Listing of Services that Require Authorization ... - HomeTownHealth

Authorization is always required for the following services:
• Services rendered by non-participating providers and facilities
• Inpatient confinements including: Elective Inpatient, Acute Inpatient, Skilled Nursing Facility, Behavioral Health, Rehabilitation and Long-term/Sub-acute care services
• Advanced Radiological, Diagnostic Cardiac, Musculoskeletal (Pain Management) and Diagnostic Sleep services
• Behavioral Health – Managed by Magellan
• Durable Medical Equipment (DME) – Refer to the DME and O/P Authorization List for details
• Orthotic/Prosthetics (O/P) – Refer to the DME and O/P Authorization List for details
• Home Health Care
• Ophthalmology services – Managed by Avesis
• Select Pharmaceuticals
• Skilled Therapy Services: Occupational, Physical and Speech Therapy services
• Transplant services
PROCEDURE
CODE
PROGRAM DESCRIPTION
ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED
POS 11 POS 22 POS 24
1935 Musculoskeletal PROCEDURES ON THE SPINE AND SPINAL CORD;
DIAGNOSTIC
ANESTHESIA FOR PERCUTANEOUS IMAGE GUIDED
Authorization Required Authorization Required No Authorization Required
1936 Musculoskeletal PROCEDURES ON THE SPINE AND SPINAL CORD;
THERAPEUTIC
ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC
Authorization Required Authorization Required No Authorization Required
1991 Musculoskeletal
NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR
INJECTION IS PERFORMED BY A DIFFERENT PROVIDER);
OTHER THAN THE PRONE POSITION
ANESTHESIA FOR DIAGNOSTIC OR THERAPEUTIC
Authorization Required Authorization Required No Authorization Required
1992 Musculoskeletal
NERVE BLOCKS AND INJECTIONS (WHEN BLOCK OR
INJECTION IS PERFORMED BY A DIFFERENT PROVIDER);
PRONE POSITION
Authorization Required Authorization Required No Authorization Required
10021
FINE NEEDLE ASPIRATION; WITHOUT IMAGING
No Authorization Required
GUIDANCE
ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR
Authorization Required No Authorization Required
10040
REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS,
PUSTULES)
INCISION AND DRAINAGE OF ABSCESS (EG,
No Authorization Required Authorization Required No Authorization Required
10060
CARBUNCLE, SUPPURATIVE HIDRADENITIS,
CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST,
FURUNC
INCISION AND DRAINAGE OF ABSCESS (EG,
No Authorization Required Authorization Required No Authorization Required
10061
CARBUNCLE, SUPPURATIVE HIDRADENITIS,
CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST,
FURUNC
No Authorization Required Authorization Required No Authorization Required
10120
INCISION AND REMOVAL OF FOREIGN BODY,
No Authorization Required
SUBCUTANEOUS TISSUES; SIMPLE
Authorization Required No Authorization Required
10140
INCISION AND DRAINAGE OF HEMATOMA, SEROMA
No Authorization Required
OR FLUID COLLECTION
Authorization Required No Authorization Required
10160
PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA,
No Authorization Required
BULLA, OR CYST
Authorization Required No Authorization Required
10180
INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE
No Authorization Required
WOUND INFECTION
Authorization Required No Authorization Required
11000
DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR
No Authorization Required
INFECTED SKIN; UP TO 10% OF BODY SURFACE
Authorization Required No Authorization Required
11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS No Authorization Required Authorization Required No Authorization Required
11044
DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE,
No Authorization Required
MUSCLE, AND BONE
Authorization Required No Authorization Required
11055
PARING OR CUTTING OF BENIGN HYPERKERATOTIC
No Authorization Required
LESION (EG, CORN OR CALLUS); SINGLE LESION
Authorization Required No Authorization Required
11056
PARING OR CUTTING OF BENIGN HYPERKERATOTIC
No Authorization Required
LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS
Authorization Required No Authorization Required
11057
LISTING OF SERVICES THAT REQUIRE AUTHORIZATION
March 2012
The information contained in this listing pertains to Wellcare of Georgia Medicaid and Medicare authorization requirements only. The codes contained on this list are limited to Current
Procedural Terminology (CPT codes) and do not include HCPCS codes. Separate authorization requirements may apply for HCPCPS codes.
We encourage you to verify member eligibility and confirm benefits prior to rendering services. Reimbursement for these services will be in accordance with the terms and conditions
of your agreement.
PARING OR CUTTING OF BENIGN HYPERKERATOTIC
LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 1 of 36 Authorization Requirements

PROCEDURE
CODE
11100
11101
11200
11300
11301
11302
11305
11306
11307
11308
11310
11311
11312
11400
11401
11402
11403
11404
11420
11421
11422
11441
11442
11601
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR
MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE),
UNLESS OTHERWISE LISTED; SINGLE LES
BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR
MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE),
UNLESS OTHERWISE LISTED; EACH SEPAR
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS
TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5
CM OR LESS
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6
TO 1.0 CM
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1
TO 2.0 CM
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, SCALP, NECK, HANDS, FEET, GENITALIA;
LESION DIAMETER 0.5 CM OR LESS
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, SCALP, NECK, HANDS, FEET, GENITALIA;
LESION DIAMETER 0.6 TO 1.0 CM
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, SCALP, NECK, HANDS, FEET, GENITALIA;
LESION DIAMETER 1.1 TO 2.0 CM
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, SCALP, NECK, HANDS, FEET, GENITALIA;
LESION DIAMETER OVER 2.0 CM
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; LESION DIAMETER 0.
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; LESION DIAMETER 0.
SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE
LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS
MEMBRANE; LESION DIAMETER 1.
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE),
TRUNK, ARMS OR LEGS; EXCISED DIAMETE
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE),
TRUNK, ARMS OR LEGS; EXCISED DIAMETE
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE),
TRUNK, ARMS OR LEGS; EXCISED DIAMETE
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE),
TRUNK, ARMS OR LEGS; EXCISED DIAMETE
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE),
TRUNK, ARMS OR LEGS; EXCISED DIAMETE
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP,
NECK, HANDS, FEET, GENITALIA;
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP,
NECK, HANDS, FEET, GENITALIA;
EXCISION, BENIGN LESION INCLUDING MARGINS,
EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP,
NECK, HANDS, FEET, GENITALIA;
EXCISION, OTHER BENIGN LESION INCLUDING
MARGINS, EXCEPT SKIN TAG (UNLESS LISTED
ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIP
EXCISION, OTHER BENIGN LESION INCLUDING
MARGINS, EXCEPT SKIN TAG (UNLESS LISTED
ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIP
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0
CM
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 2 of 36 Authorization Requirements

PROCEDURE
CODE
11602
11603
11604
11606
11622
11623
11641
11642
11643
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0
CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0
CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0
CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
TRUNK, ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0
CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED
DIAMETER 1.1 TO 2.0 CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED
DIAMETER 2.1 TO 3.0 CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER
0.6 TO 1.0 CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER
1.1 TO 2.0 CM
EXCISION, MALIGNANT LESION INCLUDING MARGINS,
FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER
2.1 TO 3.0 CM
11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO
11720
FIVE
DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR
11721
MORE
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE,
11730
SIMPLE; SINGLE
AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE,
11732
SIMPLE; EACH ADDITIONAL NAIL PLATE (LIST
SEPARATELY IN ADDITION TO CODE FOR P
EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR
11750
COMPLETE (EG, INGROWN OR DEFORMED NAIL), FOR
PERMANENT REMOVAL;
BIOPSY OF NAIL UNIT (EG, PLATE, BED, MATRIX,
11755
HYPONYCHIUM, PROXIMAL AND LATERAL NAIL FOLDS)
(SEPARATE PROCEDURE)
WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, FOR
11765
INGROWN TOENAIL)
INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7
11900
LESIONS
11901 INJECTION, INTRALESIONAL; MORE THAN 7 LESIONS
11975 INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES
11976 REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES
INSERTION, NON-BIODEGRADABLE DRUG DELIVERY
11981
IMPLANT
REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY
11982
IMPLANT
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,
12001
NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR
EXTREMITIES (INCLUDING HANDS
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP,
12002
NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR
EXTREMITIES (INCLUDING HANDS
SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE,
12013
EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS
MEMBRANES; 2.6 CM TO 5.0 CM
TREATMENT OF SUPERFICIAL WOUND DEHISCENCE;
12021
WITH PACKING
LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE,
12031
TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS
AND FEET); 2.5 CM OR LESS
LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE,
12032
TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS
AND FEET); 2.6 CM TO 7.5 CM
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 3 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
12042
LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET
No Authorization Required
AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM
LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS,
Authorization Required No Authorization Required
12052
NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO
5.0 CM
No Authorization Required Authorization Required No Authorization Required
13101 REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM No Authorization Required Authorization Required No Authorization Required
13121
REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6
No Authorization Required
CM TO 7.5 CM
REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH,
Authorization Required No Authorization Required
13131
NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 1.1
CM TO 2.5 CM
REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH,
No Authorization Required Authorization Required No Authorization Required
13132
NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6
CM TO 7.5 CM
No Authorization Required Authorization Required No Authorization Required
13151
REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;
No Authorization Required
1.1 CM TO 2.5 CM
Authorization Required No Authorization Required
13152
REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS;
No Authorization Required
2.6 CM TO 7.5 CM
ADJACENT TISSUE TRANSFER OR REARRANGEMENT,
Authorization Required No Authorization Required
14020
SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR
LESS
ADJACENT TISSUE TRANSFER OR REARRANGEMENT,
No Authorization Required Authorization Required No Authorization Required
14041
FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE,
GENITALIA, HANDS AND/OR FEET; DEF
ADJACENT TISSUE TRANSFER OR REARRANGEMENT,
No Authorization Required Authorization Required No Authorization Required
14060
EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM
OR LESS
FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT
No Authorization Required Authorization Required No Authorization Required
15260
CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS,
AND/OR LIPS; 20 SQ CM OR LESS
No Authorization Required Authorization Required No Authorization Required
15770 GRAFT; DERMA-FAT-FASCIA
No Authorization Required Authorization Required No Authorization Required
15823
BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE
No Authorization Required
SKIN WEIGHTING DOWN LID
Authorization Required No Authorization Required
16000
INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO
No Authorization Required
MORE THAN LOCAL TREATMENT IS REQUIRED
DESTRUCTION (EG, LASER SURGERY,
Authorization Required No Authorization Required
17000
ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,
SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG
DESTRUCTION (EG, LASER SURGERY,
No Authorization Required Authorization Required No Authorization Required
17003
ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,
SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG
DESTRUCTION (EG, LASER SURGERY,
No Authorization Required Authorization Required No Authorization Required
17004
ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,
SURGICAL CURETTEMENT), PREMALIGNANT LESIONS
(EG
DESTRUCTION OF CUTANEOUS VASCULAR
No Authorization Required Authorization Required No Authorization Required
17106
PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS
THAN 10 SQ CM
No Authorization Required Authorization Required No Authorization Required
17110
17111
17250
17261
17262
17263
17272
DESTRUCTION (EG, LASER SURGERY,
ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,
SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER
DESTRUCTION (EG, LASER SURGERY,
ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY,
SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER
CHEMICAL CAUTERIZATION OF GRANULATION TISSUE
(PROUD FLESH, SINUS OR FISTULA)
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK,
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK,
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK,
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP,
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 4 of 36 Authorization Requirements

