Prior authorization request form Form

Questions? Please call the Alliance Provider Services Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4540 www.alamedaalliance.org UMGC MCAL PRVDRALERT_PA CODE LIST UPDATE 12/2025 FAXED 12/01/2025 Important Update: New Prior Authorization Code List, and Covered Services Benefits Guide Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update to share with you. The new Covered Services Benefits Guide outlines covered services and prior authorization requirements for the Alliance Group Care, Medi-Cal, and Alameda Alliance Wellness (HMO D-SNP) programs.
The Covered Services Benefits Guide is effective Thursday, January 1, 2026, and available on the Alliance website at www.alamedaalliance.org/providers/authorizations.
Enclosed with this notice is a list of certain Group Care and Medi-Cal codes where PA requirements have changed since the last publication of the code list. For the most comprehensive list of codes and their PA requirements, please review the Covered Services Benefits Guide available online at www.alamedaalliance.org/providers/authorizations. Important: The Covered Services Benefits Guide is reviewed and published regularly. Updates to the guide are announced in Alliance Provider Alerts and published on the Alliance website.
Please Note: For service procedure codes that do not require PA, but are associated with a PA-required service, payment is contingent upon an approved authorization for the primary service requiring authorization. Associated codes not on the list will not be paid separately if the primary service was denied or does not have PA. Reminder: The Alliance will validate all claims against authorizations to ensure appropriate reimbursement. The following items will be validated:
• Member name • Provider NPI • Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding • Date(s) of service is within the authorized range • Number of units and/or visits • Place of service matches the site of care submitted on the authorization request form • National Drug Codes (NDCs) approved by the United States Food and Drug Administration (FDA) are required on claims submissions • Claims missing and/or without a matching NDC on a claim will be denied Thank you for your continued partnership and for providing high quality care to our members and the community.

Service Category HCPCS Code HCPCS Description Home Health G0299 DIR SNS RN HH/HOSPICE SET EA 15 MIN Home Health G0300 DIR SNS LPN HH/HOSPCE SET EA 15 MIN Pharmacy J0139 ADALIMUMAB Pharmacy J0177 AFLIBERCEPT HD Pharmacy J0725 CHORIONIC GONADOTROPIN Pharmacy J1299 ECULIZUMAB Pharmacy J1326 ZOLBETUXIMAB-CLZB (VYLOY) Pharmacy J2351 OCRELIZUMAB, 1 MG AND HYALURONIDASE-OCSQ Pharmacy J3391 ATIDARSAGENE AUTOTEMCEL (LENMELDY) Pharmacy J7172 MARSTACIMAB-HNCQ (HYMPAVZI) Pharmacy J9024 ATEZOLIZUMAB, 5 MG AND HYALURONIDASE-TQJS (TECENTRIQ HYBREZA) Pharmacy