap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6350 | DMEPOS Thoracic intern lock elbow DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6360 | DMEPOS Thoracic passive restor comp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6370 | DMEPOS Thoracic passive restor cap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6380 | DMEPOS Postop dsg cast chg wrst/elb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6382 | DMEPOS Postop dsg cast chg elb dis/ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6384 | DMEPOS Postop dsg cast chg shlder/t DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6386 | DMEPOS Postop ea cast chg & realign DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6388 | DMEPOS Postop applicat rigid dsg on DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6400 | DMEPOS Below elbow prosth tiss shap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6450 | DMEPOS Elb disart prosth tiss shap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6500 | DMEPOS Above elbow prosth tiss shap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6550 | DMEPOS Shldr disar prosth tiss shap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6570 | DMEPOS Scap thorac prosth tiss shap DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6580 | DMEPOS Wrist/elbow bowden cable mol DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6582 | DMEPOS Wrist/elbow bowden cbl dir f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6584 | DMEPOS Elbow fair lead cable molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6586 | DMEPOS Elbow fair lead cable dir fo DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6588 | DMEPOS Shdr fair lead cable molded DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6590 | DMEPOS Shdr fair lead cable direct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6600 | DMEPOS Polycentric hinge pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6605 | DMEPOS Single pivot hinge pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6610 | DMEPOS Flexible metal hinge pair DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6611 | DMEPOS Additional switch, ext power DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6615 | DMEPOS Disconnect locking wrist uni DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6616 | DMEPOS Disconnect insert locking wr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6620 | DMEPOS Flexion/extension wrist unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6621 | DMEPOS Flex/ext wrist w/wo friction DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6623 | DMEPOS Spring-ass rot wrst w/ latch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6624 | DMEPOS Flex/ext/rotation wrist unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6625 | DMEPOS Rotation wrst w/ cable lock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6628 | DMEPOS Quick disconn hook adapter o DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6629 | DMEPOS Lamination collar w/ couplin DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6630 | DMEPOS Stainless steel any wrist DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6632 | DMEPOS Latex suspension sleeve each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6635 | DMEPOS Lift assist for elbow DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6637 | DMEPOS Nudge control elbow lock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6638 | DMEPOS Elec lock on manual pw elbow DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6640 | DMEPOS Shoulder abduction joint pai DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6641 | DMEPOS Excursion amplifier pulley t DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6642 | DMEPOS Excursion amplifier lever ty DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6645 | DMEPOS Shoulder flexion-abduction j DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6646 | DMEPOS Multipo locking shoulder jnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6647 | DMEPOS Shoulder lock actuator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6648 | DMEPOS Ext pwrd shlder lock/unlock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6650 | DMEPOS Shoulder universal joint DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6655 | DMEPOS Standard control cable extra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6660 | DMEPOS Heavy duty control cable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6665 | DMEPOS Teflon or equal cable lining DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6670 | DMEPOS Hook to hand cable adapter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6672 | DMEPOS Harness chest/shlder saddle DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6675 | DMEPOS Harness figure of 8 sing con DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6676 | DMEPOS Harness figure of 8 dual con DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6677 | DMEPOS Ue triple control harness DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6680 | DMEPOS Test sock wrist disart/bel e DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6682 | DMEPOS Test sock elbw disart/above DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6684 | DMEPOS Test socket shldr disart/tho DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6686 | DMEPOS Suction socket DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6687 | DMEPOS Frame typ socket bel elbow/w DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6688 | DMEPOS Frame typ sock above elb/dis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6689 | DMEPOS Frame typ socket shoulder di DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6690 | DMEPOS Frame typ sock interscap-tho DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6691 | DMEPOS Removable insert each DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6692 | DMEPOS Silicone gel insert or equal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6693 | DMEPOS Lockingelbow forearm cntrbal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6694 | DMEPOS Elbow socket ins use w/lock DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6695 | DMEPOS Elbow socket ins use w/o lck DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6696 | DMEPOS Cus elbo skt in for con/atyp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6697 | DMEPOS Cus elbo skt in not con/atyp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6698 | DMEPOS Below/above elbow lock mech DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6700 | DMEPOS Ue add ext power myoel DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6703 | DMEPOS Term dev, passive hand mitt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6704 | DMEPOS Term dev, sport/rec/work att DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6706 | DMEPOS Term dev mech hook vol open DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6707 | DMEPOS Term dev mech hook vol close DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6708 | DMEPOS Term dev mech hand vol open DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6709 | DMEPOS Term dev mech hand vol close DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6711 | DMEPOS Ped term dev, hook, vol open DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6712 | DMEPOS Ped term dev, hook, vol clos DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6713 | DMEPOS Ped term dev, hand, vol open DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6714 | DMEPOS Ped term dev, hand, vol clos DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6715 | DMEPOS Term device, multi art digit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6721 | DMEPOS Hook/hand, hvy dty, vol open DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6722 | DMEPOS Hook/hand, hvy dty, vol clos DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6805 | DMEPOS Term dev modifier wrist unit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6810 | DMEPOS Term dev precision pinch dev DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6880 | DMEPOS Elec hand ind art digits DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6881 | DMEPOS Term dev auto grasp feature DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6882 | DMEPOS Microprocessor control uplmb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6883 | DMEPOS Replc sockt below e/w disa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6884 | DMEPOS Replc sockt above elbow disa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6885 | DMEPOS Replc sockt shldr dis/interc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6890 | DMEPOS Prefab glove for term device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6895 | DMEPOS Custom glove for term device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6900 | DMEPOS Hand restorat thumb/1 finger DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6905 | DMEPOS Hand restoration multiple fi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6910 | DMEPOS Hand restoration no fingers DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6915 | DMEPOS Hand restoration replacmnt g DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6920 | DMEPOS Wrist disarticul switch ctrl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6925 | DMEPOS Wrist disart myoelectronic c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6930 | DMEPOS Below elbow switch control DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6935 | DMEPOS Below elbow myoelectronic ct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6940 | DMEPOS Elbow disarticulation switch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6945 | DMEPOS Elbow disart myoelectronic c DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6950 | DMEPOS Above elbow switch control DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6955 | DMEPOS Above elbow myoelectronic ct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6960 | DMEPOS Shldr disartic switch contro DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6965 | DMEPOS Shldr disartic myoelectronic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6970 | DMEPOS Interscapular-thor switch ct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L6975 | DMEPOS Interscap-thor myoelectronic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7007 | DMEPOS Adult electric hand DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7008 | DMEPOS Pediatric electric hand DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7009 | DMEPOS Adult electric hook DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7040 | DMEPOS Prehensile actuator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7045 | DMEPOS Pediatric electric hook DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7170 | DMEPOS Electronic elbow hosmer swit DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7180 | DMEPOS Electronic elbow sequential DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7181 | DMEPOS Electronic elbo simultaneous DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7185 | DMEPOS Electron elbow adolescent sw DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7186 | DMEPOS Electron elbow child switch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7190 | DMEPOS Elbow adolescent myoelectron DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7191 | DMEPOS Elbow child myoelectronic ct DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7259 | DMEPOS Electronic wrist rotator any DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7360 | DMEPOS Six volt bat otto bock/eq ea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7362 | DMEPOS Battery chrgr six volt otto DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7364 | DMEPOS Twelve volt battery utah/equ DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7366 | DMEPOS Battery chrgr 12 volt utah/e DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7367 | DMEPOS Replacemnt lithium ionbatter DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7368 | DMEPOS Lithium ion battery charger DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7400 | DMEPOS Add ue prost be/wd, ultlite DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7401 | DMEPOS Add ue prost a/e ultlite mat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7402 | DMEPOS Add ue prost s/d ultlite mat DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7403 | DMEPOS Add ue prost b/e acrylic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7404 | DMEPOS Add ue prost a/e acrylic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7405 | DMEPOS Add ue prost s/d acrylic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7406 | DMEPOS Add to upp extr user adj mec DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7520 | DMEPOS Repair prosthesis per 15 min DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L7700 | DMEPOS Pros soc insert gasket/seal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8000 | DMEPOS Mastectomy bra DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8001 | DMEPOS Breast prosthesis bra & form DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8002 | DMEPOS Brst prsth bra & bilat form DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8015 | DMEPOS Ext breastprosthesis garment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8020 | DMEPOS Mastectomy form DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8030 | DMEPOS Breast prosthes w/o adhesive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8031 | DMEPOS Breast prosthesis w adhesive DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8032 | DMEPOS Reusable nipple prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8035 | DMEPOS Custom breast prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8040 | DMEPOS Nasal prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8041 | DMEPOS Midfacial prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8042 | DMEPOS Orbital prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8043 | DMEPOS Upper facial prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8044 | DMEPOS Hemi-facial prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8045 | DMEPOS Auricular prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8046 | DMEPOS Partial facial prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8047 | DMEPOS Nasal septal prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8300 | DMEPOS Truss single w/ standard pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8310 | DMEPOS Truss double w/ standard pad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8320 | DMEPOS Truss addition to std pad wa DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8330 | DMEPOS Truss add to std pad scrotal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8400 | DMEPOS Sheath below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8410 | DMEPOS Sheath above knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8415 | DMEPOS Sheath upper limb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8417 | DMEPOS Pros sheath/sock w gel cushn DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8420 | DMEPOS Prosthetic sock multi ply bk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8430 | DMEPOS Prosthetic sock multi ply ak DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8435 | DMEPOS Pros sock multi ply upper lm DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8440 | DMEPOS Shrinker below knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8460 | DMEPOS Shrinker above knee DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8465 | DMEPOS Shrinker upper limb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8470 | DMEPOS Pros sock single ply bk DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8480 | DMEPOS Pros sock single ply ak DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8485 | DMEPOS Pros sock single ply upper l DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8500 | DMEPOS Artificial larynx DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8501 | DMEPOS Tracheostomy speaking valve DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8507 | DMEPOS Trach-esoph voice pros pt in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8509 | DMEPOS Trach-esoph voice pros md in DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8510 | DMEPOS Voice amplifier DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8511 | DMEPOS Indwelling trach insert DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8512 | DMEPOS Gel cap for trach voice pros DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8513 | DMEPOS Trach pros cleaning device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8514 | DMEPOS Repl trach puncture dilator DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8515 | DMEPOS Gel cap app device for trach DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8600 | DMEPOS Implant breast silicone/eq DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8603 | DMEPOS Collagen imp urinary 2.5 ml DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8605 | DMEPOS Inj bulking agent anal canal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8606 | DMEPOS Synthetic implnt urinary 1ml DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8607 | DMEPOS Inj vocal cord bulking agent DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8609 | DMEPOS Artificial cornea DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8610 | DMEPOS Ocular implant DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8612 | DMEPOS Aqueous shunt prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8613 | DMEPOS Ossicular implant DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8614 | DMEPOS Cochlear device DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8615 | DMEPOS Coch implant headset replace DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8616 | DMEPOS Coch implant microphone repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8617 | DMEPOS Coch implant trans coil repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8618 | DMEPOS Coch implant tran cable repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8619 | DMEPOS Coch imp ext proc/contr rplc DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8621 | DMEPOS Repl zinc air battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8622 | DMEPOS Repl alkaline battery DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8623 | DMEPOS Lith ion batt cid,non-earlvl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8624 | DMEPOS Lith ion batt cid, ear level DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8625 | DMEPOS Charger coch impl/aoi battry DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8627 | DMEPOS Cid ext speech process repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8628 | DMEPOS Cid ext controller repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8629 | DMEPOS Cid transmit coil and cable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8630 | DMEPOS Metacarpophalangeal implant DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8631 | DMEPOS Mcp joint repl 2 pc or more DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8641 | DMEPOS Metatarsal joint implant DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8642 | DMEPOS Hallux implant DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8658 | DMEPOS Interphalangeal joint spacer DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8659 | DMEPOS Interphalangeal joint repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8670 | DMEPOS Vascular graft, synthetic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8678 | DMEPOS Ext sply implt neurostim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8679 | DMEPOS Imp neurosti pls gn any type DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8681 | DMEPOS Pt prgrm for implt neurostim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8682 | DMEPOS Implt neurostim radiofq rec DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8683 | DMEPOS Radiofq trsmtr for implt neu DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8684 | DMEPOS Radiof trsmtr implt scrl neu DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8689 | DMEPOS External recharg sys intern DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8690 | DMEPOS Aud osseo dev, int/ext comp DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8691 | DMEPOS Aoi snd proc repl excl actua DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8693 | DMEPOS Aud osseo dev, abutment DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8694 | DMEPOS Aoi transducer/actuator repl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8695 | DMEPOS External recharg sys extern DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8696 | DMEPOS Ext antenna phren nerve stim DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8701 | DMEPOS Pow ue rom dev ewh uprt cust DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| L8702 | DMEPOS Pow ue rom dev ewhf uprt cus DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0081 | Diagnostic & Therapeutic Infusion ther other than che | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0477 | DMEPOS Pwr Module Pt Cable Lvad Rpl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0478 | DMEPOS Power adapter, combo vad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0479 | DMEPOS Power module combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0480 | DMEPOS Driver pneumatic vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0481 | DMEPOS Microprcsr cu elec vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0482 | DMEPOS Microprcsr cu combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0483 | DMEPOS Monitor elec vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0484 | DMEPOS Monitor elec or comb vad rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0485 | DMEPOS Monitor cable elec vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0486 | DMEPOS Mon cable elec/pneum vad rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0487 | DMEPOS Leads any type vad, rep only DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0489 | DMEPOS Pwr pck base combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0490 | DMEPOS Emr pwr source elec vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0491 | DMEPOS Emr pwr source combo vad rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0492 | DMEPOS Emr pwr cbl elec vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0493 | DMEPOS Emr pwr cbl combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0494 | DMEPOS Emr hd pmp elec/combo, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0495 | DMEPOS Charger elec/combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0496 | DMEPOS Battery elec/combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0497 | DMEPOS Bat clps elec/comb vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0498 | DMEPOS Holster elec/combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0499 | DMEPOS Belt/vest elec/combo vad rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0500 | DMEPOS Filters elec/combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0501 | DMEPOS Shwr cov elec/combo vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0502 | DMEPOS Mobility cart pneum vad, rep DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0503 | DMEPOS Battery pneum vad replacemnt DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0504 | DMEPOS Pwr adpt pneum vad, rep veh DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q0506 | DMEPOS Lith-ion batt elec/pneum vad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q2026 | DMEPOS Radiesse injection DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4001 | DMEPOS Cast sup body cast plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4002 | DMEPOS Cast sup body cast fiberglas DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4003 | DMEPOS Cast sup shoulder cast plstr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4004 | DMEPOS Cast sup shoulder cast fbrgl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4005 | DMEPOS Cast sup long arm adult plst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4006 | DMEPOS Cast sup long arm adult fbrg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4007 | DMEPOS Cast sup long arm ped plster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4008 | DMEPOS Cast sup long arm ped fbrgls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4009 | DMEPOS Cast sup sht arm adult plstr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4010 | DMEPOS Cast sup sht arm adult fbrgl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4011 | DMEPOS Cast sup sht arm ped plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4012 | DMEPOS Cast sup sht arm ped fbrglas DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4013 | DMEPOS Cast sup gauntlet plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4014 | DMEPOS Cast sup gauntlet fiberglass DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4015 | DMEPOS Cast sup gauntlet ped plster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4016 | DMEPOS Cast sup gauntlet ped fbrgls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4017 | DMEPOS Cast sup lng arm splint plst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4018 | DMEPOS Cast sup lng arm splint fbrg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4019 | DMEPOS Cast sup lng arm splnt ped p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4020 | DMEPOS Cast sup lng arm splnt ped f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4021 | DMEPOS Cast sup sht arm splint plst DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4022 | DMEPOS Cast sup sht arm splint fbrg DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4023 | DMEPOS Cast sup sht arm splnt ped p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4024 | DMEPOS Cast sup sht arm splnt ped f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4025 | DMEPOS Cast sup hip spica plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4026 | DMEPOS Cast sup hip spica fiberglas DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4027 | DMEPOS Cast sup hip spica ped plstr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4028 | DMEPOS Cast sup hip spica ped fbrgl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4029 | DMEPOS Cast sup long leg plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4030 | DMEPOS Cast sup long leg fiberglass DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4031 | DMEPOS Cast sup lng leg ped plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4032 | DMEPOS Cast sup lng leg ped fbrgls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4033 | DMEPOS Cast sup lng leg cylinder pl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4034 | DMEPOS Cast sup lng leg cylinder fb DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4035 | DMEPOS Cast sup lngleg cylndr ped p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4036 | DMEPOS Cast sup lngleg cylndr ped f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4037 | DMEPOS Cast sup shrt leg plaster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4038 | DMEPOS Cast sup shrt leg fiberglass DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4039 | DMEPOS Cast sup shrt leg ped plster DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4040 | DMEPOS Cast sup shrt leg ped fbrgls DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4041 | DMEPOS Cast sup lng leg splnt plstr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4042 | DMEPOS Cast sup lng leg splnt fbrgl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4043 | DMEPOS Cast sup lng leg splnt ped p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4044 | DMEPOS Cast sup lng leg splnt ped f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4045 | DMEPOS Cast sup sht leg splnt plstr DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4046 | DMEPOS Cast sup sht leg splnt fbrgl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4047 | DMEPOS Cast sup sht leg splnt ped p DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4048 | DMEPOS Cast sup sht leg splnt ped f DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4049 | DMEPOS Finger splint, static DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4205 | Drugs & Injections Membrane graft or wrap sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4206 | Drugs & Injections Fluid flow or fluid gf 1 cc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4208 | Drugs & Injections Novafix per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4209 | Drugs & Injections Surgraft per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4211 | Drugs & Injections Amnion bio or axobio sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4212 | Drugs & Injections Allogen, per cc | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4213 | Drugs & Injections Ascent, 0.5 mg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4214 | Drugs & Injections Cellesta cord per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4215 | Drugs & Injections Axolotl ambient, cryo 0.1 mg | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4216 | Drugs & Injections Artacent cord per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4217 | Drugs & Injections Woundfix biowound plus xplus | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4218 | Drugs & Injections Surgicord per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4219 | Drugs & Injections Surgigraft dual per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4220 | Drugs & Injections Bellacell hd, surederm sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4221 | Drugs & Injections Amniowrap2 per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4222 | Drugs & Injections Progenamatrix, per sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| Q4226 | Drugs & Injections Myown harv prep proc sq cm | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2020 | DMEPOS Vision svcs frames purchases DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2100 | DMEPOS Lens spher single plano 4.00 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2101 | DMEPOS Single visn sphere 4.12-7.00 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2102 | DMEPOS Singl visn sphere 7.12-20.00 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2103 | DMEPOS Spherocylindr 4.00d/12-2.00d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2104 | DMEPOS Spherocylindr 4.00d/2.12-4d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2105 | DMEPOS Spherocylinder 4.00d/4.25-6d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2106 | DMEPOS Spherocylinder 4.00d/>6.00d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2107 | DMEPOS Spherocylinder 4.25d/12-2d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2108 | DMEPOS Spherocylinder 4.25d/2.12-4d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2109 | DMEPOS Spherocylinder 4.25d/4.25-6d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2110 | DMEPOS Spherocylinder 4.25d/over 6d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2111 | DMEPOS Spherocylindr 7.25d/.25-2.25 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2112 | DMEPOS Spherocylindr 7.25d/2.25-4d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2113 | DMEPOS Spherocylindr 7.25d/4.25-6d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2114 | DMEPOS Spherocylinder over 12.00d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2115 | DMEPOS Lens lenticular bifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2118 | DMEPOS Lens aniseikonic single DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2121 | DMEPOS Lenticular lens, single DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2200 | DMEPOS Lens spher bifoc plano 4.00d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2201 | DMEPOS Lens sphere bifocal 4.12-7.0 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2202 | DMEPOS Lens sphere bifocal 7.12-20. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2203 | DMEPOS Lens sphcyl bifocal 4.00d/.1 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2204 | DMEPOS Lens sphcy bifocal 4.00d/2.1 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2205 | DMEPOS Lens sphcy bifocal 4.00d/4.2 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2206 | DMEPOS Lens sphcy bifocal 4.00d/ove DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2207 | DMEPOS Lens sphcy bifocal 4.25-7d/. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2208 | DMEPOS Lens sphcy bifocal 4.25-7/2. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2209 | DMEPOS Lens sphcy bifocal 4.25-7/4. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2210 | DMEPOS Lens sphcy bifocal 4.25-7/ov DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2211 | DMEPOS Lens sphcy bifo 7.25-12/.25- DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2212 | DMEPOS Lens sphcyl bifo 7.25-12/2.2 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2213 | DMEPOS Lens sphcyl bifo 7.25-12/4.2 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2214 | DMEPOS Lens sphcyl bifocal over 12. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2215 | DMEPOS Lens lenticular bifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2218 | DMEPOS Lens aniseikonic bifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2219 | DMEPOS Lens bifocal seg width over DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2220 | DMEPOS Lens bifocal add over 3.25d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2221 | DMEPOS Lenticular lens, bifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2300 | DMEPOS Lens sphere trifocal 4.00d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2301 | DMEPOS Lens sphere trifocal 4.12-7. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2302 | DMEPOS Lens sphere trifocal 7.12-20 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2303 | DMEPOS Lens sphcy trifocal 4.0/.12- DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2304 | DMEPOS Lens sphcy trifocal 4.0/2.25 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2305 | DMEPOS Lens sphcy trifocal 4.0/4.25 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2306 | DMEPOS Lens sphcyl trifocal 4.00/>6 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2307 | DMEPOS Lens sphcy trifocal 4.25-7/. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2308 | DMEPOS Lens sphc trifocal 4.25-7/2. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2309 | DMEPOS Lens sphc trifocal 4.25-7/4. DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2310 | DMEPOS Lens sphc trifocal 4.25-7/>6 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2311 | DMEPOS Lens sphc trifo 7.25-12/.25- DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2312 | DMEPOS Lens sphc trifo 7.25-12/2.25 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2313 | DMEPOS Lens sphc trifo 7.25-12/4.25 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2314 | DMEPOS Lens sphcyl trifocal over 12 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2315 | DMEPOS Lens lenticular trifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2318 | DMEPOS Lens aniseikonic trifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2319 | DMEPOS Lens trifocal seg width > 28 DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2320 | DMEPOS Lens trifocal add over 3.25d DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2321 | DMEPOS Lenticular lens, trifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2410 | DMEPOS Lens variab asphericity sing DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2430 | DMEPOS Lens variable asphericity bi DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2500 | DMEPOS Contact lens pmma spherical DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2501 | DMEPOS Cntct lens pmma-toric/prism DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2502 | DMEPOS Contact lens pmma bifocal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2503 | DMEPOS Cntct lens pmma color vision DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2510 | DMEPOS Cntct gas permeable sphericl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2511 | DMEPOS Cntct toric prism ballast DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2512 | DMEPOS Cntct lens gas permbl bifocl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2513 | DMEPOS Contact lens extended wear DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2520 | DMEPOS Contact lens hydrophilic DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2521 | DMEPOS Cntct lens hydrophilic toric DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2522 | DMEPOS Cntct lens hydrophil bifocl DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2523 | DMEPOS Cntct lens hydrophil extend DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2524 | DMEPOS Cntct lens hydrophil photoch DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2530 | DMEPOS Contact lens gas impermeable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2531 | DMEPOS Contact lens gas permeable DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2623 | DMEPOS Plastic eye prosth custom DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2624 | DMEPOS Polishing artifical eye DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2625 | DMEPOS Enlargemnt of eye prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2626 | DMEPOS Reduction of eye prosthesis DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2627 | DMEPOS Scleral cover shell DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2628 | DMEPOS Fabrication & fitting DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2630 | DMEPOS Anter chamber intraocul lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2631 | DMEPOS Iris support intraoclr lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2632 | DMEPOS Post chmbr intraocular lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2700 | DMEPOS Balance lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2710 | DMEPOS Glass/plastic slab off prism DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2715 | DMEPOS Prism lens/es DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2718 | DMEPOS Fresnell prism press-on lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2730 | DMEPOS Special base curve DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2744 | DMEPOS Tint photochromatic lens/es DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2745 | DMEPOS Tint, any color/solid/grad DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2750 | DMEPOS Anti-reflective coating DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2755 | DMEPOS Uv lens/es DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2760 | DMEPOS Scratch resistant coating DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2762 | DMEPOS Polarization, any lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2770 | DMEPOS Occluder lens/es DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2780 | DMEPOS Oversize lens/es DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2782 | DMEPOS Lens, 1.54-1.65 p/1.60-1.79g DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2783 | DMEPOS Lens, >= 1.66 p/>=1.80 g DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2784 | DMEPOS Lens polycarb or equal DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |
| V2786 | DMEPOS Occupational multifocal lens DME > $1000 | 2026-01-01 | 2025-12-10 | 97% | [PDF] 2026 HTA PPO Prior Authorization Code List - HealthTeam Advantage |