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_SPC SURGERY AUTH UPDATE 07/2023 FAXED: XX/XX/XXXX Important Update: Specialty 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 specialty surgery codes that require prior authorization.
This will affect claims with the date(s) of service starting Tuesday, August 1, 2023, and onward. Enclosed with this notice is a code-specific list for specialty 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 11960 INSERT TISSUE EXPANDER(S) Alameda Alliance for Health or Delegate 11970 RPLCMT TISS XPNDR PERM IMPLT Alameda Alliance for Health or Delegate 11971 RMVL TIS XPNDR WO INSJ IMPLT Alameda Alliance for Health or Delegate 15771 GRFG AUTOL FAT LIPO 50 CC/< Alameda Alliance for Health or Delegate 15772 GRFG AUTOL FAT LIPO EA ADDL Alameda Alliance for Health or Delegate 15773 GRFG AUTOL FAT LIPO 25 CC/< Alameda Alliance for Health or Delegate 15774 GFRG AUTOL FAT LIPO EA ADDL Alameda Alliance for Health or Delegate 15780 DERMABRASION TOTAL FACE Alameda Alliance for Health or Delegate 15781 DERMABRASION SEGMENTAL FACE Alameda Alliance for Health or Delegate 15782 DERMABRASION OTHER THAN FACE Alameda Alliance for Health or Delegate 15788 CHEMICAL PEEL FACE EPIDERM Alameda Alliance for Health or Delegate 15789 CHEMICAL PEEL FACE DERMAL Alameda Alliance for Health or Delegate 15792 CHEMICAL PEEL NONFACIAL Alameda Alliance for Health or Delegate 15793 CHEMICAL PEEL NONFACIAL Alameda Alliance for Health or Delegate 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 15840 NERVE PALSY FASCIAL GRAFT Alameda Alliance for Health or Delegate 15841 NERVE PALSY MUSCLE GRAFT Alameda Alliance for Health or Delegate 15842 NERVE PALSY MICROSURG GRAFT Alameda Alliance for Health or Delegate 15845 SKIN AND MUSCLE REPAIR FACE Alameda Alliance for Health or Delegate 17311 MOHS 1 STAGE H/N/HF/G Alameda Alliance for Health or Delegate 17312 MOHS ADDL STAGE Alameda Alliance for Health or Delegate Alameda Alliance for Health Referral and Prior Authorization (PA) Procedure Codes for Specialty 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 Specialty Surgery Please note: This list does not include all services. Page 1 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 17313 MOHS 1 STAGE T/A/L Alameda Alliance for Health or Delegate 17314 MOHS ADDL STAGE T/A/L Alameda Alliance for Health or Delegate 17315 MOHS SURG ADDL BLOCK Alameda Alliance for Health or Delegate 17340 CRYOTHERAPY OF SKIN Alameda Alliance for Health or Delegate 17360 SKIN PEEL THERAPY Alameda Alliance for Health or Delegate 17999 SKIN TISSUE PROCEDURE Alameda Alliance for Health or Delegate 19300 REMOVAL OF BREAST TISSUE Alameda Alliance for Health or Delegate 19301 PARTIAL MASTECTOMY Alameda Alliance for Health or Delegate 19302 P-MASTECTOMY W/LN REMOVAL Alameda Alliance for Health or Delegate 19303 MAST SIMPLE COMPLETE Alameda Alliance for Health or Delegate 19305 MAST RADICAL Alameda Alliance for Health or Delegate 19306 MAST RAD URBAN TYPE Alameda Alliance for Health or Delegate 19307 MAST MOD RAD Alameda Alliance for Health or Delegate 19316 SUSPENSION OF BREAST 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 19328 RMVL INTACT BREAST IMPLANT Alameda Alliance for Health or Delegate 19330 RMVL RUPTURED BREAST IMPLANT Alameda Alliance for Health or Delegate 19340 INSJ BREAST IMPLT SM D MAST Alameda Alliance for Health or Delegate 19342 INSJ/RPLCMT BRST IMPLT SEP D 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 19370 REVJ PERI-IMPLT CAPSULE BRST Alameda Alliance for Health or Delegate 19371 PERI-IMPLT CAPSLC BRST COMPL Alameda Alliance for Health or Delegate 19380 REVJ RECONSTRUCTED