J9037 BELANTAMAB MAFODOTIN-BLMF (BLENREP) Pharmacy J9038 NIKTIMVO (AXATILIMAB-CSFR) Pharmacy J9054 BORTEZOMIB (BORUZU) Pharmacy J9161 DENILEUKIN DIFTITOX-CXDL Pharmacy J9174 DOCETAXEL (BEIZRAY) Pharmacy J9275 COSIBELIMAB-IPDL (UNLOXCYT) Pharmacy J9276 ZANIDATAMAB-HRII (ZIIHERA) Pharmacy J9289 NIVOLUMAB, 2 MG AND HYALURONIDASENVHY (OPDIVO QVANTIG) Pharmacy J9341 THIOTEPA (TEPYLUTE) Pharmacy J9342 THIOTEPA, NOT OTHERWISE SPECIFIED Pharmacy J9382 ZENOCUTUZUMAB-ZBCO Pharmacy Q2058 OBECABTAGENE AUTOLEUCEL (AUCATZYL) Referral and Procedure Codes That Require Prior Authorization (PA) 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 Please Note: This list does not include all services. Page 1 of 2 UMGC MCAL PRVDRREF PROC CODES PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Pharmacy Q5098 USTEKINUMAB-SRLF (IMULDOSA) Pharmacy Q5099 USTEKINUMAB-STBA (STEQEYMA) Pharmacy Q5100 USTEKINUMAB-KFCE (YESINTEK) Pharmacy Q5139 ECULIZUMAB-AEEB (BKEMV) Pharmacy Q5140 ADALIMUMAB-FKJP (HULIO) Pharmacy Q5141 ADALIMUMAB-AATY (YUFLYMA) Pharmacy Q5142 ADALIMUMAB-RYVK (SIMLANDI) Pharmacy Q5143 ADALIMUMAB-ADBM (CYLTEZO) Pharmacy Q5144 ADALIMUMAB-AACF (IDACIO) Pharmacy Q5145 ADALIMUMAB-AFZB (ABRILADA) Pharmacy Q5146 TRASTUZUMAB-STRF (HERCESSI) Pharmacy Q5147 AFLIBERCEPT-AYYH (PAVBLU) Pharmacy Q5148 FILGRASTIM-TXID (NYPOZI) Pharmacy Q5149 AFLIBERCEPT-ABZV (ENZEEVU) Pharmacy Q5150 AFLIBERCEPT-MRBB (AHZANTIVE) Pharmacy Q5151 ECULIZUMAB-AAGH (EPYSQLI) Pharmacy Q5152 ECULIZUMAB-AEEB (BKEMV) Pharmacy Q5153 AFLIBERCEPT-YSZY (OPUVIZ) Pharmacy Q9996 USTEKINUMAB-TTWE (PYZCHIVA), SUBCUTANEOUS Pharmacy Q9997 USTEKINUMAB-TTWE (PYZCHIVA), INTRAVENOUS Pharmacy Q9998 USTEKINUMAB-AEKN (SELARSDI) Pharmacy Q9999 USTEKINUMAB-AAUZ (OTULFI) Pharmacy S0122 MENOTROPINS Pharmacy S0126 FOLLITROPIN ALFA Pharmacy S0128 FOLLITROPIN BETA Pharmacy S0132 GANIRELIX ACETATE Please Note: This list does not include all services. Page 2 of 2 UMGC MCAL PRVDRREF PROC CODES PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Audiological Services V5264 EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE Blood Products P9010 BLOOD FOR TRANSFUSION PER UNIT Blood Products P9011 BLOOD SPLIT UNIT Blood Products P9012 CRYOPRECIPITATE EACH UNIT Blood Products P9016 RBCS LEUKOCYTES REDUCED EACH UNIT Blood Products P9017 FFP FRZN WITHIN 8 HRS CLCT EA UNIT Blood Products P9019 PLATELETS EACH UNIT Blood Products P9020 PLATELET RICH PLASMA EACH UNIT Blood Products P9021 RED BLOOD CELLS EACH UNIT Blood Products P9022 RED BLOOD CELLS WASHED EACH UNIT Blood Products P9023 PLASMA POOL MX DONOR FROZEN EA UNIT Blood Products P9031 PLATLTS LEUKOCYTES REDUCED EA UNIT Blood Products P9032 PLATELETS IRRADIATED EACH UNIT Blood Products P9033 PLATLTS LEUKOCYTES RDUC IRRADATD EA Blood Products P9034 PLATELETS PHERESIS EACH UNIT Blood Products P9035 PLATLTS PHERES LEUKOCYTES RDUC EA U Blood Products P9036 PLATELETS