Prior authorization request form Form

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4510 www.alamedaalliance.org UM_RECON SURGERY AUTH UPDATE 06/2023 FAXED: XX/XX/XXXX Important Update: Reconstructive Surgery Codes that Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share.
This communication provides an update on reconstructive surgery codes that require prior authorization.
This will affect claims with the date(s) of service starting Saturday, July 1, 2023, and onward. Enclosed with this notice is a code-specific list for reconstructive surgery that shows which codes require prior authorization. The list is also available on the Alliance website at www.alamedaalliance.org/providers/authorizations. Please refer to our website for the most up-to-date information about codes or benefits that require authorization. Please note, for service codes that do not require prior authorization, but are associated with a prior authorization required service, there must be an approved authorization on file for the primary service requiring authorization in order for the associated code(s) to be paid. Associated codes that are not on the prior authorization list will not be paid separately if the primary service was denied or does not have prior authorization. In addition to the codes, our claims system will also validate that claim received match the authorization when authorization is required.
The following items will be validated: • Member name
• Provider NPI • CPT and HCPC coding
• Date(s) of service is within the authorized range • Number of units and/or visits
• Place of service that matches the site of care submitted on the authorization request form
• National Drug Codes (NDCs) approved by the FDA are required on claims submissions. Claims missing and/or without a matching NDC on a claim will be denied. This update has been validated based on current and published billable coding and was confirmed to be covered by the California Department of Health Care Services (DHCS).
Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 15820 REVISION OF LOWER EYELID Alameda Alliance for Health or Delegate 15821 REVISION OF LOWER EYELID Alameda Alliance for Health or Delegate 15822 REVISION OF UPPER EYELID Alameda Alliance for Health or Delegate 15823 REVISION OF UPPER EYELID Alameda Alliance for Health or Delegate 19318 BREAST REDUCTION Alameda Alliance for Health or Delegate 19325 BREAST AUGMENTATION W/IMPLT Alameda Alliance for Health or Delegate 19350 BREAST RECONSTRUCTION Alameda Alliance for Health or Delegate 19357 TISS XPNDR PLMT BRST RCNSTJ Alameda Alliance for Health or Delegate 19361 BRST RCNSTJ LATSMS DRSI FLAP Alameda Alliance for Health or Delegate 19364 BRST RCNSTJ FREE FLAP Alameda Alliance for Health or Delegate 19367 BRST RCNSTJ 1 PDCL TRAM FLAP Alameda Alliance for Health or Delegate 19368 BRST RCNSTJ 1PDCL TRAM ANAST Alameda Alliance for Health or Delegate 19369 BRST RCNSTJ 2 PDCL TRAM FLAP Alameda Alliance for Health or Delegate 19380 REVJ RECONSTRUCTED BREAST Alameda Alliance for Health or Delegate 21740 RECONSTRUCTION OF STERNUM Alameda Alliance for Health or Delegate 21742 REPAIR STERN/NUSS W/O SCOPE Alameda Alliance for Health or Delegate 21743 REPAIR STERNUM/NUSS W/SCOPE Alameda Alliance for Health or Delegate 23470 RECONSTRUCT SHOULDER JOINT Alameda Alliance for Health or Delegate 23472 RECONSTRUCT SHOULDER JOINT Alameda Alliance for Health or Delegate 27130 TOTAL HIP ARTHROPLASTY Alameda Alliance for Health or Delegate 27132 TOTAL HIP ARTHROPLASTY Alameda Alliance for Health or Delegate 27134 REVISE HIP JOINT REPLACEMENT Alameda Alliance for Health or Delegate 27137 REVISE HIP JOINT REPLACEMENT Alameda Alliance for Health or Delegate Alameda Alliance for Health Referral and Prior Authorization (PA) Procedure Codes for Reconstructive Surgery Before services are provided, please check: Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code Questions? Please call the Alliance Provider Services Department at 1.510.747.4510 Reconstructive Surgery Please note: This list does not include all services. Page 1 of 4 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 27138 REVISE HIP JOINT REPLACEMENT Alameda Alliance for Health or Delegate 27418 REPAIR DEGENERATED KNEECAP Alameda Alliance for Health or Delegate 27420 REVISION OF UNSTABLE KNEECAP Alameda Alliance for Health or Delegate 27422 REVISION OF UNSTABLE KNEECAP Alameda Alliance for Health or Delegate 27424 REVISION/REMOVAL OF KNEECAP Alameda Alliance for Health or Delegate 27427 RECONSTRUCTION KNEE Alameda Alliance for Health or