PROCEDURE
CODE
17281
17282
17311
17312
17313
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), FACE,
DESTRUCTION, MALIGNANT LESION (EG, LASER
SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY, SURGICAL CURETTEMENT), FACE,
MOHS MICROGRAPHIC TECHNIQUE, INCLUDING
REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION
OF TISSUE SPECIMENS, MAPPING, COLOR C
MOHS MICROGRAPHIC TECHNIQUE, INCLUDING
REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION
OF TISSUE SPECIMENS, MAPPING, COLOR C
MOHS MICROGRAPHIC TECHNIQUE, INCLUDING
REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION
OF TISSUE SPECIMENS, MAPPING, COLOR C
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE No Authorization Required Authorization Required
BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE,
No Authorization Required
19100
NOT USING IMAGING GUIDANCE (SEPARATE
PROCEDURE)
No Authorization Required Authorization Required No Authorization Required
20520
REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON
No Authorization Required
SHEATH; SIMPLE
Authorization Required No Authorization Required
20526
INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC,
No Authorization Required
CORTICOSTEROID), CARPAL TUNNEL
Authorization Required No Authorization Required
20550
INJECTION(S); SINGLE TENDON SHEATH, OR
No Authorization Required
LIGAMENT, APONEUROSIS (EG, PLANTAR "FASCIA")
Authorization Required No Authorization Required
20551 INJECTION(S); SINGLE TENDON ORIGIN/INSERTION No Authorization Required Authorization Required No Authorization Required
20552 Musculoskeletal
INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S),
1OR 2 MUSCLE(S)
Authorization Required Authorization Required No Authorization Required
20553 Musculoskeletal
INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S),
3 OR MORE MUSCLE(S)
Authorization Required Authorization Required No Authorization Required
20600
ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;
No Authorization Required
SMALL JOINT OR BURSA (EG, FINGERS, TOES)
ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;
Authorization Required No Authorization Required
20605
INTERMEDIATE JOINT OR BURSA (EG,
TEMPOROMANDIBULAR, ACROMIOCLAVICULAR,
WRIST,
ARTHROCENTESIS, ASPIRATION AND/OR INJECTION;
No Authorization Required Authorization Required No Authorization Required
20610
MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE
JOINT, SUBACROMIAL BURSA)
No Authorization Required Authorization Required No Authorization Required
20612
ASPIRATION AND/OR INJECTION OF GANGLION CYST(S)
No Authorization Required
ANY LOCATION
Authorization Required No Authorization Required
20670
REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED
No Authorization Required
WIRE, PIN OR ROD) (SEPARATE PROCEDURE)
Authorization Required No Authorization Required
21025
EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE
No Authorization Required
ABSCESS); MANDIBLE
PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY
Authorization Required No Authorization Required
22520 Musculoskeletal INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY,
UNILATERAL OR BILATERAL INJECTION; THORACIC
PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY
Authorization Required Authorization Required No Authorization Required
22521 Musculoskeletal INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY,
UNILATERAL OR BILATERAL INJECTION; LUMBAR
PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY
INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY,
Authorization Required Authorization Required No Authorization Required
22522 Musculoskeletal
UNILATERAL OR BILATERAL INJECTION; EACH
ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY
(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
PERCUTANEOUS VERTEBRAL AUGMENTATION,
INCLUDING CAVITY CREATION (FRACTURE REDUCTION
Authorization Required Authorization Required No Authorization Required
22523 Musculoskeletal
AND BONE BIOPSY INCLUDED WHEN PERFORMED)
USING MECHANICAL DEVISE, 1 VERTEBRAL BODY,
UNILATERAL OR BILATERAL CANNULATION (EG,
KYPHOPLASTY); THORACIC
PERCUTANEOUS VERTEBRAL AUGMENTATION,
INCLUDING CAVITY CREATION (FRACTURE REDUCTION
Authorization Required Authorization Required No Authorization Required
22524 Musculoskeletal
AND BONE BIOPSY INCLUDED WHEN PERFORMED)
USING MECHANICAL DEVISE, 1 VERTEBRAL BODY,
UNILATERAL OR BILATERAL CANNULATION (EG,
KYPHOPLASTY); LUMBAR
Authorization Required Authorization Required No Authorization Required
Updated March 2012 5 of 36 Authorization Requirements

PROCEDURE
CODE
22525 Musculoskeletal
22526 Musculoskeletal
22527 Musculoskeletal
23500
23600
24500
24530
24576
24640
24650
24670
25260
25500
25505
25530
25560
25600
25622
26600
26605
26720
26725
26750
27096 Musculoskeletal
27530
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL
BODY (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
PERCUTANEOUS INTRADISCAL ELECTROTHERMAL
ANNULOPLASTY, UNILATERAL OR BILATERAL
INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
PERCUTANEOUS INTRADISCAL ELECTROTHERMAL
ANNULOPLASTY, UNILATERAL OR BILATERAL
INCLUDING FLUOROSCOPIC GUIDANCE; ONE OR MORE
ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO
CODE FOR PRIMARY PROCEDURE)
Authorization Required Authorization Required No Authorization Required
CLOSED TREATMENT OF CLAVICULAR FRACTURE;
No Authorization Required
WITHOUT MANIPULATION
CLOSED TREATMENT OF PROXIMAL HUMERAL
Authorization Required No Authorization Required
(SURGICAL OR ANATOMICAL NECK) FRACTURE; No Authorization Required Authorization Required No Authorization Required
WITHOUT MANIPULATION
CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE;
No Authorization Required
WITHOUT MANIPULATION
CLOSED TREATMENT OF SUPRACONDYLAR OR
Authorization Required No Authorization Required
TRANSCONDYLAR HUMERAL FRACTURE, WITH OR
WITHOUT INTERCONDYLAR EXTENSION; WITHOUT
MANI
CLOSED TREATMENT OF HUMERAL CONDYLAR
No Authorization Required Authorization Required No Authorization Required
FRACTURE, MEDIAL OR LATERAL; WITHOUT No Authorization Required Authorization Required No Authorization Required
MANIPULATION
CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION
IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION
CLOSED TREATMENT OF RADIAL HEAD OR NECK
FRACTURE; WITHOUT MANIPULATION
CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL
END (EG, OLECRANON OR CORONOID PROCESS[ES]);
WITHOUT MANIPULATION
REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM
AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR
MUSCLE
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE;
WITHOUT MANIPULATION
CLOSED TREATMENT OF RADIAL SHAFT FRACTURE;
WITH MANIPULATION
CLOSED TREATMENT OF ULNAR SHAFT FRACTURE;
WITHOUT MANIPULATION
CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT
FRACTURES; WITHOUT MANIPULATION
CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG,
COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION,
INCLUDES CLOSED TREATMENT
CLOSED TREATMENT OF CARPAL SCAPHOID
(NAVICULAR) FRACTURE; WITHOUT MANIPULATION
CLOSED TREATMENT OF METACARPAL FRACTURE,
SINGLE; WITHOUT MANIPULATION, EACH BONE
CLOSED TREATMENT OF METACARPAL FRACTURE,
SINGLE; WITH MANIPULATION, EACH BONE
CLOSED TREATMENT OF PHALANGEAL SHAFT
FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER
OR THUMB; WITHOUT MANIPULATION, EACH
CLOSED TREATMENT OF PHALANGEAL SHAFT
FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER
OR THUMB; WITH MANIPULATION, WITH OR WIT
CLOSED TREATMENT OF DISTAL PHALANGEAL
FRACTURE, FINGER OR THUMB; WITHOUT
MANIPULATION, EACH
INJECTION PROCEDURE FOR SACROILIAC JOINT,
ANESTHETIC/STEROID, WITH IMAGE GUIDANCE
(FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY
WHEN PERFORMED
CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL
(PLATEAU); WITHOUT MANIPULATION
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 6 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE
POS 11 POS 22 POS 24
27750
(WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT
MANIPULATION
No Authorization Required Authorization Required No Authorization Required
27760
CLOSED TREATMENT OF MEDIAL MALLEOLUS
No Authorization Required
FRACTURE; WITHOUT MANIPULATION
Authorization Required No Authorization Required
27786
CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE
No Authorization Required
(LATERAL MALLEOLUS); WITHOUT MANIPULATION
CLOSED TREATMENT OF BIMALLEOLAR ANKLE
Authorization Required No Authorization Required
27808
FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR
LATERAL AND POSTERIOR MALLEOLI OR MEDI
CLOSED TREATMENT OF FRACTURE OF WEIGHT
No Authorization Required Authorization Required No Authorization Required
27824
BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG,
PILON OR TIBIAL PLAFOND), WITH OR WI
No Authorization Required Authorization Required No Authorization Required
28008 FASCIOTOMY, FOOT AND/OR TOE
No Authorization Required Authorization Required No Authorization Required
28043 EXCISION, TUMOR, FOOT; SUBCUTANEOUS TISSUE No Authorization Required Authorization Required No Authorization Required
28190 REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS
28270
28470
28490
28510
29806
29807
29822
29823
29824
29826
29827
29848
29870
29873
29874
29875
29876
29877
29879
29880
CAPSULOTOMY; METATARSOPHALANGEAL JOINT,
WITH OR WITHOUT TENORRHAPHY, EACH JOINT
(SEPARATE PROCEDURE)
CLOSED TREATMENT OF METATARSAL FRACTURE;
WITHOUT MANIPULATION, EACH
CLOSED TREATMENT OF FRACTURE GREAT TOE,
PHALANX OR PHALANGES; WITHOUT MANIPULATION
CLOSED TREATMENT OF FRACTURE, PHALANX OR
PHALANGES, OTHER THAN GREAT TOE; WITHOUT
MANIPULATION, EACH
ARTHROSCOPY, SHOULDER, SURGICAL;
CAPSULORRHAPHY
ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF
SLAP LESION
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT,
LIMITED
ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT,
EXTENSIVE
ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL
CLAVICULECTOMY INCLUDING DISTAL ARTICULAR
SURFACE (MUMFORD PROCEDURE)
ARTHROSCOPY, SHOULDER, SURGICAL;
DECOMPRESSION OF SUBACROMIAL SPACE WITH
PARTIAL ACROMIOPLASTY, WITH OR WITHOUT
CORACOACRO
ARTHROSCOPY, SHOULDER, SURGICAL; WITH
ROTATOR CUFF REPAIR
ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF
TRANSVERSE CARPAL LIGAMENT
ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR
WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)
ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL
RELEASE
ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF
LOOSE BODY OR FOREIGN BODY (EG,
OSTEOCHONDRITIS DISSECANS FRAGMENTATION,
CHOND
ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY,
LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE
PROCEDURE)
ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY,
MAJOR, TWO OR MORE COMPARTMENTS (EG, MEDIAL
OR LATERAL)
ARTHROSCOPY, KNEE, SURGICAL;
DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE
(CHONDROPLASTY)
ARTHROSCOPY, KNEE, SURGICAL; ABRASION
ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE
NECESSARY) OR MULTIPLE DRILLING OR MICROF
ARTHROSCOPY, KNEE, SURGICAL; WITH
MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING
ANY MENISCAL SHAVING)
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 7 of 36 Authorization Requirements