PHERESIS IRRADATD EA UNIT Blood Products P9037 PLATLT PHERES LEUKOCYT RDUC IRRADTD Blood Products P9038 RBCS IRRADIATED EACH UNIT Blood Products P9039 RBCS DEGLYCEROLIZED EACH UNIT Blood Products P9040 RBCS LEUKOCYTES RDUC IRRADATD EA U Blood Products P9041 INFUSION ALBUMIN HUMAN 5% 50 ML Blood Products P9043 INFUS PLSMA PROT FRAC HUMN 5% 50 ML Referral and Procedure Codes That No Longer Require Prior Authorization (PA) 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 Please Note: This list does not include all services. Page 1 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Blood Products P9044 PLSMA CRYOPRECIPITATE RDUC EA UNIT Blood Products P9045 INFUSION ALBUMIN HUMAN 5% 250 ML Blood Products P9046 INFUSION ALBUMIN HUMAN 25% 20 ML Blood Products P9047 INFUSION ALBUMIN HUMAN 25% 50 ML Blood Products P9048 INFUS PLSMA PROT FRAC HU 5% 250 ML Blood Products P9050 GRANULOCYTES PHERESIS EACH UNIT Blood Products P9051 WHOLE BLD/RBCS LEUKOCYTES RDUC CMV Blood Products P9052 PLT HLA-MATCHD LEUKOCYTES RDUC EACH Blood Products P9053 PLT PHERES LEUKOCYT RDUC CMV-NEG EA Blood Products P9054 WHOLE BLD/RBCS LEUKOCYTES RDUC FRZN Blood Products P9055 PLT LEUKOCYT RDUC CMV-NEG APH/PHERS Blood Products P9056 WHOLE BLD LEUKOCYTES RDUC IRRADATD Blood Products P9057 RBCS FRZN/DEGLYCEROLIZED/WASHED LEU Blood Products P9058 RBCS LEUKOCYTES RDUC CMV-NEG IRRADA Blood Products P9059 FRESH FRZN PLAS BETWN 8-24 HR CLCT Blood Products P9060 FRESH FRZN PLSMA DONR RETESTED EA U Blood Products P9073 PLATELETS PHERESIS PATHOGEN-REDUCED Blood Products P9100 PATHOGEN TEST FOR PLATELETS Blood Products 36440 BL PUSH TRANSFUSE 2 YR/< Blood Products 36450 BL EXCHANGE/TRANSFUSE NB Blood Products 36455 BL EXCHANGE/TRANSFUSE NON-NB Blood Products 36456 PRTL EXCHANGE TRANSFUSE NB Blood Products 36460 TRANSFUSION SERVICE FETAL Blood Products 86850 RBC ANTIBODY SCREEN Blood Products 86860 RBC ANTIBODY ELUTION Blood Products 86870 RBC ANTIBODY IDENTIFICATION Blood Products 86927 PLASMA FRESH FROZEN Blood Products 86945 BLOOD PRODUCT/IRRADIATION Blood Products 86999 TRANSFUSION PROCEDURE Cardiac Therapy 93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session) Cardiac Therapy 93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session) Please Note: This list does not include all services. Page 2 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Dental Services 170 ANESTH PROCEDURE ON MOUTH Dental Services 172 ANESTH CLEFT PALATE REPAIR Dental Services 174 ANESTH PHARYNGEAL SURGERY Dental Services 176 ANESTH PHARYNGEAL SURGERY Dialysis 36825 ARTERY-VEIN AUTOGRAFT Dialysis 36830 ARTERY-VEIN NONAUTOGRAFT Dialysis 36831 OPEN THROMBECT AV FISTULA Dialysis 36832 AV FISTULA REVISION OPEN Dialysis 36833 AV FISTULA REVISION Dialysis 36835 ARTERY TO VEIN SHUNT Dialysis 36908 STENT PLMT CTR DIALYSIS SEG EEG (Electroencephalogram) 95711 VEEG 2-12 HR UNMONITORED EEG (Electroencephalogram) 95712 VEEG 2-12 HR INTMT MNTR EEG (Electroencephalogram) 95713 VEEG 2-12 HR CONT MNTR EEG (Electroencephalogram) 95714 VEEG EA 12-26 HR UNMNTR EEG (Electroencephalogram) 95715 VEEG EA 12-26HR INTMT MNTR EEG (Electroencephalogram) 95716 VEEG EA 12-26HR CONT MNTR Enteral Formula and Supplies E0776 IV POLE Home Health 99341 HOME VISIT NEW PATIENT Home Health 99342 HOME VISIT NEW PATIENT Home Health 99343 HOME VISIT NEW PATIENT Home Health 99344 HOME VISIT NEW PATIENT Home Health 99345 HOME VISIT NEW PATIENT Home Health 99347 HOME VISIT EST PATIENT Home Health 99348 HOME VISIT EST PATIENT Home Health 99349 HOME VISIT EST PATIENT Home Health 99350 HOME VISIT EST PATIENT Home Health 99501 HOME VISIT POSTNATAL Home Health 99502 HOME VISIT NB CARE Infusion E0776 IV POLE Infusion E0779 AMB INFUS PUMP MECH INFUS 8 HR/> Infusion E0780 AMB INFUS PUMP MECH INFUS < 8 HR Lab 81420 FETAL ANEUPLOIDY Please Note: This list does not include all services. Page 3 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Lab 81507 FETAL ANEUPLOIDY Orthotics L2492 ADD KNEE LIFT LOOP DROP LOCK RING Orthotics L3000 FT INSRT MOLD UCB TYPE BERKLY SHELL Palliative Care 99304 NURSING FACILITY CARE INIT Palliative Care 99305 NURSING FACILITY CARE INIT Palliative Care 99306 NURSING FACILITY CARE INIT Palliative Care 99307 NURSING FAC CARE SUBSEQ Palliative Care 99341 HOME VISIT NEW PATIENT Palliative Care 99342 HOME VISIT NEW PATIENT Palliative Care 99343 HOME VISIT NEW PATIENT Palliative Care 99344 HOME VISIT NEW PATIENT Palliative Care 99345 HOME VISIT NEW PATIENT Palliative Care 99347 HOME VISIT EST PATIENT Palliative Care 99348 HOME VISIT EST PATIENT Palliative Care 99349 HOME VISIT EST PATIENT Palliative Care 99350 HOME VISIT EST PATIENT Palliative Care 99497 ADVNCD CARE PLAN 30 MIN Palliative Care 99498 ADVNCD CARE PLAN ADDL 30 MIN Prosthetics 21243 RECONSTRUCTION OF JAW JOINT Prosthetics C1839 IRIS PROSTHESIS Pulmonary Therapy 94626 Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session) Radiology 70010 CONTRAST X-RAY OF BRAIN Radiology 70015 CONTRAST X-RAY OF BRAIN Radiology 70450 CT HEAD/BRAIN W/O DYE Radiology 70460 CT HEAD/BRAIN W/DYE Radiology 70470 CT HEAD/BRAIN W/O & W/DYE Radiology 70480 CT ORBIT/EAR/FOSSA W/O DYE Radiology 70481 CT ORBIT/EAR/FOSSA W/DYE Radiology 70482 CT ORBIT/EAR/FOSSA W/O&W/DYE Radiology 70486 CT MAXILLOFACIAL W/O DYE Radiology 70487 CT MAXILLOFACIAL W/DYE Radiology 70488 CT MAXILLOFACIAL W/O & W/DYE Please Note: This list does not include all services. Page 4 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 70490 CT SOFT TISSUE NECK W/O DYE Radiology 70491 CT SOFT TISSUE NECK W/DYE Radiology 70492 CT SFT TSUE NCK W/O & W/DYE Radiology 70496 CT ANGIOGRAPHY HEAD Radiology 70498 CT ANGIOGRAPHY NECK Radiology 70554 FMRI BRAIN BY TECH Radiology 70555 FMRI BRAIN BY PHYS/PSYCH Radiology 71250 CT THORAX DX C- Radiology 