Prior authorization request form Form

Questions? Please call the Alliance Pharmacy Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4541 www.alamedaalliance.org OPUM_PROSTHETIC AUTH UPDATE 01/2023 Important Update: Prosthetic 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 prosthetic codes that require prior authorization (PA).
This will affect claims with the date(s) of service starting Friday, February 10, 2023, and onward. Enclosed with this notice is a code-specific list of prosthetic codes that shows which codes require PA. The list can be found on our 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.
In addition to the codes, our claims system will also validate that claims received match the authorization when an authorization is required. The following items will be validated: • Member name • Provider NPI • CPT and HCPC coding • Date(s) of service are within the authorized range • Number of units and/or visits • Place of service matches the site of care submitted on the authorization request form This update has been validated based on current publishable/billable coding and was confirmed to be covered by the California Department of Health Care Services (DHCS).
If you have any questions, please call the Alliance Provider Services Department at 1.510.747.4510. 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 Prosthetics 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 19396 DESIGN CUSTOM BREAST IMPLANT Alameda Alliance for Health or Delegate 21243 RECONSTRUCTION OF JAW JOINT Alameda Alliance for Health or Delegate 27438 REVISE KNEECAP WITH IMPLANT Alameda Alliance for Health or Delegate 27445 REVISION OF KNEE JOINT Alameda Alliance for Health or Delegate 30220 INSERT NASAL SEPTAL BUTTON Alameda Alliance for Health or Delegate 54408 REPAIR MULTI-COMP PENIS PROS Alameda Alliance for Health or Delegate 54699 LAPAROSCOPE PROC TESTIS Alameda Alliance for Health or Delegate 55899 GENITAL SURGERY PROCEDURE Alameda Alliance for Health or Delegate 65770 REVISE CORNEA WITH IMPLANT 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 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 C1839 IRIS PROSTHESIS Alameda Alliance for Health or Delegate L2006 KAF DVC ANY MATERIAL ADJ CUSTOM FAB Alameda Alliance for Health or Delegate L5782 ADD LW LIMB PROS LIMB MGMT HVY DUTY Alameda Alliance for Health or Delegate L5785 ADD EXOSKEL BELW KNEE ULTRA-LT MATL Alameda Alliance for Health or Delegate L6611 ADD UP EXT PROS EXT PWR ADD SWITCH Alameda Alliance for Health or Delegate L6624 UP EXT ADD FLX/EXT ROT WRIST UNIT Alameda Alliance for Health or Delegate ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR PROSTHETICS 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 3 OPUM_PROSTHETICS PROC CODES REQ PA 1/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Prosthetics (cont.) L6694 ADD UP EXT PROS CSTM W/LOCK MECH Alameda Alliance for Health or Delegate L6695 ADD UP EXT PROS CSTM W/O LOCK MECH Alameda Alliance for Health or Delegate L6696 ADD UP EXT PROS CNGN/TRAUMAT AMP Alameda Alliance for Health or Delegate L6697 ADD UP EXT PROS NOT CNGN/TRAUM AMP Alameda Alliance for Health or Delegate L6698 ADD UP EXT PROS LOCK MECH EXC INSRT Alameda Alliance for Health or Delegate L6882 MICRPROCSS CNTRL ADD UP LIMB PROSTH Alameda Alliance for Health or