PROCEDURE
CODE
29881
29882
29888
30130
30300
30901
30903
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
ARTHROSCOPY, KNEE, SURGICAL; WITH
MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING
ANY MENISCAL SHAVING)
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS
REPAIR (MEDIAL OR LATERAL)
ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE
LIGAMENT REPAIR/AUGMENTATION OR
RECONSTRUCTION
EXCISION INFERIOR TURBINATE, PARTIAL OR
COMPLETE, ANY METHOD
REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE
PROCEDURE
CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE
(LIMITED CAUTERY AND/OR PACKING) ANY METHOD
CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX
(EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD
LAVAGE BY CANNULATION; MAXILLARY SINUS
31000
(ANTRUM PUNCTURE OR NATURAL OSTIUM)
31002 LAVAGE BY CANNULATION; SPHENOID SINUS
NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR
31231
BILATERAL (SEPARATE PROCEDURE)
NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH
31233
MAXILLARY SINUSOSCOPY (VIA INFERIOR MEATUS OR
CANINE FOSSA PUNCTURE)
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY,
31237
POLYPECTOMY OR DEBRIDEMENT (SEPARATE
PROCEDURE)
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL
31238
OF NASAL HEMORRHAGE
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA
31240
BULLOSA RESECTION
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH
31254
ETHMOIDECTOMY, PARTIAL (ANTERIOR)
NASAL/SINUS ENDOSCOPY, SURGICAL; WITH
31255
ETHMOIDECTOMY, TOTAL (ANTERIOR AND
POSTERIOR)
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH
31256
MAXILLARY ANTROSTOMY;
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH
31267
MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE
FROM MAXILLARY SINUS
NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL
31276
SINUS EXPLORATION, WITH OR WITHOUT REMOVAL
OF TISSUE FROM FRONTAL SINUS
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH
31287
SPHENOIDOTOMY;
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH
31288
SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM
THE SPHENOID SINUS
LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE
31505
PROCEDURE)
LARYNGOSCOPY DIRECT, WITH OR WITHOUT
31525
TRACHEOSCOPY; DIAGNOSTIC, EXCEPT NEWBORN
LARYNGOSCOPY DIRECT, WITH OR WITHOUT
31526
TRACHEOSCOPY; DIAGNOSTIC, WITH OPERATING
MICROSCOPE OR TELESCOPE
31535 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;
LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY;
31536
WITH OPERATING MICROSCOPE OR TELESCOPE
LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION
31540
OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR
EPIGLOTTIS;
LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION
31541
OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR
EPIGLOTTIS; WITH OPERATING MICR
31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC
LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, WITH
31579
STROBOSCOPY
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
31622
WITHOUT FLUOROSCOPIC GUIDANCE; DIAGNOSTIC,
WITH OR WITHOUT CELL WASHING (SEPARATE
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 8 of 36 Authorization Requirements

PROCEDURE
CODE
31623
31624
31625
31628
31629
33206 Cardiology
33207 Cardiology
33208 Cardiology
33212 Cardiology
33213 Cardiology
33214 Cardiology
33221 Cardiology
33224 Cardiology
33225 Cardiology
33227 Cardiology
33228 Cardiology
33229 Cardiology
33230 Cardiology
33231 Cardiology
33240 Cardiology
33249 Cardiology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
WITHOUT FLUOROSCOPIC GUIDANCE; WITH
BRUSHING OR PROTECTED BRUSHINGS
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
WITHOUT FLUOROSCOPIC GUIDANCE; WITH
BRONCHIAL ALVEOLAR LAVAGE
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
WITHOUT FLUOROSCOPIC GUIDANCE; WITH
BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
WITHOUT FLUOROSCOPIC GUIDANCE; WITH
TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE
BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR
WITHOUT FLUOROSCOPIC GUIDANCE; WITH
TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), T
INSERTION OF NEW OR REPLACEMENT OF
PERMANENT PACEMAKER WITH TRANSVENOUS
ELECTRODE(S); ATRIAL
INSERTION OF NEW OR REPLACEMENT OF
PERMANENT PACEMAKER WITH TRANSVENOUS
ELECTRODE(S); VENTRICULAR
INSERTION OF NEW OR REPLACEMENT OF
PERMANENT PACEMAKER WITH TRANSVENOUS
ELECTRODE(S); ATRIAL AND VENTRICULAR
INSERTION OF PACEMAKER PULSE GENERATOR ONLY;
WITH EXISTING SINGLE LEAD
INSERTION OF PACEMAKER PULSE GENERATOR ONLY;
WITH EXISTING DUAL LEADS
UPGRADE OF IMPLANTED PACEMAKER SYSTEM,
CONVERSION OF SINGLE CHAMBER SYSTEM TO DUAL
CHAMBER SYSTEM (INCLUDES REMOVAL OF
PREVIOUSLY PLACED PULSE GENERATOR, TESTING OF
EXISTING LEAD, INSERTION OF NEW LEAD, INSERTION
OF NEW GENERATOR)
INSERTION OF PACEMAKER PULSE GENERATOR ONLY;
WITH EXISTING MULTIPLE LEADS
INSERTION OF PACING ELECTRODE, CARDIAC VENOUS
SYSTEM, FOR LEFT VENTRICULAR PACING, WITH
ATTACHMENT TO PREVIOUSLY PLACED PACEMAKER
OR PACING CARDIOVERTER-DEFIBRILLATOR PULSE
GENERATOR (INCLUDING REVISION OF POCKET,
REMOVAL, INSERTION, AND/OR REPLACEMENT OF
EXISTING GENERATOR)
INSERTION OF PACING ELECTRODE, CARDIAC VENOUS
SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF
INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR
OR PACEMAKER PULSE GENERATOR (INCLUDING
UPGRADE TO DUAL CHAMBER SYSTEM AND POCKET
REVISION) (LIST SEPARATELY IN ADDITION TO CODE
FOR PRIMARY PROCEDURE)
REMOVAL OF PERMANENT PACEMAKER PULSE
GENERATOR WITH REPLACEMENT OF PACEMAKER
PULSE GENERATOR; SINGLE LEAD SYSTEM
REMOVAL OF PERMANENT PACEMAKER PULSE
GENERATOR WITH REPLACEMENT OF PACEMAKER
PULSE GENERATOR; DUAL LEAD SYSTEM
REMOVAL OF PERMANENT PACEMAKER PULSE
GENERATOR WITH REPLACEMENT OF PACEMAKER
PULSE GENERATOR; MULTIPLE LEAD SYSTEM
INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR ONLY; WITH EXISTING DUAL LEADS
INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR ONLY; WITH EXISTING MULTIPLE
LEADS
INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR ONLY; WITH EXISTING SINGLE LEAD
INSERTION OR REPLACEMENT OF PERMANENT PACING
CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH
TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 9 of 36 Authorization Requirements

PROCEDURE
CODE
33262 Cardiology
33263 Cardiology
33264 Cardiology
36011
36012
36145
36147
36148
36471
36475
36478
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR WITH REPLACEMENT OF PACING
CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR;
SINGLE LEAD SYSTEM
REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR WITH REPLACEMENT OF PACING
CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR;
DUAL LEAD SYSTEM
REMOVAL OF PACING CARDIOVERTER-DEFIBRILLATOR
PULSE GENERATOR WITH REPLACEMENT OF PACING
CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR;
MULTIPLE LEAD SYSTEM
SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM;
FIRST ORDER BRANCH (EG, RENAL VEIN, JUGULAR
VEIN)
SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM;
SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG,
LEFT ADRENAL VEIN, PETROSAL SINU
INTRODUCTION OF NEEDLE OR INTRACATHETER;
ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS
(CANNULA, FISTULA, OR GRAFT)
INTRODUCTION OF NEEDLE AND/OR CATHETER,
ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS
(GRAFT/FISTULA); INITIAL ACCESS WITH COMPLETE
RAD
INTRODUCTION OF NEEDLE AND/OR CATHETER,
ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS
(GRAFT/FISTULA); ADDITIONAL ACCESS FOR
THERAPEUTI
INJECTION OF SCLEROSING SOLUTION; MULTIPLE
VEINS, SAME LEG
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT
VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING
GUIDANCE AND MONITORING, PERCUTANEOUS
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT
VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING
GUIDANCE AND MONITORING, PERCUTANEOUS
37765
STAB PHLEBECTOMY OF VARICOSE VEINS, ONE
EXTREMITY; 10-20 STAB INCISIONS
38220 BONE MARROW; ASPIRATION ONLY
40490 BIOPSY OF LIP
40812
41520
42820
42821
42825
42826
EXCISION OF LESION OF MUCOSA AND SUBMUCOSA,
VESTIBULE OF MOUTH; WITH SIMPLE REPAIR
FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG,
WITH Z-PLASTY)
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER
THAN AGE 12
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR
OVER
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER
THAN AGE 12
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12
OR OVER
42830 ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12
42831 ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER
42835
ADENOIDECTOMY, SECONDARY; YOUNGER THAN AGE
12
ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC,
43200
WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY
BRUSHING OR WASHING (SEPARATE P
43215
ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL
OF FOREIGN BODY
43235
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; DIAG
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 10 of 36 Authorization Requirements

PROCEDURE
CODE
43236
43239
43242
43244
43245
43246
43247
43248
43249
43250
43251
43255
43259
43450
43760
44361
45300
45330
45331
45378
45380
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING
ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM
AND/OR JEJUNUM AS APPROPRIATE; WITH
DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR
BOUGIE, SINGLE OR MULTIPLE PASSES
CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS,
WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE
SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY
BEYOND SECOND PORTION OF DUODENUM, NOT
INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MUL
PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH
OR WITHOUT COLLECTION OF SPECIMEN(S) BY
BRUSHING OR WASHING (SEPARATE PROCEDU
SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR
WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING
OR WASHING (SEPARATE PROCEDURE)
SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR
MULTIPLE
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; DIAGNOSTIC, WITH OR WITHOUT
COLLECTION OF SPECIMEN(S) BY BRUSHING OR W
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH BIOPSY, SINGLE OR MULTIPLE
No Authorization Required Authorization Required No Authorization Required
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Updated March 2012 11 of 36 Authorization Requirements