71260 CT THORAX DX C+ Radiology 71270 CT THORAX DX C-/C+ Radiology 71275 CT ANGIOGRAPHY CHEST Radiology 72125 CT NECK SPINE W/O DYE Radiology 72126 CT NECK SPINE W/DYE Radiology 72127 CT NECK SPINE W/O & W/DYE Radiology 72128 CT CHEST SPINE W/O DYE Radiology 72129 CT CHEST SPINE W/DYE Radiology 72130 CT CHEST SPINE W/O & W/DYE Radiology 72131 CT LUMBAR SPINE W/O DYE Radiology 72132 CT LUMBAR SPINE W/DYE Radiology 72133 CT LUMBAR SPINE W/O & W/DYE Radiology 72191 CT ANGIOGRAPH PELV W/O&W/DYE Radiology 72192 CT PELVIS W/O DYE Radiology 72193 CT PELVIS W/DYE Radiology 72194 CT PELVIS W/O & W/DYE Radiology 73700 CT LOWER EXTREMITY W/O DYE Radiology 73701 CT LOWER EXTREMITY W/DYE Radiology 73702 CT LWR EXTREMITY W/O&W/DYE Radiology 73706 CT ANGIO LWR EXTR W/O&W/DYE Radiology 74150 CT ABDOMEN W/O DYE Radiology 74160 CT ABDOMEN W/DYE Radiology 74170 CT ABDOMEN W/O & W/DYE Radiology 74174 CT ANGIO ABD&PELV W/O&W/DYE Radiology 74175 CT ANGIO ABDOM W/O & W/DYE Please Note: This list does not include all services. Page 5 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 74176 CT ABD & PELVIS W/O CONTRAST Radiology 74177 CT ABD & PELV W/CONTRAST Radiology 74178 CT ABD & PELV 1/> REGNS Radiology 74235 REMOVE ESOPHAGUS OBSTRUCTION Radiology 74283 THER NMA RDCTJ INTUS/OBSTRCJ Radiology 74290 CONTRAST X-RAY GALLBLADDER Radiology 75600 CONTRAST EXAM THORACIC AORTA Radiology 75605 CONTRAST EXAM THORACIC AORTA Radiology 75625 CONTRAST EXAM ABDOMINL AORTA Radiology 75635 CT ANGIO ABDOMINAL ARTERIES Radiology 75901 REMOVE CVA DEVICE OBSTRUCT Radiology 75902 REMOVE CVA LUMEN OBSTRUCT Radiology 75956 XRAY ENDOVASC THOR AO REPR Radiology 75957 XRAY ENDOVASC THOR AO REPR Radiology 75958 XRAY PLACE PROX EXT THOR AO Radiology 75959 XRAY PLACE DIST EXT THOR AO Radiology 75970 VASCULAR BIOPSY Radiology 76380 CAT SCAN FOLLOW-UP STUDY Radiology 77001 FLUOROGUIDE FOR VEIN DEVICE Radiology 77002 NEEDLE LOCALIZATION BY XRAY Radiology 77003 FLUOROGUIDE FOR SPINE INJECT Radiology 77011 CT SCAN FOR LOCALIZATION Radiology 77012 CT SCAN FOR NEEDLE BIOPSY Radiology 77013 CT GUIDE FOR TISSUE ABLATION Radiology 77014 CT SCAN FOR THERAPY GUIDE Radiology 77021 MRI GUIDANCE NDL PLMT RS&I Radiology 77022 MRI GDN PARNCHYMA TISS ABLTJ Radiology 77261 RADIATION THERAPY PLANNING Radiology 77262 RADIATION THERAPY PLANNING Radiology 77263 RADIATION THERAPY PLANNING Radiology 77280 SET RADIATION THERAPY FIELD Radiology 77285 SET RADIATION THERAPY FIELD Radiology 77290 SET RADIATION THERAPY FIELD Please Note: This list does not include all services. Page 6 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 77295 3-D RADIOTHERAPY PLAN Radiology 77299 RADIATION THERAPY PLANNING Radiology 77300 RADIATION THERAPY DOSE PLAN Radiology 77301 RADIOTHERAPY DOSE PLAN IMRT Radiology 77306 TELETHX ISODOSE PLAN SIMPLE Radiology 77307 TELETHX ISODOSE PLAN CPLX Radiology 77316 BRACHYTX ISODOSE PLAN