Starting March 1, 2022, the following clinical categories will require prior authorization for Individual Exchange plans:
See below to view the list of applicable codes.
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
29820 |
ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY PART Adding prior authorization for medical necessity in all states |
29821 |
ARTHROSCOPY SHOULDER SURG; SYNOVECTOMY COMPLT Adding prior authorization for medical necessity in all states |
29830 |
ARTHROSCOPY ELBOW DIAG W/WO SYNOVIAL BIOPSY SPX Adding prior authorization for medical necessity in all states |
29835 |
ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL Adding prior authorization for medical necessity in all states |
29836 |
ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE Adding prior authorization for medical necessity in all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
0314T |
LAPS RMVL VGL ARRY & PLS GEN Adding prior authorization in all states |
0315T |
RMVL VAGUS NERVE PLS GEN Adding prior authorization in all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
T1024 |
Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter Adding prior authorization in IL |
H0040 |
Assertive community treatment program, per diem Adding prior authorization in IL |
H0037 |
Community Psychiatric Supportive Treatment program, Per diem Adding prior authorization in IL |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
E2360 |
Power wheelchair accessory, 22 NF nonsealed lead acid battery, each Adding prior authorization to MD |
E2362 |
Power wheelchair accessory, group 24 nonsealed lead acid battery, each Adding prior authorization to MD |
E2364 |
Power wheelchair accessory, U-1 nonsealed lead acid battery, each Adding prior authorization to MD |
E2372 |
Power wheelchair accessory, group 27 nonsealed lead acid battery, each Adding prior authorization to MD |
K0800 |
Power operated vehicle, group 1 standard, patient weight capacity up to and including Adding prior authorization to MD |
K0801 |
Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds Adding prior authorization to MD |
K0802 |
Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds Adding prior authorization to MD |
K0812 |
Power operated vehicle, not otherwise classified Adding prior authorization to MD |
K0813 |
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds Adding prior authorization to MD |
K0815 |
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds Adding prior authorization to MD |
K0898 |
POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED Adding prior authorization to TN, VA and MD |
K0820 |
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds Adding prior authorization to TN, VA and MD |
K0822 |
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds Adding prior authorization to TN, VA and MD |
K0823 |
Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including Adding prior authorization to TN, VA and MD |
K0825 |
Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds Adding prior authorization to TN, VA and MD |
K0830 |
Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds Adding prior authorization to TN, VA and MD |
K0831 |
Power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds Adding prior authorization to TN, VA and MD |
K0835 |
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Adding prior authorization to TN, VA and MD |
K0837 |
Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds Adding prior authorization to TN, VA and MD |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
B4150 |
ENTRL FRMLA CATEG I SEMI-SYN PROTEIN 100 CAL=1U Adding prior authorization to all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
58720 |
Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Adding prior authorization to AL |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
V5252 |
Hearing aid, digitally programmable, binaural, ITE Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX |
V5253 |
Hearing aid, digitally programmable, binaural, ITE Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX |
V5298 |
Hearing aid, not otherwise classified Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX |
V5299 |
Hearing service, miscellaneous Adding prior authorization to AZ, MD, NC, OK, TN, LS, IL and TX |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
T1001 |
Nursing assessment/evaluation Adding prior authorization to OK |
T1004 |
Services of a qualified nursing aide, up to 15 minutes Adding prior authorization to OK |
S9122 |
HOME HEALTH AIDE/CNA CARE/HOME/HOUR Adding prior authorization to OK, AZ and TN |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
58760 |
FIMBRIOPLASTY Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA |
89260 |
SPERM ISOLATN; SIMPL PREP-INSEM/DX W/SEMEN ANAL Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA |
89261 |
SPERM ISOLATN; CMPLX PREP-INSEM/DX W/SEMEN ANAL Adding prior authorization to AL, AZ, FL, GA, LA,MI, NC, OK, TN, TX, VA, WA |
S4027 |
STORAGE OF PREVIOUSLY FROZEN EMBRYOS Adding prior authorization to MD and IL |
S4040 |
MON & STOR CRYOPRESRV EMBRYOS 30 DA Adding prior authorization to MD and IL |
S4042 |
MANAGEMENT OF OVULATION INDUCTION PER CYCLE Adding prior authorization to MD and IL |
S4017 |
INCPL CYCL TX CANCELD PRIOR TO STIM Adding prior authorization to MD and IL |
S4018 |
FROZEN EMBRYO TRANSFER PROCEDURE CANCELLED BEFORE TRANSFER, CASE RATE Adding prior authorization to MD and IL |
S4020 |
IN VITRO FERTILIZATION PROCEDURE CANCELLED BEFORE ASPIRATION, CASE RATE Adding prior authorization to MD and IL |
S4021 |
IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE Adding prior authorization to MD and IL |
58770 |
SALPINGOSTOMY (SALPINGONEOSTOMY) Adding prior authorization to AL |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
S0122 |
Injection, menotropins, 75 IU Adding prior authorization to MD and IL |
S0126 |
Injection, follitropin alfa, 75 IU Adding prior authorization to MD and IL |
S0128 |
Injection, follitropin beta, 75 IU Adding prior authorization to MD and IL |
S0132 |
Injection, ganirelix acetate, 250 mcg Adding prior authorization to MD and IL |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
96130 |
Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report and interactive feedback to the patient, family member(s) or caregiver(s), when performed, first hour Adding prior authorization to all states |
96131 |
Psychological testing evaluation services, by physician or other qualified health care professional, Adding prior authorization to all states |
96136 |
Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, 2 or more tests, any method, first 30 minutes Adding prior authorization to all states |
96137 |
Psychological or neuropsychological test admin and scoring by physician or other qualified health care professional, 2 or more tests, any method, each additional 30 minutes Adding prior authorization to all states |
96138 |
Psychological or neuropsychological test admin and scoring by technician, 2 or more tests, Adding prior authorization to all states |
96139 |
Psychological or neuropsychological test admin and scoring by technician, 2 or more tests, Adding prior authorization to all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
11981 |
Insertion of drug delivery implant device Adding prior authorization to all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
19300 |
MASTECTOMY FOR GYNECOMASTIA Adding prior authorization to MD |
15847 |
EXCIS, XS SKIN AND SUBCUT TISSUE ABDOMINOPLASTY (LIST SEPARATELY) Adding prior authorization to all states |
| CPT® code | Description |
|---|---|
| SBRT/SRS | |
T1000 |
PRIVATE DUTY/INDEPENDEND NURSING LICENSED UP TO 15 MIN Adding prior authorization to VA |
T1002 |
RN SERVICES, UP TO 15 MINUTES Adding prior authorization to MD and VA |
T1003 |
LPN/LVN SERVICES, UP TO 15 MINUTES Adding prior authorization to MD and VA |
Questions?
Call Provider Services at 888-478-4760.