PROCEDURE
CODE
45381
45382
45383
45384
45385
45990
46221
46600
46924
46930
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH DIRECTED SUBMUCOSAL INJECTION(S),
ANY SUBSTANCE
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH CONTROL OF BLEEDING (EG,
INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAU
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), OR
OTHER LESION(S) NOT AMENABLE T
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR
OTHER LESION(S) BY HOT BIOPSY F
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC
FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR
OTHER LESION(S) BY SNARE TECHNI
ANORECTAL EXAM, SURGICAL, REQUIRING
ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL),
DIAGNOSTIC
HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG,
RUBBER BAND)
ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT
COLLECTION OF SPECIMEN(S) BY BRUSHING OR
WASHING (SEPARATE PROCEDURE)
DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA,
PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC
VESICLE), EXTENSIVE (EG, LASER S
DESTRUCTION INTERNAL HEMORRHOID THERMAL
ENERGY DESTRUCTION OF INTERNAL HEMORRHOID(S)
BY THERMAL ENERGY (EG, INFRARED COAGULATION,
46946
LIGATION OF INTERNAL HEMORRHOIDS; MULTIPLE
PROCEDURES
51700
BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR
INSTILLATION
INSERTION OF NON-INDWELLING BLADDER CATHETER
51701
(EG, STRAIGHT CATHETERIZATION FOR RESIDUAL
URINE)
51702
INSERTION OF TEMPORARY INDWELLING BLADDER
CATHETER; SIMPLE (EG, FOLEY)
INSERTION OF TEMPORARY INDWELLING BLADDER
51703
CATHETER; COMPLICATED (EG, ALTERED ANATOMY,
FRACTURED CATHETER/BALLOON)
51705 CHANGE OF CYSTOSTOMY TUBE; SIMPLE
51720
BLADDER INSTILLATION OF ANTICARCINOGENIC
AGENT (INCLUDING RETENTION TIME)
51725
SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL
MANOMETER)
51726
COMPLEX CYSTOMETROGRAM (EG, CALIBRATED
ELECTRONIC EQUIPMENT)
51727
51728
51729
51736
51741
51772
51784
COMPLEX CYSTOMETROGRAM (IE, CALIBRATED
ELECTRONIC EQUIPMENT); WITH URETHRAL PRESSURE
PROFILE STUDIES (IE, URETHRAL CLOSURE PRESSUR
COMPLEX CYSTOMETROGRAM (IE, CALIBRATED
ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE
STUDIES (IE, BLADDER VOIDING PRESSURE), ANY TE
COMPLEX CYSTOMETROGRAM (IE, CALIBRATED
ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE
STUDIES (IE, BLADDER VOIDING PRESSURE) AND URE
SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH
FLOW RATE, MECHANICAL UROFLOWMETER)
COMPLEX UROFLOWMETRY (EG, CALIBRATED
ELECTRONIC EQUIPMENT)
URETHRAL PRESSURE PROFILE STUDIES (UPP)
(URETHRAL CLOSURE PRESSURE PROFILE), ANY
TECHNIQUE
ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR
URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY
TECHNIQUE
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 12 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
51785
NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF
No Authorization Required
ANAL OR URETHRAL SPHINCTER, ANY TECHNIQUE
Authorization Required No Authorization Required
51792
STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF
No Authorization Required
BULBOCAVERNOSUS REFLEX LATENCY TIME)
Authorization Required No Authorization Required
51795
VOIDING PRESSURE STUDIES (VP); BLADDER VOIDING
No Authorization Required
PRESSURE, ANY TECHNIQUE
VOIDING PRESSURE STUDIES (VP); INTRA-ABDOMINAL
Authorization Required No Authorization Required
51797
VOIDING PRESSURE (AP) (RECTAL, GASTRIC,
INTRAPERITONEAL) (LIST SEPARATELY I
MEASUREMENT OF POST-VOIDING RESIDUAL URINE
No Authorization Required Authorization Required No Authorization Required
51798
AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-
IMAGING
No Authorization Required Authorization Required No Authorization Required
52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) No Authorization Required Authorization Required
CYSTOURETHROSCOPY, WITH FULGURATION
No Authorization Required
52214
(INCLUDING CRYOSURGERY OR LASER SURGERY) OF
TRIGONE, BLADDER NECK, PROSTATIC FOSSA, UR
CYSTOURETHROSCOPY, WITH FULGURATION
No Authorization Required Authorization Required No Authorization Required
52224
(INCLUDING CRYOSURGERY OR LASER SURGERY) OR
TREATMENT OF MINOR (LESS THAN 0.5 CM) LESI
No Authorization Required Authorization Required No Authorization Required
52275
CYSTOURETHROSCOPY, WITH INTERNAL
No Authorization Required
URETHROTOMY; MALE
CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR
Authorization Required No Authorization Required
52281
DILATION OF URETHRAL STRICTURE OR STENOSIS,
WITH OR WITHOUT MEATOTOMY, WITH OR
CYSTOURETHROSCOPY FOR TREATMENT OF THE
No Authorization Required Authorization Required No Authorization Required
52285
FEMALE URETHRAL SYNDROME WITH ANY OR ALL OF
THE FOLLOWING: URETHRAL MEATOTOMY, URET
No Authorization Required Authorization Required No Authorization Required
52310
53850
54056
CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN
BODY, CALCULUS, OR URETERAL STENT FROM
URETHRA OR BLADDER (SEPARATE PROCEDURE);
TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE;
BY MICROWAVE THERMOTHERAPY
DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA,
PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC
VESICLE), SIMPLE; CRYOSURGERY
CIRCUMCISION, USING CLAMP OR OTHER DEVICE
54150
WITH REGIONAL DORSAL PENILE OR RING BLOCK
CIRCUMCISION, SURGICAL EXCISION OTHER THAN
54160
CLAMP, DEVICE, OR DORSAL SLIT; NEONATE (28 DAYS
OF AGE OR LESS)
INJECTION OF CORPORA CAVERNOSA WITH
54235
PHARMACOLOGIC AGENT(S) (EG, PAPAVERINE,
PHENTOLAMINE)
FORESKIN MANIPULATION INCLUDING LYSIS OF
54450
PREPUTIAL ADHESIONS AND STRETCHING
VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE
55250
PROCEDURE), INCLUDING POSTOPERATIVE SEMEN
EXAMINATION(S)
BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR
55700
MULTIPLE, ANY APPROACH
PLACEMENT OF INTERSTITIAL DEVICE(S) FOR
55876
RADIATION THERAPY GUIDANCE (EG, FIDUCIAL
MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE
INCISION AND DRAINAGE OF VULVA OR PERINEAL
56405
ABSCESS
INCISION AND DRAINAGE OF BARTHOLIN'S GLAND
56420
ABSCESS
56441 LYSIS OF LABIAL ADHESIONS
DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG,
56501
LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY)
DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG,
56515
LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY)
BIOPSY OF VULVA OR PERINEUM (SEPARATE
56605
PROCEDURE); ONE LESION
56820 COLPOSCOPY OF THE VULVA;
DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG,
57061
LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY)
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 13 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG,
POS 11 POS 22 POS 24
57065
LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
CHEMOSURGERY)
No Authorization Required Authorization Required No Authorization Required
57100
BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE
No Authorization Required
PROCEDURE)
IRRIGATION OF VAGINA AND/OR APPLICATION OF
Authorization Required No Authorization Required
57150
MEDICAMENT FOR TREATMENT OF BACTERIAL,
PARASITIC, OR FUNGOID DISEASE
No Authorization Required Authorization Required No Authorization Required
57155
INSERTION OF UTERINE TANDEMS AND/OR VAGINAL
No Authorization Required
OVOIDS FOR CLINICAL BRACHYTHERAPY
Authorization Required No Authorization Required
57160
FITTING AND INSERTION OF PESSARY OR OTHER
No Authorization Required
INTRAVAGINAL SUPPORT DEVICE
Authorization Required No Authorization Required
57410 PELVIC EXAMINATION UNDER ANESTHESIA No Authorization Required Authorization Required No Authorization Required
57420
COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF
No Authorization Required
PRESENT;
Authorization Required No Authorization Required
57421
COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF
No Authorization Required
PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX
Authorization Required No Authorization Required
57452
COLPOSCOPY OF THE CERVIX INCLUDING
No Authorization Required
UPPER/ADJACENT VAGINA;
COLPOSCOPY OF THE CERVIX INCLUDING
Authorization Required No Authorization Required
57454
UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE No Authorization Required Authorization Required No Authorization Required
CERVIX AND ENDOCERVICAL CURETTAGE
COLPOSCOPY OF THE CERVIX INCLUDING
57455
UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF THE
CERVIX
COLPOSCOPY OF THE CERVIX INCLUDING
No Authorization Required Authorization Required No Authorization Required
57456
UPPER/ADJACENT VAGINA; WITH ENDOCERVICAL No Authorization Required Authorization Required No Authorization Required
CURETTAGE
COLPOSCOPY OF THE CERVIX INCLUDING
57460
UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE
BIOPSY(S) OF THE CERVIX
COLPOSCOPY OF THE CERVIX INCLUDING
No Authorization Required Authorization Required No Authorization Required
57461
UPPER/ADJACENT VAGINA; WITH LOOP ELECTRODE No Authorization Required Authorization Required No Authorization Required
CONIZATION OF THE CERVIX
BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL
57500
EXCISION OF LESION, WITH OR WITHOUT
FULGURATION (SEPARATE PROCEDURE)
No Authorization Required Authorization Required No Authorization Required
57505
ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A
No Authorization Required
DILATION AND CURETTAGE)
Authorization Required No Authorization Required
57510 CAUTERY OF CERVIX; ELECTRO OR THERMAL No Authorization Required Authorization Required No Authorization Required
57511
CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR
No Authorization Required
REPEAT
Authorization Required No Authorization Required
57513 CAUTERY OF CERVIX; LASER ABLATION No Authorization Required Authorization Required No Authorization Required
57800
DILATION OF CERVICAL CANAL, INSTRUMENTAL
No Authorization Required
(SEPARATE PROCEDURE)
Authorization Required No Authorization Required
58100
ENDOMETRIAL SAMPLING (BIOPSY) WITH OR
WITHOUT ENDOCERVICAL SAMPLING (BIOPSY),
WITHOUT CERVICAL DILATION, ANY METHOD (SEPAR
58300 INSERTION OF INTRAUTERINE DEVICE (IUD)
58301 REMOVAL OF INTRAUTERINE DEVICE (IUD)
CATHETERIZATION AND INTRODUCTION OF SALINE OR
58340
CONTRAST MATERIAL FOR SALINE INFUSION
SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALP
58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY)
58558
OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR
WITHOUT D & C
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF
58562
IMPACTED FOREIGN BODY
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL
58563
ABLATION (EG, ENDOMETRIAL RESECTION,
ELECTROSURGICAL ABLATION, THERMOABLATION)
HYSTEROSCOPY, SURGICAL; WITH BILATERAL
FALLOPIAN TUBE CANNULATION TO INDUCE
58565
OCCLUSION BY PLACEMENT OF PERMANENT
IMPLANTS
59000 AMNIOCENTESIS; DIAGNOSTIC
59025 FETAL NON-STRESS TEST
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 14 of 36 Authorization Requirements