SIMPLE Radiology 77317 BRACHYTX ISODOSE INTERMED Radiology 77318 BRACHYTX ISODOSE COMPLEX Radiology 77321 SPECIAL TELETX PORT PLAN Radiology 77331 SPECIAL RADIATION DOSIMETRY Radiology 77332 RADIATION TREATMENT AID(S) Radiology 77333 RADIATION TREATMENT AID(S) Radiology 77334 RADIATION TREATMENT AID(S) Radiology 77336 RADIATION PHYSICS CONSULT Radiology 77338 DESIGN MLC DEVICE FOR IMRT Radiology 77370 RADIATION PHYSICS CONSULT Radiology 77371 SRS MULTISOURCE Radiology 77372 SRS LINEAR BASED Radiology 77373 SBRT DELIVERY Radiology 77385 NTSTY MODUL RAD TX DLVR SMPL Radiology 77386 NTSTY MODUL RAD TX DLVR CPLX Radiology 77387 GUIDANCE FOR RADJ TX DLVR Radiology 77399 EXTERNAL RADIATION DOSIMETRY Radiology 77401 RADIATION TREATMENT DELIVERY Radiology 77402 RADIATION TREATMENT DELIVERY Radiology 77407 RADIATION TREATMENT DELIVERY Radiology 77412 RADIATION TREATMENT DELIVERY Radiology 77417 RADIOLOGY PORT IMAGES(S) Radiology 77423 NEUTRON BEAM TX COMPLEX Radiology 77424 IO RAD TX DELIVERY BY X-RAY Radiology 77425 IO RAD TX DELIVER BY ELCTRNS Radiology 77427 RADIATION TX MANAGEMENT X5 Please Note: This list does not include all services. Page 7 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 77431 RADIATION THERAPY MANAGEMENT Radiology 77432 STEREOTACTIC RADIATION TRMT Radiology 77435 SBRT MANAGEMENT Radiology 77469 IO RADIATION TX MANAGEMENT Radiology 77470 SPECIAL RADIATION TREATMENT Radiology 77499 RADIATION THERAPY MANAGEMENT Radiology 77520 PROTON TRMT SIMPLE W/O COMP Radiology 77522 PROTON TRMT SIMPLE W/COMP Radiology 77523 PROTON TRMT INTERMEDIATE Radiology 77525 PROTON TREATMENT COMPLEX Radiology 77750 INFUSE RADIOACTIVE MATERIALS Radiology 77761 APPLY INTRCAV RADIAT SIMPLE Radiology 77762 APPLY INTRCAV RADIAT INTERM Radiology 77763 APPLY INTRCAV RADIAT COMPL Radiology 77767 HDR RDNCL SKN SURF BRACHYTX Radiology 77768 HDR RDNCL SKN SURF BRACHYTX Radiology 77770 HDR RDNCL NTRSTL/ICAV BRCHTX Radiology 77771 HDR RDNCL NTRSTL/ICAV BRCHTX Radiology 77772 HDR RDNCL NTRSTL/ICAV BRCHTX Radiology 77778 APPLY INTERSTIT RADIAT COMPL Radiology 77789 APPLY SURF LDR RADIONUCLIDE Radiology 77790 RADIATION HANDLING Radiology 77799 RADIUM/RADIOISOTOPE THERAPY Radiology 78075 ADRENAL CORTEX & MEDULLA IMG Radiology 78099 ENDOCRINE NUCLEAR PROCEDURE Radiology 78102 BONE MARROW IMAGING LTD Radiology 78103 BONE MARROW IMAGING MULT Radiology 78104 BONE MARROW IMAGING BODY Radiology 78201 LIVER IMAGING Radiology 78202 LIVER IMAGING WITH FLOW Radiology 78215 LIVER AND SPLEEN IMAGING Radiology 78216 LIVER & SPLEEN IMAGE/FLOW Radiology 78226 HEPATOBILIARY SYSTEM IMAGING Please Note: This list does not include all services. Page 8 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 78227 HEPATOBIL SYST IMAGE W/DRUG Radiology 78299 GI NUCLEAR PROCEDURE Radiology 78300 BONE IMAGING LIMITED AREA Radiology 78305 BONE IMAGING MULTIPLE AREAS Radiology 78306 BONE IMAGING