BREAST Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 2 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 19396 DESIGN CUSTOM BREAST IMPLANT Alameda Alliance for Health or Delegate 19499 BREAST SURGERY PROCEDURE Alameda Alliance for Health or Delegate 20999 MUSCULOSKELETAL SURGERY Alameda Alliance for Health or Delegate 21010 INCISION OF JAW JOINT Alameda Alliance for Health or Delegate 21050 REMOVAL OF JAW JOINT Alameda Alliance for Health or Delegate 21060 REMOVE JAW JOINT CARTILAGE Alameda Alliance for Health or Delegate 21070 REMOVE CORONOID PROCESS Alameda Alliance for Health or Delegate 21073 MNPJ OF TMJ W/ANESTH Alameda Alliance for Health or Delegate 21299 CRANIO/MAXILLOFACIAL SURGERY Alameda Alliance for Health or Delegate 21499 HEAD SURGERY PROCEDURE Alameda Alliance for Health or Delegate 21685 HYOID MYOTOMY & SUSPENSION Alameda Alliance for Health or Delegate 21700 REVISION OF NECK MUSCLE Alameda Alliance for Health or Delegate 21705 REVISION OF NECK MUSCLE/RIB Alameda Alliance for Health or Delegate 21720 REVISION OF NECK MUSCLE Alameda Alliance for Health or Delegate 21725 REVISION OF NECK MUSCLE 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 21899 NECK/CHEST SURGERY PROCEDURE Alameda Alliance for Health or Delegate 22510 PERQ CERVICOTHORACIC INJECT Alameda Alliance for Health or Delegate 22511 PERQ LUMBOSACRAL INJECTION Alameda Alliance for Health or Delegate 22512 VERTEBROPLASTY ADDL INJECT Alameda Alliance for Health or Delegate 22513 PERQ VERTEBRAL AUGMENTATION Alameda Alliance for Health or Delegate 22514 PERQ VERTEBRAL AUGMENTATION Alameda Alliance for Health or Delegate 22515 PERQ VERTEBRAL AUGMENTATION Alameda Alliance for Health or Delegate 22899 SPINE SURGERY PROCEDURE Alameda Alliance for Health or Delegate 22999 ABDOMEN SURGERY PROCEDURE Alameda Alliance for Health or Delegate 23000 REMOVAL OF CALCIUM DEPOSITS 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 Specialty Surgery (cont.) Please note: This list does not include all services. Page 3 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 23473 REVIS RECONST SHOULDER JOINT Alameda Alliance for Health or Delegate 23474 REVIS RECONST SHOULDER JOINT Alameda Alliance for Health or Delegate 23929 SHOULDER SURGERY PROCEDURE Alameda Alliance for Health or Delegate 24105 REMOVAL OF ELBOW BURSA Alameda Alliance for Health or Delegate 24999 UPPER ARM/ELBOW SURGERY Alameda Alliance for Health or Delegate 25999 FOREARM OR WRIST SURGERY Alameda Alliance for Health or Delegate 27120 REPAIR, REVISION, AND/OR RECONSTRUCTION PROCEDURES ON THE PELVIS AND HIP JOINT Alameda Alliance for Health or Delegate 27122 REPAIR, REVISION, AND/OR RECONSTRUCTION PROCEDURES ON THE PELVIS AND HIP JOINT Alameda Alliance for Health or Delegate 27125 PARTIAL HIP REPLACEMENT 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 27138 REVISE HIP JOINT REPLACEMENT Alameda Alliance for Health or Delegate 27279 ARTHRODESIS SACROILIAC JOINT 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 27425 LAT RETINACULAR RELEASE OPEN 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 Specialty Surgery (cont.) Please note: This list does not include all services. Page 4 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 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 27599 UNLISTED PX FEMUR/KNEE 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 28288 PARTIAL REMOVAL OF FOOT BONE Alameda Alliance for Health or Delegate 28289 CORRJ HALUX RIGDUS W/O IMPLT Alameda Alliance for Health or Delegate 28291 CORRJ HALUX RIGDUS W/IMPLT Alameda Alliance for Health or Delegate 28292 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28295 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28296 