PROCEDURE
CODE
61790 Musculoskeletal
61791 Musculoskeletal
62263 Musculoskeletal
62264 Musculoskeletal
62280 Musculoskeletal
62281 Musculoskeletal
62282 Musculoskeletal
62287 Musculoskeletal
62290 Musculoskeletal
62291 Musculoskeletal
62292 Musculoskeletal
62310 Musculoskeletal
62311 Musculoskeletal
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
CREATION OF LESION BY STEREOTACTIC METHOD,
PERCUTANEOUS, BY NEUROLYTIC AGENT (EG,
ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY);
GASSERIAN GANGLION
CREATION OF LESION BY STEREOTACTIC METHOD,
PERCUTANEOUS, BY NEUROLYTIC AGENT (EG,
ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY);
TRIGEMINAL MEDULLARY TRACT
PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING
SOLUTION INJECTION (EG, HYPERTONIC SALINE,
ENZYME) OR MECHANICAL MEANS (EG, CATHETER)
INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES
CONTRAST WHEN ADMINISTERED), MULTIPLE
ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS
PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING
SOLUTION INJECTION (EG, HYPERTONIC SALINE,
ENZYME) OR MECHANICAL MEANS (EG, CATHETER)
INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES
CONTRAST WHEN ADMINISTERED), MULTIPLE
ADHESIOLYSIS SESSIONS; 1DAY
INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG,
ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH
OR WITHOUT OTHER THERAPEUTIC SUBSTANCE;
SUBARACHNOID
INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG,
ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH
OR WITHOUT OTHER THERAPEUTIC SUBSTANCE;
EPIDURAL, CERVICAL OR THORACIC
INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG,
ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH
OR WITHOUT OTHER THERAPEUTIC SUBSTANCE;
EPIDURAL, LUMBAR, SACRAL (CAUDAL)
DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF
NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, ANY
METHOD UTILIZING NEEDLE BASED TECHNIQUE TO
REMOVE DISC MATERIAL UNDER FLUOROSCOPIC
IMAGING OR OTHER FORM OF INDIRECT
VISUALIZATION, WITH THE USE OF AN ENDOSCOPE,
WITH DISCOGRAPHY AND/OR EPIDURAL INJECTION(S)
AT THE TREATED LEVEL(S), WHEN PERFORMED, SINGLE
OR MULTIPLE LEVELS, LUMBAR
INJECTION PROCEDURE FOR DISCOGRAPHY, EACH
LEVEL; LUMBAR
INJECTION PROCEDURE FOR DISCOGRAPHY, EACH
LEVEL; CERVICAL OR THORACIC
INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS,
INCLUDING DISCOGRAPHY, INTERVERTEBRAL DISC,
SINGLE OR MULTIPLE LEVELS, LUMBAR
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC
SUBSTANCE(S) (INCLUDING ANESTHETIC,
ANTISPASMODIC, OPIOID, STEROID, OTHER
SOLUTION), NOT INCLUDING NEUROLYTIC
SUBSTANCES, INCLUDING NEEDLE OR CATHETER
PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION
WHEN PERFORMED, EPIDURAL OR SUBARACHNOID;
CERVICAL OR THORACIC
INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC
SUBSTANCE(S) (INCLUDING ANESTHETIC,
ANTISPASMODIC, OPIOID, STEROID, OTHER
SOLUTION), NOT INCLUDING NEUROLYTIC
SUBSTANCES, INCLUDING NEEDLE OR CATHETER
PLACEMENT, INCLUDES CONTRAST FOR LOCALIZATION
WHEN PERFORMED, EPIDURAL OR SUBARACHNOID;
LUMBAR, OR SACRAL (CAUDAL)
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 15 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
INJECTION(S), INCLUDING INDWELLING CATHETER
PLACEMENT, CONTINUOUS INFUSION OR
INTERMITTENT BOLUS OF DIAGNOSTIC OR
THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC,
POS 11 POS 22 POS 24
62318 Musculoskeletal ANTISPASMODIC, OPIOID, STEROID, OTHER
SOLUTION), NOT INCLUDING NEUROLYTIC
SUBSTANCES, INCLUDES CONTRAST FOR
LOCALIZATION WHEN PERFORMED, EPIDURAL OR
INJECTION(S), SUBARACHNOID; INCLUDING CERVICAL INDWELLING OR THORACIC CATHETER
PLACEMENT, CONTINUOUS INFUSION OR
INTERMITTENT BOLUS OF DIAGNOSTIC OR
THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC,
Authorization Required Authorization Required No Authorization Required
62319 Musculoskeletal ANTISPASMODIC, OPIOID, STEROID, OTHER
SOLUTION), NOT INCLUDING NEUROLYTIC
SUBSTANCES, INCLUDES CONTRAST FOR
LOCALIZATION WHEN PERFORMED, EPIDURAL OR
SUBARACHNOID; LUMBAR, OR SACRAL (CAUDAL)
IMPLANTATION, REVISION OR REPOSITIONING OF
TUNNELED INTRATHECAL OR EPIDURAL CATHETER,
Authorization Required Authorization Required No Authorization Required
62350 Musculoskeletal
FOR LONG-TERM MEDICATION ADMINISTRATION VIA
AN EXTERNAL PUMP OR IMPLANTABLE
RESERVOIR/INFUSION PUMP; WITHOUT
LAMINECTOMY
IMPLANTATION, REVISION OR REPOSITIONING OF
TUNNELED INTRATHECAL OR EPIDURAL CATHETER,
Authorization Required Authorization Required No Authorization Required
62351 Musculoskeletal FOR LONG-TERM MEDICATION ADMINISTRATION VIA
AN EXTERNAL PUMP OR IMPLANTABLE
RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY
IMPLANTATION OR REPLACEMENT OF DEVICE FOR
Authorization Required Authorization Required No Authorization Required
62360 Musculoskeletal INTRATHECAL OR EPIDURAL DRUG INFUSION;
SUBCUTANEOUS RESERVOIR
IMPLANTATION OR REPLACEMENT OF DEVICE FOR
Authorization Required Authorization Required No Authorization Required
62361 Musculoskeletal
INTRATHECAL OR EPIDURAL DRUG INFUSION;
SUBCUTANEOUS RESERVOIR; NONPROGRAMMABLE
PUMP
IMPLANTATION OR REPLACEMENT OF DEVICE FOR
Authorization Required Authorization Required No Authorization Required
62362 Musculoskeletal
INTRATHECAL OR EPIDURAL DRUG INFUSION;
PROGRAMMABLE PUMP, INCLUDING PREPARATION
OF PUMP, WITH OR WITHOUT PROGRAMMING
ELECTRONIC ANALYSIS OF PROGRAMMABLE,
Authorization Required Authorization Required No Authorization Required
62368
IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL
DRUG INFUSION (INCLUDES EVALUATION OF RESE
No Authorization Required Authorization Required No Authorization Required
63650 Musculoskeletal
PERCUTANEOUS IMPLANTATION OF
NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL
LAMINECTOMY FOR IMPLANTATION OF
Authorization Required Authorization Required No Authorization Required
63655 Musculoskeletal NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE,
EPIDURAL
REVISION INCLUDING REPLACEMENT, WHEN
Authorization Required Authorization Required No Authorization Required
63663 Musculoskeletal
PERFORMED, OF SPINAL NEUROSTIMULATOR
ELECTRODE PERCUTANEOUS ARRAY(S) INCLUDING
FLUOROSCOPY, WHEN PERFORMED
REVISION INCLUDING REPLACEMENT, WHEN
PERFORMED, OF SPINAL NEUROSTIMULATOR
Authorization Required Authorization Required No Authorization Required
63664 Musculoskeletal
ELECTRODE PLATE/PADDLE(S) PLACED VIA
LAMINOTOMY OR LAMINECTOMY, INCLUDING
FLUOROSCOPY, WHEN PERFORMED
INSERTION OR REPLACEMENT OF SPINAL
Authorization Required Authorization Required No Authorization Required
63685 Musculoskeletal NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER,
DIRECT OR INDUCTIVE COUPLING
Authorization Required Authorization Required No Authorization Required
63688 Musculoskeletal
REVISION OR REMOVAL OF IMPLANTED SPINAL
NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER
64405 Musculoskeletal
INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL
NERVE
64418
INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR
NERVE
64421
INJECTION, ANESTHETIC AGENT; INTERCOSTAL
NERVES, MULTIPLE, REGIONAL BLOCK
64425
INJECTION, ANESTHETIC AGENT; ILIOINGUINAL,
ILIOHYPOGASTRIC NERVES
64430 INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 16 of 36 Authorization Requirements

PROCEDURE
CODE
64435
64445
64450
64455
64470
64472
64475
64476
64479 Musculoskeletal
64480 Musculoskeletal
64483 Musculoskeletal
64484 Musculoskeletal
64490 Musculoskeletal
64491 Musculoskeletal
64492 Musculoskeletal
64493 Musculoskeletal
64494 Musculoskeletal
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
INJECTION, ANESTHETIC AGENT; PARACERVICAL
(UTERINE) NERVE
INJECTION, ANESTHETIC AGENT; SCIATIC NERVE,
SINGLE
INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL
NERVE OR BRANCH
NJX ANES&/STEROID PLANTAR COMMON DIGITAL
NERVE INJECTION(S), ANESTHETIC AGENT AND/OR
STEROID, PLANTAR COMMON DIGITAL NERVE(S) (EG
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE;
CERVICAL OR THORACIC, SINGLE L
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE;
CERVICAL OR THORACIC, EACH ADD
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE;
LUMBAR OR SACRAL, SINGLE LEVEL
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE;
LUMBAR OR SACRAL, EACH ADDITIO
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
TRANSFORAMINAL EPIDURAL, WITH IMAGING
GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR
THORACIC, SINGLE LEVEL
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
TRANSFORAMINAL EPIDURAL, WITH IMAGING
GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR
THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY
IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
TRANSFORAMINAL EPIDURAL, WITH IMAGING
GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR
SACRAL, SINGLE LEVEL
INJECTION, ANESTHETIC AGENT AND/OR STEROID,
TRANSFORAMINAL EPIDURAL, WITH IMAGING
GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR
SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR
THORACIC; SINGLE LEVEL
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR
THORACIC; SECOND LEVEL (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR
THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR
SACRAL; SINGLE LEVEL
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR
SACRAL; SECOND LEVEL (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 17 of 36 Authorization Requirements

PROCEDURE
CODE
64495 Musculoskeletal
64510 Musculoskeletal
64520 Musculoskeletal
64550
64555
64612
64613
64614
64622
64623
64626
64627
64633 Musculoskeletal
64634 Musculoskeletal
64635 Musculoskeletal
64636 Musculoskeletal
64640
64727
65210 Ophthalmology
65222 Ophthalmology
65420 Ophthalmology
65426 Ophthalmology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT,
PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR
NERVES INNERVATING THAT JOINT) WITH IMAGE
GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR
SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
Authorization Required Authorization Required No Authorization Required
PROCEDURE)
INJECTION, ANESTHETIC AGENT; STELLATE GANGLION
(CERVICAL SYMPATHETIC)
Authorization Required Authorization Required No Authorization Required
INJECTION, ANESTHETIC AGENT; LUMBAR OR
THORACIC (PARAVERTEBRAL SYMPATHETIC)
Authorization Required Authorization Required No Authorization Required
APPLICATION OF SURFACE (TRANSCUTANEOUS)
No Authorization Required
NEUROSTIMULATOR
PERCUTANEOUS IMPLANTATION OF
Authorization Required No Authorization Required
NEUROSTIMULATOR ELECTRODES; PERIPHERAL NERVE No Authorization Required Authorization Required No Authorization Required
(EXCLUDES SACRAL NERVE)
CHEMODENERVATION OF MUSCLE(S); MUSCLE(S)
INNERVATED BY FACIAL NERVE (EG, FOR No Authorization Required Authorization Required No Authorization Required
BLEPHAROSPASM, HEMIFACIAL SPASM)
CHEMODENERVATION OF MUSCLE(S); NECK
MUSCLE(S) (EG, FOR SPASMODIC TORTICOLLIS, No Authorization Required Authorization Required No Authorization Required
SPASMODIC DYSPHONIA)
CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S)
AND/OR TRUNK MUSCLE(S) (EG, FOR DYSTONIA,
CEREBRAL PALSY, MULTIPLE SCLEROSIS)
DESTRUCTION BY NEUROLYTIC AGENT,
No Authorization Required Authorization Required No Authorization Required
PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR No Authorization Required Authorization Required No Authorization Required
SACRAL, SINGLE LEVEL
DESTRUCTION BY NEUROLYTIC AGENT,
PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR No Authorization Required Authorization Required No Authorization Required
SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY
DESTRUCTION BY NEUROLYTIC AGENT,
PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR
THORACIC, SINGLE LEVEL
DESTRUCTION BY NEUROLYTIC AGENT,
No Authorization Required Authorization Required No Authorization Required
PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR
THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARA
DESTRUCTION BY NEUROLYTIC AGENT,
No Authorization Required Authorization Required No Authorization Required
PARAVERTEBRAL FACET JOINT NERVE(S), WITH
IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL
OR THORACIC, SINGLE FACET JOINT
DESTRUCTION BY NEUROLYTIC AGENT,
PARAVERTEBRAL FACET JOINT NERVE(S), WITH
Authorization Required Authorization Required No Authorization Required
IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL
OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
DESTRUCTION BY NEUROLYTIC AGENT,
Authorization Required Authorization Required No Authorization Required
PARAVERTEBRAL FACET JOINT NERVE(S), WITH
IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR
OR SACRAL, SINGLE FACET JOINT
DESTRUCTION BY NEUROLYTIC AGENT,
PARAVERTEBRAL FACET JOINT NERVE(S), WITH
Authorization Required Authorization Required No Authorization Required
IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR
OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Authorization Required Authorization Required No Authorization Required
DESTRUCTION BY NEUROLYTIC AGENT; OTHER
No Authorization Required
PERIPHERAL NERVE OR BRANCH
INTERNAL NEUROLYSIS, REQUIRING USE OF
Authorization Required No Authorization Required
OPERATING MICROSCOPE (LIST SEPARATELY IN No Authorization Required Authorization Required No Authorization Required
ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLA
REMOVAL OF FOREIGN BODY, EXTERNAL EYE;
CONJUNCTIVAL EMBEDDED (INCLUDES
CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL
NONPERFOR
Authorization Required Authorization Required No Authorization Required
REMOVAL OF FOREIGN BODY, EXTERNAL EYE;
Authorization Required
CORNEAL, WITH SLIT LAMP
Authorization Required No Authorization Required
EXCISION OR TRANSPOSITION OF PTERYGIUM;
Authorization Required
WITHOUT GRAFT
Authorization Required No Authorization Required
EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH
Authorization Required
GRAFT
Authorization Required No Authorization Required
Updated March 2012 18 of 36 Authorization Requirements