Delegate L8000 BREAST PROS MAST BRA NO INTEG FORM Alameda Alliance for Health or Delegate L8001 BREAST PROS MAST BRA INTEG FORM UNI Alameda Alliance for Health or Delegate L8002 BREAST PROS MAST BRA INTEG FORM BIL Alameda Alliance for Health or Delegate L8500 ARTIFICIAL LARYNX ANY TYPE Alameda Alliance for Health or Delegate L8505 ARTFICL LARYNX REPLCMT BATTRY/ACSS Alameda Alliance for Health or Delegate L8507 TRACHEO-ESOPH VOICE PROSTH PT INSRT Alameda Alliance for Health or Delegate L8614 COCHLEAR DEVC INCL INT&EXT COMPNENT Alameda Alliance for Health or Delegate L8615 HEADSET/HEADPIECE COCHLR IMPL REPL Alameda Alliance for Health or Delegate L8616 MICROPHONE COCHLEAR IMPL DEVC REPL Alameda Alliance for Health or Delegate L8617 TRNSMTTING COIL COCHLEAR IMPL REPL Alameda Alliance for Health or Delegate L8618 TX CBL U CI/AUD OSSEOINTG DVC REPL Alameda Alliance for Health or Delegate L8619 COCHLR IMPL SPCH PRCSSR/CNTLR REPL Alameda Alliance for Health or Delegate L8621 ZUBC AIR BA CI & AUD SD PRC RPL E Alameda Alliance for Health or Delegate L8622 ALKALIN BATT COCHLR IMPL ANY SZ RPL Alameda Alliance for Health or Delegate L8623 LITH ION BATT NOT EAR LEVEL REPL EA Alameda Alliance for Health or Delegate L8624 LIB CI/AO DVC SP EAR LEVEL REPL EA Alameda Alliance for Health or Delegate L8625 EXT RECHRG BATT CI/AO DEVC REPL EA Alameda Alliance for Health or Delegate L8627 COCHLEAR IMPL EXT PROCSSR CMPNT RPL Alameda Alliance for Health or Delegate L8628 COCHLR IMPL EXT CONTRLLR CMPNT REPL Alameda Alliance for Health or Delegate L8629 TRANSMIT COIL CABLE COCHLR DEV RPL Alameda Alliance for Health or Delegate L8680 IMPL NEUROSTIMULATOR ELECTRODE EA Alameda Alliance for Health or Delegate L8681 PT PROG IMPL NEUROSTM PLSE GEN REPL Alameda Alliance for Health or Delegate L8682 IMPL NEUROSTIMULATOR RADIOFREQ RECV Alameda Alliance for Health or Delegate L8683 RF TRNSMT W/IMPL NEUROSTIM RF RECV Alameda Alliance for Health or Delegate L8685 IMPL NEUROSTIM 1 ARRAY RECHARGEABLE Alameda Alliance for Health or Delegate L8686 IMPL NEUROSTIM 1 ARRAY NON-RECHARGE Alameda Alliance for Health or Delegate Please Note: This list does not include all services. Page 2 of 3 OPUM_PROSTHETICS PROC CODES REQ PA 1/2023

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Prosthetics (cont.) L8687 IMPL NEUROSTIM 2 ARRAY RECHARGEABLE Alameda Alliance for Health or Delegate L8688 IMPL NEUROSTIM 2 ARRAY NON-RECHARGE Alameda Alliance for Health or Delegate L8689 EXT RECHARG SYS IMPL NEUROSTIM REPL Alameda Alliance for Health or Delegate L8695 EXT RECHARG SYS IMPL NEUROSTIM REPL Alameda Alliance for Health or Delegate L8696 ANT FOR IMPL DIA/PN ST DEV REPL EA Alameda Alliance for Health or Delegate L8699 PROSTHETIC IMPLANT NOS Alameda Alliance for Health or Delegate V2623 PROSTHETIC EYE PLASTIC CUSTOM Alameda Alliance for Health or Delegate V2625 ENLARGEMENT OF OCULAR PROSTHESIS Alameda Alliance for Health or Delegate V2626 REDUCTION OF OCULAR PROSTHESIS Alameda Alliance for Health or Delegate V2627 SCLERAL COVER SHELL Alameda Alliance for Health or Delegate V2628 FABRICATION&FIT OCULAR CONFORMER Alameda Alliance for Health or Delegate V2629 PROSTHETIC EYE OTHER TYPE Alameda Alliance for Health or Delegate Please Note: This list does not include all services. Page 3 of 3 OPUM_PROSTHETICS PROC CODES REQ PA 1/2032