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28297 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28298 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28299 CORRECTION HALLUX VALGUS Alameda Alliance for Health or Delegate 28306 INCISION OF METATARSAL Alameda Alliance for Health or Delegate 28307 INCISION OF METATARSAL Alameda Alliance for Health or Delegate 28308 INCISION OF METATARSAL Alameda Alliance for Health or Delegate 28309 INCISION OF METATARSALS Alameda Alliance for Health or Delegate 28310 REVISION OF BIG TOE Alameda Alliance for Health or Delegate 28312 REVISION OF TOE Alameda Alliance for Health or Delegate 28313 REPAIR DEFORMITY OF TOE Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 5 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 28315 REMOVAL OF SESAMOID BONE 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 28899 FOOT/TOES SURGERY PROCEDURE Alameda Alliance for Health or Delegate 29800 JAW ARTHROSCOPY/SURGERY Alameda Alliance for Health or Delegate 29804 JAW ARTHROSCOPY/SURGERY Alameda Alliance for Health or Delegate 30130 EXCISE INFERIOR TURBINATE Alameda Alliance for Health or Delegate 30140 RESECT INFERIOR TURBINATE Alameda Alliance for Health or Delegate 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 30465 REPAIR NASAL STENOSIS Alameda Alliance for Health or Delegate 30520 REPAIR OF NASAL SEPTUM Alameda Alliance for Health or Delegate 30999 NASAL SURGERY PROCEDURE Alameda Alliance for Health or Delegate 31051 SPHENOID SINUS SURGERY Alameda Alliance for Health or Delegate 31080 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31081 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31084 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31085 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31086 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31087 REMOVAL OF FRONTAL SINUS Alameda Alliance for Health or Delegate 31299 SINUS SURGERY PROCEDURE Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 6 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 32851 LUNG TRANSPLANT SINGLE Alameda Alliance for Health or Delegate 32852 LUNG TRANSPLANT WITH BYPASS Alameda Alliance for Health or Delegate 32853 LUNG TRANSPLANT DOUBLE Alameda Alliance for Health or Delegate 32854 LUNG TRANSPLANT WITH BYPASS Alameda Alliance for Health or Delegate 33517 CABG ARTERY-VEIN SINGLE Alameda Alliance for Health or Delegate 33518 CABG ARTERY-VEIN TWO Alameda Alliance for Health or Delegate 33519 CABG ARTERY-VEIN THREE Alameda Alliance for Health or Delegate 33521 CABG ARTERY-VEIN FOUR Alameda Alliance for Health or Delegate 33522 CABG ARTERY-VEIN FIVE Alameda Alliance for Health or Delegate 33523 CABG ART-VEIN SIX OR MORE Alameda Alliance for Health or Delegate 33533 CABG ARTERIAL SINGLE Alameda Alliance for Health or Delegate 33534 CABG ARTERIAL TWO Alameda Alliance for Health or Delegate 33535 CABG ARTERIAL THREE Alameda Alliance for Health or Delegate 33536 CABG ARTERIAL FOUR OR MORE Alameda Alliance for Health or Delegate 33935 TRANSPLANTATION HEART/LUNG Alameda Alliance for Health or Delegate 33945 TRANSPLANTATION OF HEART Alameda Alliance for Health or Delegate 33946 ECMO/ECLS INITIATION VENOUS Alameda Alliance for Health or Delegate 33947 ECMO/ECLS INITIATION ARTERY Alameda Alliance for Health or Delegate 33948 ECMO/ECLS DAILY MGMT-VENOUS Alameda Alliance for Health or Delegate 33949 ECMO/ECLS DAILY MGMT ARTERY Alameda Alliance for Health or Delegate 33951 ECMO/ECLS INSJ PRPH CANNULA Alameda Alliance for Health or Delegate 33952 ECMO/ECLS INSJ PRPH CANNULA Alameda Alliance for Health or Delegate 33953 ECMO/ECLS INSJ PRPH CANNULA Alameda