WHOLE BODY Radiology 78315 BONE IMAGING 3 PHASE Radiology 78399 MUSCULOSKELETAL NUCLEAR EXAM Radiology 78428 CARDIAC SHUNT IMAGING Radiology 78451 HT MUSCLE IMAGE SPECT SING Radiology 78452 HT MUSCLE IMAGE SPECT MULT Radiology 78453 HT MUSCLE IMAGE PLANAR SING Radiology 78454 HT MUSC IMAGE PLANAR MULT Radiology 78466 HEART INFARCT IMAGE Radiology 78468 HEART INFARCT IMAGE (EF) Radiology 78472 GATED HEART PLANAR SINGLE Radiology 78473 GATED HEART MULTIPLE Radiology 78481 HEART FIRST PASS SINGLE Radiology 78483 HEART FIRST PASS MULTIPLE Radiology 78494 HEART IMAGE SPECT Radiology 78496 HEART FIRST PASS ADD-ON Radiology 78499 CARDIOVASCULAR NUCLEAR EXAM Radiology 78579 LUNG VENTILATION IMAGING Radiology 78580 LUNG PERFUSION IMAGING Radiology 78582 LUNG VENTILAT&PERFUS IMAGING Radiology 78597 LUNG PERFUSION DIFFERENTIAL Radiology 78598 LUNG PERF&VENTILAT DIFERENTL Radiology 78599 RESPIRATORY NUCLEAR EXAM Radiology 78600 BRAIN IMAGE < 4 VIEWS Radiology 78601 BRAIN IMAGE W/FLOW < 4 VIEWS Radiology 78605 BRAIN IMAGE 4+ VIEWS Radiology 78606 BRAIN IMAGE W/FLOW 4 + VIEWS Radiology 78610 BRAIN FLOW IMAGING ONLY Radiology 78630 CEREBROSPINAL FLUID SCAN Please Note: This list does not include all services. Page 9 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Radiology 78699 NERVOUS SYSTEM NUCLEAR EXAM Radiology 78799 GENITOURINARY NUCLEAR EXAM Radiology 78800 RP LOCLZJ TUM 1 AREA 1 D IMG Radiology 78801 RP LOCLZJ TUM 2+AREA 1+D IMG Radiology 78802 RP LOCLZJ TUM WHBDY 1 D IMG Radiology 78804 RP LOCLZJ TUM WHBDY 2+D IMG Radiology 78808 IV INJ RA DRUG DX STUDY Radiology 78999 NUCLEAR DIAGNOSTIC EXAM Radiology 79005 NUCLEAR RX ORAL ADMIN Radiology 79101 NUCLEAR RX IV ADMIN Radiology 79200 NUCLEAR RX INTRACAV ADMIN Radiology 79300 NUCLR RX INTERSTIT COLLOID Radiology 79403 HEMATOPOIETIC NUCLEAR TX Radiology 79440 NUCLEAR RX INTRA-ARTICULAR Radiology 79445 NUCLEAR RX INTRA-ARTERIAL Radiology 79999 NUCLEAR MEDICINE THERAPY Reconstructive Surgery 53410 RECONSTRUCTION OF URETHRA Reconstructive Surgery 53415 RECONSTRUCTION OF URETHRA Reconstructive Surgery 53420 RECONSTRUCT URETHRA STAGE 1 Reconstructive Surgery 53425 RECONSTRUCT URETHRA STAGE 2 Reconstructive Surgery 53430 RECONSTRUCTION OF URETHRA Reconstructive Surgery 53431 RECONSTRUCT URETHRA/BLADDER Sleep Study 95782 POS AIRWAY PRESSURE CPAP Sleep Study 95783 POLYSOM <6 YRS 4/> PARAMTRS Sleep Study 95805 POLYSOM <6 YRS CPAP/BILVL Sleep Study 95807 MULTIPLE SLEEP LATENCY TEST Sleep Study 95808 SLEEP STUDY ATTENDED Sleep Study 95810 POLYSOM ANY AGE 1-3> PARAM Sleep Study 95811 POLYSOM 6/> YRS 4/> PARAM Speciality Surgery 27120 REPAIR, REVISION, AND/OR RECONSTRUCTION PROCEDURES ON THE PELVIS AND HIP JOINT Speciality Surgery 27122 REPAIR, REVISION, AND/OR RECONSTRUCTION PROCEDURES ON THE PELVIS AND HIP JOINT Please Note: This list does not include all services. Page 10 