PROCEDURE
CODE
65805 Ophthalmology
65855 Ophthalmology
66170 Ophthalmology
66711 Ophthalmology
66761 Ophthalmology
66762 Ophthalmology
66821 Ophthalmology
66982 Ophthalmology
66984 Ophthalmology
67028 Ophthalmology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
PARACENTESIS OF ANTERIOR CHAMBER OF EYE
(SEPARATE PROCEDURE); WITH THERAPEUTIC RELEASE
OF AQUEOUS
TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE
SESSIONS (DEFINED TREATMENT SERIES)
FISTULIZATION OF SCLERA FOR GLAUCOMA;
TRABECULECTOMY AB EXTERNO IN ABSENCE OF
PREVIOUS SURGERY
CILIARY BODY DESTRUCTION;
CYCLOPHOTOCOAGULATION, ENDOSCOPIC
IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR
GLAUCOMA) (ONE OR MORE SESSIONS)
IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR MORE
SESSIONS) (EG, FOR IMPROVEMENT OF VISION, FOR
WIDENING OF ANTERIOR CHAMBER AN
DISCISSION OF SECONDARY MEMBRANOUS CATARACT
(OPACIFIED POSTERIOR LENS CAPSULE AND/OR
ANTERIOR HYALOID); LASER SURGERY (EG,
EXTRACAPSULAR CATARACT REMOVAL WITH
INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE
STAGE PROCEDURE), MANUAL OR MECHANICAL T
EXTRACAPSULAR CATARACT REMOVAL WITH
INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE
STAGE PROCEDURE), MANUAL OR MECHANICAL T
INTRAVITREAL INJECTION OF A PHARMACOLOGIC
AGENT (SEPARATE PROCEDURE)
67036 Ophthalmology VITRECTOMY, MECHANICAL, PARS PLANA APPROACH;
67145 Ophthalmology
67210 Ophthalmology
67228 Ophthalmology
67311 Ophthalmology
67332 Ophthalmology
67515 Ophthalmology
PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL
BREAK, LATTICE DEGENERATION) WITHOUT
DRAINAGE, ONE OR MORE SESSIONS; PHOTOC
DESTRUCTION OF LOCALIZED LESION OF RETINA (EG,
MACULAR EDEMA, TUMORS), ONE OR MORE
SESSIONS; PHOTOCOAGULATION
TREATMENT OF EXTENSIVE OR PROGRESSIVE
RETINOPATHY, ONE OR MORE SESSIONS; (EG,
DIABETIC RETINOPATHY), PHOTOCOAGULATION
STRABISMUS SURGERY, RECESSION OR RESECTION
PROCEDURE; ONE HORIZONTAL MUSCLE
STRABISMUS SURGERY ON PATIENT WITH SCARRING
OF EXTRAOCULAR MUSCLES (EG, PRIOR OCULAR
INJURY, STRABISMUS OR RETINAL DETACHM
INJECTION OF MEDICATION OR OTHER SUBSTANCE
INTO TENON'S CAPSULE
67800 Ophthalmology EXCISION OF CHALAZION; SINGLE
67810 Ophthalmology BIOPSY OF EYELID
67820 Ophthalmology
67840 Ophthalmology
67904 Ophthalmology
67961 Ophthalmology
CORRECTION OF TRICHIASIS; EPILATION, BY FORCEPS
ONLY
EXCISION OF LESION OF EYELID (EXCEPT CHALAZION)
WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE
REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR
RESECTION OR ADVANCEMENT, EXTERNAL APPROACH
EXCISION AND REPAIR OF EYELID, INVOLVING LID
MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL
THICKNESS, MAY INCLUDE PREPARAT
68110 Ophthalmology EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM
68200 Ophthalmology SUBCONJUNCTIVAL INJECTION
68700 Ophthalmology PLASTIC REPAIR OF CANALICULI
68761 Ophthalmology
68801 Ophthalmology
68810 Ophthalmology
CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG,
EACH
DILATION OF LACRIMAL PUNCTUM, WITH OR
WITHOUT IRRIGATION
PROBING OF NASOLACRIMAL DUCT, WITH OR
WITHOUT IRRIGATION;
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 19 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
PROBING OF NASOLACRIMAL DUCT, WITH OR
POS 11 POS 22 POS 24
68811 Ophthalmology WITHOUT IRRIGATION; REQUIRING GENERAL
ANESTHESIA
PROBING OF NASOLACRIMAL DUCT, WITH OR
Authorization Required Authorization Required No Authorization Required
68815 Ophthalmology WITHOUT IRRIGATION; WITH INSERTION OF TUBE OR
STENT
Authorization Required Authorization Required No Authorization Required
68840 Ophthalmology
PROBING OF LACRIMAL CANALICULI, WITH OR
Authorization Required
WITHOUT IRRIGATION
Authorization Required No Authorization Required
69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS No Authorization Required Authorization Required No Authorization Required
69100 BIOPSY EXTERNAL EAR
No Authorization Required Authorization Required No Authorization Required
69110 EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR No Authorization Required Authorization Required No Authorization Required
69145
EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY
No Authorization Required
CANAL
Authorization Required No Authorization Required
69200
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY
No Authorization Required
CANAL; WITHOUT GENERAL ANESTHESIA
Authorization Required No Authorization Required
69205
REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY
No Authorization Required
CANAL; WITH GENERAL ANESTHESIA
Authorization Required No Authorization Required
69210
REMOVAL IMPACTED CERUMEN (SEPARATE
No Authorization Required
PROCEDURE), ONE OR BOTH EARS
Authorization Required No Authorization Required
69220
DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG,
No Authorization Required
ROUTINE CLEANING)
DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX
Authorization Required No Authorization Required
69222
(EG, WITH ANESTHESIA OR MORE THAN ROUTINE
CLEANING)
No Authorization Required Authorization Required No Authorization Required
69401
EUSTACHIAN TUBE INFLATION, TRANSNASAL;
No Authorization Required
WITHOUT CATHETERIZATION
Authorization Required No Authorization Required
69420
MYRINGOTOMY INCLUDING ASPIRATION AND/OR
No Authorization Required
EUSTACHIAN TUBE INFLATION
MYRINGOTOMY INCLUDING ASPIRATION AND/OR
Authorization Required No Authorization Required
69421
EUSTACHIAN TUBE INFLATION REQUIRING GENERAL
ANESTHESIA
No Authorization Required Authorization Required No Authorization Required
69424
VENTILATING TUBE REMOVAL REQUIRING GENERAL
No Authorization Required
ANESTHESIA
Authorization Required No Authorization Required
69433
TYMPANOSTOMY (REQUIRING INSERTION OF
No Authorization Required
VENTILATING TUBE), LOCAL OR TOPICAL ANESTHESIA
Authorization Required No Authorization Required
69436
TYMPANOSTOMY (REQUIRING INSERTION OF
No Authorization Required
VENTILATING TUBE), GENERAL ANESTHESIA
TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT
Authorization Required No Authorization Required
69610
SITE PREPARATION OF PERFORATION FOR CLOSURE,
WITH OR WITHOUT PATCH
No Authorization Required Authorization Required No Authorization Required
69620
MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD
No Authorization Required
AND DONOR AREA)
TYMPANOPLASTY WITHOUT MASTOIDECTOMY
Authorization Required No Authorization Required
69631
(INCLUDING CANALPLASTY, ATTICOTOMY AND/OR
MIDDLE EAR SURGERY), INITIAL OR REVISION; WI
No Authorization Required Authorization Required No Authorization Required
69641
TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING
CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC
MEMBRANE REPAIR); WITHOUT OSSICULAR
No Authorization Required Authorization Required No Authorization Required
70336 Advanced Radiology MRI TMJ Authorization Required Authorization Required No Authorization Required
70450 Advanced Radiology CT HEAD/BRAIN W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70460 Advanced Radiology CT HEAD/BRAIN W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70470 Advanced Radiology CT HEAD/BRAIN W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70480 Advanced Radiology CT ORBIT W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70481 Advanced Radiology CT ORBIT W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70482 Advanced Radiology CT ORBIT W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70486 Advanced Radiology CT MAXLLFCL W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70487 Advanced Radiology CT MAXLLFCL W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70488 Advanced Radiology CT MAXLLFCL W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70490 Advanced Radiology CT SOFT TISSUE NECK W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70491 Advanced Radiology CT SOFT TISSUE NECK W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70492 Advanced Radiology CT SOFT TISSUE NECK W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70496 Advanced Radiology CT ANGIOGRAPHY HEAD Authorization Required Authorization Required No Authorization Required
70498 Advanced Radiology CT ANGIOGRAPHY NECK Authorization Required Authorization Required No Authorization Required
70540 Advanced Radiology MRI FACE, ORBIT, NECK W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70542 Advanced Radiology MRI FACE, ORBIT, NECK W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70543 Advanced Radiology MRI FACE, ORBIT, NECK W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70544 Advanced Radiology MRA HEAD W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70545 Advanced Radiology MRA HEAD W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70546 Advanced Radiology MRA HEAD W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70547 Advanced Radiology MRA NECK W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70548 Advanced Radiology MRA NECK W CONTRAST Authorization Required Authorization Required No Authorization Required
70549 Advanced Radiology MRA NECK W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
Updated March 2012 20 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
70551 Advanced Radiology MRI HEAD W/O CONTRAST Authorization Required Authorization Required No Authorization Required
70552 Advanced Radiology MRI HEAD W/ CONTRAST Authorization Required Authorization Required No Authorization Required
70553 Advanced Radiology MRI HEAD W/ & W/O CONTRAST
MRI, BRAIN, FUNCTIONAL MRI; INCLUDING TEST
SELECTION AND ADMINISTRATION OF REPETITIVE
Authorization Required Authorization Required No Authorization Required
70554 Advanced Radiology BODY PART MOVEMENT AND/OR VISUAL
STIMULATION, NOT REQUIRING PHYSICIAN OR
PSYCHOLOGIST ADMINISTRATION
MRI, BRAIN, FUNCTIONAL MRI; REQUIRING PHYSICIAN
Authorization Required Authorization Required No Authorization Required
70555 Advanced Radiology OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE
NEUROFUNCTIONAL TESTING
Authorization Required Authorization Required No Authorization Required
71250 Advanced Radiology CT THORAX W/O CONTRAST Authorization Required Authorization Required No Authorization Required
71260 Advanced Radiology CT THORAX W/ CONTRAST Authorization Required Authorization Required No Authorization Required
71270 Advanced Radiology CT THORAX W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
71275 Advanced Radiology CT ANGIOGRAPHY CHEST, NON-CORONARY Authorization Required Authorization Required No Authorization Required
71550 Advanced Radiology MRI CHEST W/O CONTRAST Authorization Required Authorization Required No Authorization Required
71551 Advanced Radiology MRI CHEST W CONTRAST Authorization Required Authorization Required No Authorization Required
71552 Advanced Radiology MRI CHEST W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
71555 Advanced Radiology
MRA CHEST (EXC MYOCARDIUM) W/ OR W/O
CONTRAST
Authorization Required Authorization Required No Authorization Required