Alliance for Health or Delegate 33954 ECMO/ECLS INSJ PRPH CANNULA Alameda Alliance for Health or Delegate 33955 ECMO/ECLS INSJ CTR CANNULA Alameda Alliance for Health or Delegate 33956 ECMO/ECLS INSJ CTR CANNULA Alameda Alliance for Health or Delegate 33957 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate 33958 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate 33959 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate 33962 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 7 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 33963 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate 33964 ECMO/ECLS REPOS PERPH CNULA Alameda Alliance for Health or Delegate 33965 ECMO/ECLS RMVL PERPH CANNULA Alameda Alliance for Health or Delegate 33966 ECMO/ECLS RMVL PRPH CANNULA Alameda Alliance for Health or Delegate 33999 CARDIAC SURGERY PROCEDURE Alameda Alliance for Health or Delegate 36473 ENDOVENOUS MCHNCHEM 1ST VEIN Alameda Alliance for Health or Delegate 36474 ENDOVENOUS MCHNCHEM ADD-ON Alameda Alliance for Health or Delegate 36475 ENDOVENOUS RF 1ST VEIN Alameda Alliance for Health or Delegate 36476 ENDOVENOUS RF VEIN ADD-ON Alameda Alliance for Health or Delegate 36478 ENDOVENOUS LASER 1ST VEIN Alameda Alliance for Health or Delegate 36479 ENDOVENOUS LASER VEIN ADDON Alameda Alliance for Health or Delegate 36511 APHERESIS WBC Alameda Alliance for Health or Delegate 36512 APHERESIS RBC Alameda Alliance for Health or Delegate 36513 APHERESIS PLATELETS Alameda Alliance for Health or Delegate 36514 APHERESIS PLASMA Alameda Alliance for Health or Delegate 36516 APHERESIS IMMUNOADS SLCTV Alameda Alliance for Health or Delegate 36522 PHOTOPHERESIS Alameda Alliance for Health or Delegate 38205 HARVEST ALLOGENEIC STEM CELL Alameda Alliance for Health or Delegate 38206 HARVEST AUTO STEM CELLS Alameda Alliance for Health or Delegate 38230 BONE MARROW HARVEST ALLOGEN Alameda Alliance for Health or Delegate 38232 BONE MARROW HARVEST AUTOLOG Alameda Alliance for Health or Delegate 38240 TRANSPLT ALLO HCT/DONOR Alameda Alliance for Health or Delegate 38241 TRANSPLT AUTOL HCT/DONOR Alameda Alliance for Health or Delegate 38242 TRANSPLT ALLO LYMPHOCYTES Alameda Alliance for Health or Delegate 38243 TRANSPLJ HEMATOPOIETIC BOOST Alameda Alliance for Health or Delegate 41899 DENTAL SURGERY PROCEDURE Alameda Alliance for Health or Delegate 42145 REPAIR PALATE PHARYNX/UVULA Alameda Alliance for Health or Delegate 42820 REMOVE TONSILS AND ADENOIDS Alameda Alliance for Health or Delegate 42821 REMOVE TONSILS AND ADENOIDS Alameda Alliance for Health or Delegate 42825 REMOVAL OF TONSILS Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 8 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 42826 REMOVAL OF TONSILS Alameda Alliance for Health or Delegate 42830 REMOVAL OF ADENOIDS Alameda Alliance for Health or Delegate 42831 REMOVAL OF ADENOIDS Alameda Alliance for Health or Delegate 42835 REMOVAL OF ADENOIDS Alameda Alliance for Health or Delegate 42836 REMOVAL OF ADENOIDS Alameda Alliance for Health or Delegate 43999 STOMACH SURGERY PROCEDURE Alameda Alliance for Health or Delegate 44799 UNLISTED PX SMALL INTESTINE Alameda Alliance for Health or Delegate 45399 UNLISTED PROCEDURE COLON Alameda Alliance for Health or Delegate 46999 ANUS SURGERY PROCEDURE Alameda Alliance for Health or Delegate 47135 TRANSPLANTATION OF LIVER Alameda Alliance for Health or Delegate 47140 PARTIAL REMOVAL DONOR LIVER Alameda Alliance for Health or Delegate 47141 PARTIAL REMOVAL DONOR LIVER Alameda Alliance for Health or Delegate 47142 PARTIAL REMOVAL DONOR LIVER Alameda Alliance for Health or Delegate 47399 LIVER SURGERY PROCEDURE Alameda