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Speciality Surgery 27125 PARTIAL HIP REPLACEMENT Speciality Surgery 28291 CORRJ HALUX RIGDUS W/IMPLT Speciality Surgery 28295 CORRECTION HALLUX VALGUS Speciality Surgery 28296 CORRECTION HALLUX VALGUS Speciality Surgery 28307 INCISION OF METATARSAL Speciality Surgery 33948 ECMO/ECLS DAILY MGMT-VENOUS Speciality Surgery 33949 ECMO/ECLS DAILY MGMT ARTERY Speciality Surgery 33951 ECMO/ECLS INSJ PRPH CANNULA Speciality Surgery 33952 ECMO/ECLS INSJ PRPH CANNULA Speciality Surgery 33953 ECMO/ECLS INSJ PRPH CANNULA Speciality Surgery 33954 ECMO/ECLS INSJ PRPH CANNULA Speciality Surgery 33955 ECMO/ECLS INSJ CTR CANNULA Speciality Surgery 33956 ECMO/ECLS INSJ CTR CANNULA Speciality Surgery 33957 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33958 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33959 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33962 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33963 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33964 ECMO/ECLS REPOS PERPH CNULA Speciality Surgery 33965 ECMO/ECLS RMVL PERPH CANNULA Speciality Surgery 33966 ECMO/ECLS RMVL PRPH CANNULA Speciality Surgery 50370 REMOVE TRANSPLANTED KIDNEY Speciality Surgery 53855 INSERT PROST URETHRAL STENT Speciality Surgery 53860 TRANSURETHRAL RF TREATMENT Speciality Surgery 58920 PARTIAL REMOVAL OF OVARY(S) Speciality Surgery 58925 REMOVAL OF OVARIAN CYST(S) Speciality Surgery 61885 INSRT/REDO NEUROSTIM 1 ARRAY Speciality Surgery 61886 IMPLANT NEUROSTIM ARRAYS Speciality Surgery 65710 CORNEAL TRANSPLANT Speciality Surgery 65730 CORNEAL TRANSPLANT Speciality Surgery 65750 CORNEAL TRANSPLANT Speciality Surgery 65755 CORNEAL TRANSPLANT Speciality Surgery 65756 CORNEAL TRNSPL ENDOTHELIAL Please Note: This list does not include all services. Page 11 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025

Service Category HCPCS Code HCPCS Description Speciality Surgery 66986 EXCHANGE LENS PROSTHESIS Speech Therapy 92507 SPEECH/HEARING THERAPY Speech Therapy 92508 SPEECH/HEARING THERAPY Speech Therapy 92521 EVALUATION OF SPEECH FLUENCY Speech Therapy 92522 EVALUATE SPEECH PRODUCTION Speech Therapy 92526 ORAL FUNCTION THERAPY Transportation A0120 OR OTHER TRANSPORTATION SYSTEMS Vision 92371 REPAIR & ADJUST SPECTACLES Vision Q1004 IN FEDERAL REGISTER NOTICE Vision Q1005 IN FEDERAL REGISTER NOTICE Vision V2118 ANISEIKONIC LENS, SINGLE VISION Vision V2121 LENTICULAR LENS, SINGLE Vision V2215 LENS LENTICULAR MYODISC BIFOCAL Vision V2221 LENTICULAR LENS, BIFOCAL Vision V2318 ANISEIKONIC LENS, TRIFOCAL Vision V2321 LENTICULAR LENS, TRIFOCAL Vision V2630 ANTER CHAMBER INTRAOCUL LENS Vision V2631 IRIS SUPPORT INTRAOCLR LENS Vision V2632 POST CHMBR INTRAOCULAR LENS UM Medications J1300 ECULIZUMAB (SOLIRIS) Please Note: This list does not include all services. Page 12 of 12 UMGC MCAL PRVDRREF PROC CODES NO PA REQ_GENERAL 11/2025