Delegate 27428 RECONSTRUCTION KNEE Alameda Alliance for Health or Delegate 27429 RECONSTRUCTION KNEE Alameda Alliance for Health or Delegate 27437 REVISE KNEECAP Alameda Alliance for Health or Delegate 27438 REVISE KNEECAP WITH IMPLANT Alameda Alliance for Health or Delegate 27440 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27441 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27442 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27443 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27445 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27446 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 27447 TOTAL KNEE ARTHROPLASTY Alameda Alliance for Health or Delegate 27486 REVISE/REPLACE KNEE JOINT Alameda Alliance for Health or Delegate 27487 REVISE/REPLACE KNEE JOINT Alameda Alliance for Health or Delegate 27700 REVISION OF ANKLE JOINT Alameda Alliance for Health or Delegate 27702 RECONSTRUCT ANKLE JOINT Alameda Alliance for Health or Delegate 27703 RECONSTRUCTION ANKLE JOINT Alameda Alliance for Health or Delegate 28285 REPAIR OF HAMMERTOE Alameda Alliance for Health or Delegate 28286 REPAIR OF HAMMERTOE Alameda Alliance for Health or Delegate 28313 REPAIR DEFORMITY OF TOE Alameda Alliance for Health or Delegate 28340 RESECT ENLARGED TOE TISSUE Alameda Alliance for Health or Delegate 28341 RESECT ENLARGED TOE Alameda Alliance for Health or Delegate 28344 REPAIR EXTRA TOE(S) Alameda Alliance for Health or Delegate 28345 REPAIR WEBBED TOE(S) Alameda Alliance for Health or Delegate 28360 RECONSTRUCT CLEFT FOOT Alameda Alliance for Health or Delegate Reconstructive Surgery (cont.) Please note: This list does not include all services. Page 2 of 4 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 30400 RECONSTRUCTION OF NOSE Alameda Alliance for Health or Delegate 30410 RECONSTRUCTION OF NOSE Alameda Alliance for Health or Delegate 30420 RECONSTRUCTION OF NOSE Alameda Alliance for Health or Delegate 30430 REVISION OF NOSE Alameda Alliance for Health or Delegate 30435 REVISION OF NOSE Alameda Alliance for Health or Delegate 30450 REVISION OF NOSE Alameda Alliance for Health or Delegate 30460 REVISION OF NOSE Alameda Alliance for Health or Delegate 30462 REVISION OF NOSE Alameda Alliance for Health or Delegate 30520 REPAIR OF NASAL SEPTUM Alameda Alliance for Health or Delegate 37799 VASCULAR SURGERY PROCEDURE Alameda Alliance for Health or Delegate 42140 EXCISION OF UVULA Alameda Alliance for Health or Delegate 42145 REPAIR PALATE PHARYNX/UVULA Alameda Alliance for Health or Delegate 43644 LAP GASTRIC BYPASS/ROUX-EN-Y Alameda Alliance for Health or Delegate 43645 LAP GASTR BYPASS INCL SMLL I Alameda Alliance for Health or Delegate 43659 LAPAROSCOPE PROC STOM Alameda Alliance for Health or Delegate 43775 LAP SLEEVE GASTRECTOMY Alameda Alliance for Health or Delegate 43842 V-BAND GASTROPLASTY Alameda Alliance for Health or Delegate 43843 GASTROPLASTY W/O V-BAND Alameda Alliance for Health or Delegate 43845 GASTROPLASTY DUODENAL SWITCH Alameda Alliance for Health or Delegate 43846 GASTRIC BYPASS FOR OBESITY Alameda Alliance for Health or Delegate 43847 GASTRIC BYPASS INCL SMALL I Alameda Alliance for Health or Delegate 43848 REVISION GASTROPLASTY Alameda Alliance for Health or Delegate 43886 REVISE GASTRIC PORT OPEN Alameda Alliance for Health or Delegate 53410 RECONSTRUCTION OF URETHRA Alameda Alliance for Health or Delegate 53415 RECONSTRUCTION OF URETHRA Alameda Alliance for Health or Delegate 53420 RECONSTRUCT URETHRA STAGE 1 Alameda Alliance for Health or Delegate 53425 RECONSTRUCT URETHRA STAGE 2 Alameda Alliance for Health or Delegate 53430 RECONSTRUCTION OF URETHRA Alameda Alliance for Health or Delegate 53431 RECONSTRUCT URETHRA/BLADDER Alameda Alliance for Health or Delegate 54360 PENIS PLASTIC SURGERY Alameda Alliance for Health or Delegate Reconstructive Surgery (cont.) Please note: This list does not include all services. Page 3 of 4 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 64999 NERVOUS SYSTEM SURGERY Alameda Alliance for Health or Delegate 65770 REVISE CORNEA WITH IMPLANT Alameda Alliance for Health or Delegate 67950 REVISION OF EYELID Alameda Alliance for Health or Delegate 67971 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate 67973 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate 67974 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate 67975 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate Reconstructive Surgery (cont.) Please note: This list does not include all services. Page 4 of 4 UM_RECON SURG PROC CODES REQ PA 04/2023