Alliance for Health or Delegate 47999 BILE TRACT SURGERY PROCEDURE Alameda Alliance for Health or Delegate 48554 TRANSPL ALLOGRAFT PANCREAS Alameda Alliance for Health or Delegate 48556 REMOVAL ALLOGRAFT PANCREAS Alameda Alliance for Health or Delegate 48999 PANCREAS SURGERY PROCEDURE Alameda Alliance for Health or Delegate 50320 REMOVE KIDNEY LIVING DONOR Alameda Alliance for Health or Delegate 50340 REMOVAL OF KIDNEY Alameda Alliance for Health or Delegate 50360 TRANSPLANTATION OF KIDNEY Alameda Alliance for Health or Delegate 50365 TRANSPLANTATION OF KIDNEY Alameda Alliance for Health or Delegate 50370 REMOVE TRANSPLANTED KIDNEY Alameda Alliance for Health or Delegate 50380 REIMPLANTATION OF KIDNEY Alameda Alliance for Health or Delegate 50540 REVISION OF HORSESHOE KIDNEY Alameda Alliance for Health or Delegate 52601 PROSTATECTOMY (TURP) Alameda Alliance for Health or Delegate 52630 REMOVE PROSTATE REGROWTH Alameda Alliance for Health or Delegate 52640 RELIEVE BLADDER CONTRACTURE Alameda Alliance for Health or Delegate 52647 LASER SURGERY OF PROSTATE Alameda Alliance for Health or Delegate 52648 LASER SURGERY OF PROSTATE Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 9 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 52649 PROSTATE LASER ENUCLEATION Alameda Alliance for Health or Delegate 53850 PROSTATIC MICROWAVE THERMOTX Alameda Alliance for Health or Delegate 53852 PROSTATIC RF THERMOTX Alameda Alliance for Health or Delegate 53854 TRURL DSTRJ PRST8 TISS RF WV Alameda Alliance for Health or Delegate 53855 INSERT PROST URETHRAL STENT Alameda Alliance for Health or Delegate 53860 TRANSURETHRAL RF TREATMENT Alameda Alliance for Health or Delegate 53899 UROLOGY SURGERY PROCEDURE Alameda Alliance for Health or Delegate 54120 PARTIAL REMOVAL OF PENIS Alameda Alliance for Health or Delegate 54125 REMOVAL OF PENIS Alameda Alliance for Health or Delegate 54130 REMOVE PENIS & NODES Alameda Alliance for Health or Delegate 54135 REMOVE PENIS & NODES Alameda Alliance for Health or Delegate 54360 PENIS PLASTIC SURGERY Alameda Alliance for Health or Delegate 54520 REMOVAL OF TESTIS Alameda Alliance for Health or Delegate 54530 REMOVAL OF TESTIS Alameda Alliance for Health or Delegate 54535 EXTENSIVE TESTIS SURGERY Alameda Alliance for Health or Delegate 54620 SUSPENSION OF TESTIS Alameda Alliance for Health or Delegate 58150 TOTAL HYSTERECTOMY Alameda Alliance for Health or Delegate 58152 TOTAL HYSTERECTOMY Alameda Alliance for Health or Delegate 58180 PARTIAL HYSTERECTOMY Alameda Alliance for Health or Delegate 58200 EXTENSIVE HYSTERECTOMY Alameda Alliance for Health or Delegate 58210 EXTENSIVE HYSTERECTOMY Alameda Alliance for Health or Delegate 58240 REMOVAL OF PELVIS CONTENTS Alameda Alliance for Health or Delegate 58260 VAGINAL HYSTERECTOMY Alameda Alliance for Health or Delegate 58262 VAG HYST INCLUDING T/O Alameda Alliance for Health or Delegate 58263 VAG HYST W/T/O & VAG REPAIR Alameda Alliance for Health or Delegate 58267 VAG HYST W/URINARY REPAIR Alameda Alliance for Health or Delegate 58270 VAG HYST W/ENTEROCELE REPAIR Alameda Alliance for Health or Delegate 58275 HYSTERECTOMY/REVISE VAGINA Alameda Alliance for Health or Delegate 58280 HYSTERECTOMY/REVISE VAGINA Alameda Alliance for Health or Delegate 58285 EXTENSIVE HYSTERECTOMY Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 10 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 58290 VAG HYST COMPLEX Alameda Alliance for Health or Delegate 58291 VAG HYST INCL T/O COMPLEX Alameda Alliance for Health or Delegate 58292 VAG HYST T/O & REPAIR COMPL Alameda Alliance for Health or Delegate 58294 VAG HYST W/ENTEROCELE COMPL Alameda Alliance for Health