72125 Advanced Radiology CT C SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72126 Advanced Radiology CT C SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72127 Advanced Radiology CT C SPINE W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72128 Advanced Radiology CT T SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72129 Advanced Radiology CT T SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72130 Advanced Radiology CT T SPINE W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72131 Advanced Radiology CT L SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72132 Advanced Radiology CT L SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72133 Advanced Radiology CT L SPINE W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72141 Advanced Radiology MRI CERVICAL SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72142 Advanced Radiology MRI CERVICAL SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72146 Advanced Radiology MRI THORACIC SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72147 Advanced Radiology MRI THORACIC SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72148 Advanced Radiology MRI LUMBAR SPINE W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72149 Advanced Radiology MRI LUMBAR SPINE W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72156 Advanced Radiology MRI C SPINE W/ & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72157 Advanced Radiology MRI T SPINE W/ & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72158 Advanced Radiology MRI L SPINE W/ & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72159 Advanced Radiology MRA SPINAL CANAL W/ OR W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72191 Advanced Radiology CT ANGIOGRAPHY PELVIS Authorization Required Authorization Required No Authorization Required
72192 Advanced Radiology CT PELVIS W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72193 Advanced Radiology CT PELVIS W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72194 Advanced Radiology CT PELVIS W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
72195 Advanced Radiology MRI PELVIS W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72196 Advanced Radiology MRI PELVIS W CONTRAST Authorization Required Authorization Required No Authorization Required
72197 Advanced Radiology MRI PELVIS W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72198 Advanced Radiology MRA PELVIS W/ OR W/O CONTRAST Authorization Required Authorization Required No Authorization Required
72275 Musculoskeletal
EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION AND
INTERPRETATION
Authorization Required Authorization Required No Authorization Required
72285 Musculoskeletal
DISCOGRAPHY, CERVICAL OR THORACIC,
RADIOLOGICAL SUPERVISION AND INTERPRETATION
Authorization Required Authorization Required No Authorization Required
72295 Musculoskeletal
DISCOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION
AND INTERPRETATION
Authorization Required Authorization Required No Authorization Required
73200 Advanced Radiology CT UPPER EXTREMITY W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73201 Advanced Radiology CT UPPER EXTREMITY W/ CONTRAST Authorization Required Authorization Required No Authorization Required
73202 Advanced Radiology CT UPPER EXTREMITY W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
73206 Advanced Radiology CT ANGIOGRAPHY UPPER EXTREMITY Authorization Required Authorization Required No Authorization Required
73218 Advanced Radiology MRI UPPER EXTREMITY W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73219 Advanced Radiology MRI UPPER EXTREMITY W CONTRAST Authorization Required Authorization Required No Authorization Required
73220 Advanced Radiology MRI UPPER EXTREMITY W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73221 Advanced Radiology MRI UPPER EXTREMITY JOINT W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73222 Advanced Radiology MRI UPPER EXTREMITY JOINT W CONTRAST Authorization Required Authorization Required No Authorization Required
73223 Advanced Radiology MRI UPPER EXTREMITY JOINT W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73225 Advanced Radiology MRA UPPER EXTREMITY W/ OR W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73700 Advanced Radiology CT LOWER EXTREMITY W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73701 Advanced Radiology CT LOWER EXTREMITY W/ CONTRAST Authorization Required Authorization Required No Authorization Required
73702 Advanced Radiology CT LOWER EXTREMITY W/O & W/ CONTRAST Authorization Required Authorization Required No Authorization Required
73706 Advanced Radiology CT ANGIOGRAPHY LOWER EXTREMITY Authorization Required Authorization Required No Authorization Required
73718 Advanced Radiology MRI LOWER EXTREMITY W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73719 Advanced Radiology MRI LOWER EXTREMITY W CONTRAST Authorization Required Authorization Required No Authorization Required
73720 Advanced Radiology MRI LOWER EXTREMITY W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73721 Advanced Radiology MRI LOWER EXTREMITY JOINT W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73722 Advanced Radiology MRI LOWER EXTREMITY JOINT W CONTRAST Authorization Required Authorization Required No Authorization Required
Updated March 2012 21 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
73723 Advanced Radiology MRI LOWER EXTREMITY JOINT W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
73725 Advanced Radiology MRA LOWER EXTREMITY W/ OR W/O CONTRAST Authorization Required Authorization Required No Authorization Required
74150 Advanced Radiology CT ABDOMEN W/O CONTRAST Authorization Required Authorization Required No Authorization Required
74160 Advanced Radiology CT ABDOMEN W/ CONTRAST Authorization Required Authorization Required No Authorization Required
74170 Advanced Radiology CT ABDOMEN W/O & W/ CONTRAST
COMPUTED TOMOGRAPHIC ANGIOGRAPHY,
Authorization Required Authorization Required No Authorization Required
74174 Advanced Radiology
ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S),
INCLUDING NONCONTRAST IMAGES, IF PERFORMED,
AND IMAGE POSTPROCESSING
Authorization Required Authorization Required No Authorization Required
74175 Advanced Radiology CT ANGIOGRAPHY ABDOMEN Authorization Required Authorization Required No Authorization Required
74176 Advanced Radiology
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS;
WITHOUT CONTRAST MATERIAL
Authorization Required Authorization Required No Authorization Required
74177 Advanced Radiology
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS;
WITH CONTRAST MATERIAL(S)
COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS;
WITHOUT CONTRAST MATERIAL IN ONE OR BOTH
Authorization Required Authorization Required No Authorization Required
74178 Advanced Radiology BODY REGIONS, FOLLOWED BY CONTRAST
MATERIAL(S) AND FURTHER SECTIONS IN ONE OR
Authorization Required Authorization Required No Authorization Required
BOTH BODY REGIONS
74181 Advanced Radiology MRI ABDOMEN W/O CONTRAST Authorization Required Authorization Required No Authorization Required
74182 Advanced Radiology MRI ABDOMEN W CONTRAST Authorization Required Authorization Required No Authorization Required
74183 Advanced Radiology MRI ABDOMEN W & W/O CONTRAST Authorization Required Authorization Required No Authorization Required
74185 Advanced Radiology MRA ABDOMEN W/ OR W/O CONTRAST
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY,
Authorization Required Authorization Required No Authorization Required
74261 Advanced Radiology DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING;
WITHOUT CONTRAST MATERIAL
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY,
Authorization Required Authorization Required No Authorization Required
74262 Advanced Radiology
DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING;
WITH CONTRAST MATERIAL (S) INCLUDING NON-
CONTRAST IMAGES, IF PERFORMED
Authorization Required Authorization Required No Authorization Required
74263 Advanced Radiology
COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY,
SCREENING, INCLUDING IMAGE POSTPROCESSING
CARDIAC MAGNETIC RESONANCE IMAGING FOR
Authorization Required Authorization Required No Authorization Required
75557 Cardiology MORPHOLOGY AND FUNCTION WITHOUT CONTRAST
MATERIAL
CARDIAC MAGNETIC RESONANCE IMAGING FOR
Authorization Required Authorization Required No Authorization Required
75559 Cardiology MORPHOLOGY AND FUNCTION WITHOUT CONTRAST Authorization Required Authorization Required No Authorization Required
MATERIAL; WITH STRESS IMAGING
CARDIAC MAGNETIC RESONANCE IMAGING FOR
75559 Advanced Radiology MORPHOLOGY AND FUNCTION WITHOUT CONTRAST
MATERIAL; WITH STRESS IMAGING
CARDIAC MAGNETIC RESONANCE IMAGING FOR
Authorization Required Authorization Required No Authorization Required
75561 Cardiology
MORPHOLOGY AND FUNCTION WITHOUT CONTRAST
MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S)
Authorization Required Authorization Required No Authorization Required
AND FURTHER SEQUENCES
75563 Cardiology
75565 Cardiology
75565 Advanced Radiology
75571 Cardiology
75572 Cardiology
CARDIAC MAGNETIC RESONANCE IMAGING FOR
MORPHOLOGY AND FUNCTION WITHOUT CONTRAST
MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S)
AND FURTHER SEQUENCES; WITH STRESS IMAGING
CARDIAC MAGNETIC RESONANCE IMAGING FOR
VELOCITY FLOW MAPPING (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
CARDIAC MRI FOR VELOCITY FLOW MAPPING (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
COMPUTED TOMOGRAPHY, HEART, WITHOUT
CONTRAST MATERIAL, WITH QUANTITATIVE
EVALUATION OF CORONARY CALCIUM
COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST
MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE
AND MORPHOLOGY (INCLUDING 3D IMAGE
POSTPROCESSING, ASSESSMENT OF CARDIAC
FUNCTION, AND EVALUATION OF VENOUS
STRUCTURES, IF PERFORMED)
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
75572 Advanced Radiology CARDIAC CT FOR MORPHOLOGY Authorization Required Authorization Required No Authorization Required
Updated March 2012 22 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST
MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE
AND MORPHOLOGY IN THE SETTING OF CONGENITAL
POS 11 POS 22 POS 24
75573 Cardiology
HEART DISEASE (INCLUDING 3D IMAGE
POSTPROCESSING, ASSESSMENT OF LV CARDIAC
FUNCTION, RV STRUCTURE AND FUNCTION AND
EVALUATION OF VENOUS STRUCTURES, IF
PERFORMED)
COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART,
CORONARY ARTERIES AND BYPASS GRAFTS (WHEN
PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D
Authorization Required Authorization Required No Authorization Required
75574 Cardiology
IMAGE POSTPROCESSING (INCLUDING EVALUATION OF
CARDIAC STRUCTURE AND MORPHOLOGY,
ASSESSMENT OF CARDIAC FUNCTION, AND
EVALUATION OF VENOUS STRUCTURES, IF
Authorization Required Authorization Required No Authorization Required
75635 Advanced Radiology
PERFORMED)
CT ANGIOGRAPHY ABDOMINAL AORTA
3D RENDERING WITH INTERPRETATION AND
REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC
Authorization Required Authorization Required No Authorization Required
76376 Advanced Radiology
RESONANCE IMAGING, ULTRASOUND, OR OTHER
TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE
POSTPROCESSING ON AN INDEPENDENT
WORKSTATION
3D RENDERING WITH INTERPRETATION AND
REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC
Authorization Required Authorization Required No Authorization Required
76377 Advanced Radiology
RESONANCE IMAGING, ULTRASOUND, OR OTHER
TOMOGRAPHIC MODALITY; REQUIRING IMAGE
POSTPROCESSING ON AN INDEPENDENT
Authorization Required Authorization Required No Authorization Required
WORKSTATION
76380 Advanced Radiology CT LIMITED OR LOCALIZED FOLLOW-UP STUDY Authorization Required Authorization Required No Authorization Required
76390 Advanced Radiology MRI SPECTROSCOPY Authorization Required Authorization Required No Authorization Required
76497 Advanced Radiology UNLISTED COMPUTED TOMOGRAPHY PROCEDURE Authorization Required Authorization Required No Authorization Required
76498 Advanced Radiology UNLISTED MRI PROCEDURE Authorization Required Authorization Required No Authorization Required
76499 Advanced Radiology UNLISTED RADIOLOGIC PROCEDURE Authorization Required Authorization Required No Authorization Required
76801 Advanced Radiology
76802 Advanced Radiology
U/S OB PELVIS, PREGNANT UTERUS, FIRST TRIMESTER