or Delegate 58346 INSERT HEYMAN UTERI CAPSULE Alameda Alliance for Health or Delegate 58541 LSH UTERUS 250 G OR LESS Alameda Alliance for Health or Delegate 58542 LSH W/T/O UT 250 G OR LESS Alameda Alliance for Health or Delegate 58543 LSH UTERUS ABOVE 250 G Alameda Alliance for Health or Delegate 58544 LSH W/T/O UTERUS ABOVE 250 G Alameda Alliance for Health or Delegate 58548 LAP RADICAL HYST Alameda Alliance for Health or Delegate 58550 LAPARO-ASST VAG HYSTERECTOMY Alameda Alliance for Health or Delegate 58552 LAPARO-VAG HYST INCL T/O Alameda Alliance for Health or Delegate 58553 LAPARO-VAG HYST COMPLEX Alameda Alliance for Health or Delegate 58554 LAPARO-VAG HYST W/T/O COMPL Alameda Alliance for Health or Delegate 58570 TLH UTERUS 250 G OR LESS Alameda Alliance for Health or Delegate 58571 TLH W/T/O 250 G OR LESS Alameda Alliance for Health or Delegate 58572 TLH UTERUS OVER 250 G Alameda Alliance for Health or Delegate 58573 TLH W/T/O UTERUS OVER 250 G Alameda Alliance for Health or Delegate 58575 LAPS TOT HYST RESJ MAL Alameda Alliance for Health or Delegate 58578 LAPARO PROC UTERUS Alameda Alliance for Health or Delegate 58920 PARTIAL REMOVAL OF OVARY(S) Alameda Alliance for Health or Delegate 58925 REMOVAL OF OVARIAN CYST(S) Alameda Alliance for Health or Delegate 58940 REMOVAL OF OVARY(S) Alameda Alliance for Health or Delegate 58943 REMOVAL OF OVARY(S) Alameda Alliance for Health or Delegate 58953 TAH RAD DISSECT FOR DEBULK Alameda Alliance for Health or Delegate 58954 TAH RAD DEBULK/LYMPH REMOVE Alameda Alliance for Health or Delegate 58956 BSO OMENTECTOMY W/TAH Alameda Alliance for Health or Delegate 58999 GENITAL SURGERY PROCEDURE Alameda Alliance for Health or Delegate 61867 IMPLANT NEUROELECTRODE Alameda Alliance for Health or Delegate 61868 IMPLANT NEUROELECTRDE ADDL Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 11 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 61880 REVISE/REMOVE NEUROELECTRODE Alameda Alliance for Health or Delegate 61885 INSRT/REDO NEUROSTIM 1 ARRAY Alameda Alliance for Health or Delegate 61886 IMPLANT NEUROSTIM ARRAYS Alameda Alliance for Health or Delegate 61888 REVISE/REMOVE NEURORECEIVER Alameda Alliance for Health or Delegate 63650 IMPLANT NEUROELECTRODES Alameda Alliance for Health or Delegate 63655 IMPLANT NEUROELECTRODES Alameda Alliance for Health or Delegate 64553 IMPLANT NEUROELECTRODES Alameda Alliance for Health or Delegate 64721 CARPAL TUNNEL SURGERY Alameda Alliance for Health or Delegate 65710 CORNEAL TRANSPLANT Alameda Alliance for Health or Delegate 65730 CORNEAL TRANSPLANT Alameda Alliance for Health or Delegate 65750 CORNEAL TRANSPLANT Alameda Alliance for Health or Delegate 65755 CORNEAL TRANSPLANT Alameda Alliance for Health or Delegate 65756 CORNEAL TRNSPL ENDOTHELIAL Alameda Alliance for Health or Delegate 65770 REVISE CORNEA WITH IMPLANT Alameda Alliance for Health or Delegate 65785 IMPLTJ NTRSTRML CRNL RNG SEG Alameda Alliance for Health or Delegate 66982 XCAPSL CTRC RMVL CPLX WO ECP Alameda Alliance for Health or Delegate 66983 CATARACT SURG W/IOL 1 STAGE Alameda Alliance for Health or Delegate 66984 XCAPSL CTRC RMVL W/O ECP Alameda Alliance for Health or Delegate 66985 INSERT LENS PROSTHESIS Alameda Alliance for Health or Delegate 66986 EXCHANGE LENS PROSTHESIS Alameda Alliance for Health or Delegate 66987 XCAPSL CTRC RMVL CPLX W/ECP Alameda Alliance for Health or Delegate 66988 XCAPSL CTRC RMVL W/ECP Alameda Alliance for Health or Delegate 66989 XCPSL CTRC RMVL CPLX INSJ 1+ Alameda Alliance for Health or Delegate 66991 XCAPSL CTRC RMVL INSJ 1+ Alameda Alliance for Health or Delegate 67299 EYE SURGERY PROCEDURE Alameda Alliance for Health or Delegate 67311 REVISE EYE MUSCLE Alameda Alliance for Health or Delegate 67312 REVISE TWO EYE MUSCLES Alameda Alliance for Health or Delegate 67314 REVISE EYE MUSCLE Alameda Alliance for Health or Delegate 67316 REVISE TWO EYE MUSCLES Alameda Alliance for Health or Delegate 67318 REVISE EYE MUSCLE(S) Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 12 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 67320 REVISE EYE MUSCLE(S) ADD-ON Alameda Alliance for Health or Delegate 67331 EYE SURGERY FOLLOW-UP ADD-ON Alameda Alliance for Health or Delegate 67332 REREVISE EYE MUSCLES ADD-ON Alameda Alliance for Health or Delegate 67334 REVISE EYE MUSCLE W/SUTURE Alameda Alliance for Health or Delegate 67340 REVISE EYE MUSCLE ADD-ON Alameda Alliance for Health or Delegate 67343 RELEASE EYE TISSUE Alameda Alliance for Health or Delegate 67399 UNLISTED PX EXTRAOCULAR MUSC Alameda Alliance for Health or Delegate 67599 ORBIT SURGERY PROCEDURE Alameda Alliance for Health or Delegate 67901 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67902 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67903 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67904 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67906 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67908 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67909 REVISE EYELID DEFECT Alameda Alliance for Health or Delegate 67911 REVISE EYELID DEFECT Alameda Alliance for Health or Delegate 67912 CORRECTION EYELID W/IMPLANT Alameda Alliance for Health or Delegate 67914 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67915 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67916 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67917 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67921 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67922 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67923 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67924 REPAIR EYELID DEFECT Alameda Alliance for Health or Delegate 67950 REVISION OF EYELID Alameda Alliance for Health or Delegate 67961 REVISION OF EYELID Alameda Alliance for Health or Delegate 67966 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 Specialty Surgery (cont.) Please note: This list does not include all services. Page 13 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 67974 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate 67975 RECONSTRUCTION OF EYELID Alameda Alliance for Health or Delegate 67999 REVISION OF EYELID Alameda Alliance for Health or Delegate 68399 EYELID LINING SURGERY Alameda Alliance for Health or Delegate 69399 OUTER EAR SURGERY PROCEDURE Alameda Alliance for Health or Delegate 69799 MIDDLE EAR SURGERY PROCEDURE Alameda Alliance for Health or Delegate 69930 IMPLANT COCHLEAR DEVICE Alameda Alliance for Health or Delegate 69949 INNER EAR SURGERY PROCEDURE Alameda Alliance for Health or Delegate S2065 SIMULTANEOUS PANC KIDNEY TPLNT Alameda Alliance for Health or Delegate S2066 BREAST RECON W/GAP FLAP UNILATERAL Alameda Alliance for Health or Delegate S2067 BRST RECN 1 BRST DIEP&/GAP FLP(S) Alameda Alliance for Health or Delegate S2068 BREAST RECON DIEP/SIEA FLAP UNI Alameda Alliance for Health or Delegate S2117 ARTHROEREISIS SUBTALAR Alameda Alliance for Health or Delegate S2118 MTL-ON-MTL TOT HIP RSRFC ACETAB&FEM Alameda Alliance for Health or Delegate S2230 IMPL MAGNT CMPNT SEMI-IMPL HEAR DVC Alameda Alliance for Health or Delegate S2235 IMPL AUDITRY BRAIN STEM IMPLANT Alameda Alliance for Health or Delegate Specialty Surgery (cont.) Please note: This list does not include all services. Page 14 of 14 UM_RECON SURG PROC CODES REQ PA 04/2023