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
76825 Advanced Radiology
U/S OB ECHOCARDIOGRAPHY, FETAL,
CARDIOVASCULAR SYSTEM
Authorization Required Authorization Required No Authorization Required
76826 Advanced Radiology FOLLOW UP OR REPEAT STUDY Authorization Required Authorization Required No Authorization Required
76827 Advanced Radiology DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE Authorization Required Authorization Required No Authorization Required
76828 Advanced Radiology FOLLOW UP OR REPEAT STUDY Authorization Required Authorization Required No Authorization Required
76975 Advanced Radiology U/S GASTROINTESTINAL, ENDOSCOPIC
FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF
NEEDLE OR CATHETER TIP FOR SPINE OR
Authorization Required Authorization Required No Authorization Required
77003 Musculoskeletal PARASPINOUS DIAGNOSTIC OR THERAPEUTIC
INJECTION PROCEDURES (EPIDURAL OR
Authorization Required Authorization Required No Authorization Required
SUBARACHNOID)
77011 Advanced Radiology CT GUIDANCE STEREOTACTIC LOCALIZATION Authorization Required Authorization Required No Authorization Required
77012 Advanced Radiology CT GUIDANCE NEEDLE BX-RAD S & I Authorization Required Authorization Required No Authorization Required
77013 Advanced Radiology
CT GUIDANCE FOR AND MONITORING OF TISSUE
ABLATION
Authorization Required Authorization Required No Authorization Required
77014 Advanced Radiology
CT GUIDANCE FOR PLACEMENT OF RADIATION
THERAPY FIELDS
Authorization Required Authorization Required No Authorization Required
77021 Advanced Radiology MRI GUIDANCE FOR NEEDLE PLACEMENT Authorization Required Authorization Required No Authorization Required
77022 Advanced Radiology
MRI GUIDANCE FOR AND MONITORING OF TISSUE
ABLATION
Authorization Required Authorization Required No Authorization Required
77058 Advanced Radiology
MRI BREAST W/ AND/OR W/O CONTRAST;
UNILATERAL
Authorization Required Authorization Required No Authorization Required
77059 Advanced Radiology MRI BREAST BILATERAL Authorization Required Authorization Required No Authorization Required
77078 Advanced Radiology CT BONE DENSITY STUDY, AXIAL SKELETON Authorization Required Authorization Required No Authorization Required
77079 Advanced Radiology CT BONE DENSITY STUDY, APPENDICULAR SKELETON Authorization Required Authorization Required No Authorization Required
77084 Advanced Radiology MRI BONE MARROW BLOOD SUPPLY Authorization Required Authorization Required No Authorization Required
78000 Advanced Radiology THYROID RAI UPTAKE Authorization Required Authorization Required No Authorization Required
78001 Advanced Radiology THYROID MULTIPLE UPTAKE Authorization Required Authorization Required No Authorization Required
78003 Advanced Radiology THYROID SUPPRESS OR STIMULATION Authorization Required Authorization Required No Authorization Required
78006 Advanced Radiology THYROID UPTAKE AND SCAN Authorization Required Authorization Required No Authorization Required
78007 Advanced Radiology THYROID IMAGE, MULTIPLE UPTAKES Authorization Required Authorization Required No Authorization Required
78010 Advanced Radiology THYROID SCAN ONLY Authorization Required Authorization Required No Authorization Required
78011 Advanced Radiology THYROID IMAGING W FLOW Authorization Required Authorization Required No Authorization Required
78015 Advanced Radiology THYROID MET IMAGING Authorization Required Authorization Required No Authorization Required
78016 Advanced Radiology THYROID MET IMAGING WITH ADDITIONAL STUDIES Authorization Required Authorization Required No Authorization Required
78018 Advanced Radiology THYROID SCAN WHOLE BODY Authorization Required Authorization Required No Authorization Required
78020 Advanced Radiology
THYROID CARCINOMA METASTASES UPTAKE (add on
code - use w/ code 78018 only)
Authorization Required Authorization Required No Authorization Required
78070 Advanced Radiology PARATHYROID NUCLEAR IMAGING Authorization Required Authorization Required No Authorization Required
78075 Advanced Radiology ADRENAL NUCLEAR IMAGING Authorization Required Authorization Required No Authorization Required
78099 Advanced Radiology UNLISTED ENDOCRINE PROCEDURE Authorization Required Authorization Required No Authorization Required
78102 Advanced Radiology BONE MARROW IMAGING, LIMITED Authorization Required Authorization Required No Authorization Required
78103 Advanced Radiology BONE MARROW IMAGING, MULTIPLE Authorization Required Authorization Required No Authorization Required
78104 Advanced Radiology BONE MARROW IMAGING, WHOLE BODY Authorization Required Authorization Required No Authorization Required
78135 Advanced Radiology DIFFERENTIAL ORGAN/TISSUES KINETIC Authorization Required Authorization Required No Authorization Required
78140 Advanced Radiology LABELED RED CELL SEQUESTRATION Authorization Required Authorization Required No Authorization Required
78185 Advanced Radiology SPLEEN IMAGING W/WO VASCULAR FLOW Authorization Required Authorization Required No Authorization Required
78190 Advanced Radiology PLATELET SURVIVAL, KINETICS Authorization Required Authorization Required No Authorization Required
78191 Advanced Radiology PLATELET SURVIVAL Authorization Required Authorization Required No Authorization Required
78195 Advanced Radiology LYMPH SYSTEM IMAGING Authorization Required Authorization Required No Authorization Required
78199 Advanced Radiology UNLISTED HEMATOPOETIC PROCEDURE Authorization Required Authorization Required No Authorization Required
78201 Advanced Radiology LIVER IMAGING Authorization Required Authorization Required No Authorization Required
78202 Advanced Radiology LIVER IMAGING W FLOW Authorization Required Authorization Required No Authorization Required
78205 Advanced Radiology LIVER IMAGING SPECT Authorization Required Authorization Required No Authorization Required
78206 Advanced Radiology LIVER IMAGING SPECT W VASCULAR FLOW Authorization Required Authorization Required No Authorization Required
78215 Advanced Radiology LIVER AND SPLEEN IMAGING Authorization Required Authorization Required No Authorization Required
78216 Advanced Radiology LIVER AND SPLEEN IMAGING W FLOW Authorization Required Authorization Required No Authorization Required
78220 Advanced Radiology
LIVER FUNCTION STUDY WITH HEPATOBILIARY
AGENTS, WITH SERIAL IMAGES;
HEPATOBILIARY DUCTAL SYSTEM IMAGING,
INCLUDING GALLBLADDER, WITH OR WITHOUT
Authorization Required Authorization Required No Authorization Required
78223 Advanced Radiology PHARMACOLOGIC INTERVENTION, WITH OR WITHOUT
QUANTITATIVE MEASUREMENT OF GALLBLADDER
FUNCTION;
Authorization Required Authorization Required No Authorization Required
78226 Advanced Radiology
HEPATOBILIARY SYSTEM IMAGING, INCLUDING
GALLBLADDER WHEN PRESENT;
Authorization Required Authorization Required No Authorization Required
78227 Advanced Radiology
HEPATOBILIARY SYSTEM IMAGING, INCLUDING
GALLBLADDER WHEN PRESENT; WITH
PHARMACOLOGIC INTERVENTION, INCLUDING
QUANTITATIVE MEASUREMENT(S) WHEN PERFORMED
Authorization Required Authorization Required No Authorization Required
78230 Advanced Radiology SALIVARY GLAND IMAGING Authorization Required Authorization Required No Authorization Required
78231 Advanced Radiology SERIAL SALIVARY GLAND Authorization Required Authorization Required No Authorization Required
Updated March 2012 24 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
78232 Advanced Radiology SALIVARY GLAND FUNCTION TEST Authorization Required Authorization Required No Authorization Required
78258 Advanced Radiology ESOPHAGUS MOTILITY STUDY Authorization Required Authorization Required No Authorization Required
78261 Advanced Radiology GASTRIC MUCOSA IMAGING Authorization Required Authorization Required No Authorization Required
78262 Advanced Radiology GASTROESOPHAGAEL REFLUX EXAM Authorization Required Authorization Required No Authorization Required
78264 Advanced Radiology GASTRIC EMPTYING STUDY Authorization Required Authorization Required No Authorization Required
78278 Advanced Radiology GI BLEEDER SCAN Authorization Required Authorization Required No Authorization Required
78282 Advanced Radiology GI PROTEIN LOSS EXAM Authorization Required Authorization Required No Authorization Required
78290 Advanced Radiology MECKEL'S DIVERTICULUM IMAGING Authorization Required Authorization Required No Authorization Required
78291 Advanced Radiology LEVEEN SHUNT PATENCY EXAM Authorization Required Authorization Required No Authorization Required
78299 Advanced Radiology UNLISTED GASTROINTESTINAL PROCEDURE Authorization Required Authorization Required No Authorization Required
78300 Advanced Radiology BONE OR JOINT IMAGING LTD Authorization Required Authorization Required No Authorization Required
78305 Advanced Radiology BONE OR JOINT IMAGING MULTIPLE Authorization Required Authorization Required No Authorization Required
78306 Advanced Radiology BONE SCAN WHOLE BODY Authorization Required Authorization Required No Authorization Required
78315 Advanced Radiology BONE AND/OR JOINT IMAGING; 3 PHASE STUDY Authorization Required Authorization Required No Authorization Required
78320 Advanced Radiology BONE JOINT IMAGING TOMO TEST SPECT Authorization Required Authorization Required No Authorization Required
78399 Advanced Radiology UNLISTED MUSCULOSKELETAL PROCEDURE Authorization Required Authorization Required No Authorization Required
78414 Advanced Radiology NON-IMAGING HEART FUNCTION Authorization Required Authorization Required No Authorization Required
78428 Advanced Radiology CARDIAC SHUNT IMAGING Authorization Required Authorization Required No Authorization Required
78445 Advanced Radiology RADIONUCLIDE VENOGRAM NON-CARDIAC
78451 MYOCARDIAL PERFUSION IMAGING,
TOMOGRAPHIC (SPECT) INCLUDING ATTENUATION
CORRECTION, QUALITATIVE OR QUANTITATIVE WALL
Authorization Required Authorization Required No Authorization Required
78451 Cardiology MOTION, EJECTION FRACTION BY FIRST PASS OR
GATED TECHNIQUE, ADDITIONAL QUANTIFICATION,
WHEN PERFORMED); SINGLE STUDY, AT REST OR
STRESS (EXERCISE OR PHARMACOLOGIC)
MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC
(SPECT) (INCLUDING ATTENUATION CORRECTION,
QUALITATIVE OR QUANTITATIVE WALL MOTION,
Authorization Required Authorization Required No Authorization Required
78452 Cardiology
EJECTION FRACTION BY FIRST PASS OR GATED
TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN
PERFORMED); MULTIPLE STUDIES, AT REST AND/OR
STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR
REDISTRIBUTION AND/OR REST REINJECTION
MYOCARDIAL PERFUSION IMAGING, PLANAR
(INCLUDING QUALITATIVE OR QUANTITATIVE WALL
Authorization Required Authorization Required No Authorization Required
78453 Cardiology
MOTION, EJECTION FRACTION BY FIRST PASS OR
GATED TECHNIQUE, ADDITIONAL QUANTIFICATION,
WHEN PERFORMED); SINGLE STUDY, AT REST OR
STRESS (EXERCISE OR PHARMACOLOGIC)
MYOCARDIAL PERFUSION IMAGING, PLANAR
(INCLUDING QUALITATIVE OR QUANTITATIVE WALL
MOTION, EJECTION FRACTION BY FIRST PASS OR
Authorization Required Authorization Required No Authorization Required
78454 Cardiology GATED TECHNIQUE, ADDITIONAL QUANTIFICATION,
WHEN PERFORMED); MULTIPLE STUDIES, AT REST
AND/OR STRESS (EXERCISE OR PHARMACOLOGIC)
AND/OR REDISTRIBUTION AND/OR REST REINJECTION
Authorization Required Authorization Required No Authorization Required
78456 Advanced Radiology ACUTE VENOUS THROMBOSIS IMAGING Authorization Required Authorization Required No Authorization Required
78457 Advanced Radiology VENOUS THROMBOSIS IMAGING UNILATERAL Authorization Required Authorization Required No Authorization Required
78458 Advanced Radiology VENOUS THROMBOSIS IMAGING BILATERAL Authorization Required Authorization Required No Authorization Required
78459 Cardiology
MYOCARDIAL IMAGING, POSITRON EMISSION
TOMOGRAPHY (PET), METABOLIC EVALUATION
Authorization Required Authorization Required No Authorization Required
78466 Advanced Radiology MYOCARDIAL INFARCTION SCAN Authorization Required Authorization Required No Authorization Required
78468 Advanced Radiology HEART INFARCT IMAGE EF Authorization Required Authorization Required No Authorization Required
78469 Advanced Radiology HEART INFARCT IMAGE SPECT Authorization Required Authorization Required No Authorization Required
78472 Advanced Radiology GATED HEART, REST OR STRESS Authorization Required Authorization Required No Authorization Required
78473 Advanced Radiology CARDIAC BLOOD POOL MUGA SCAN Authorization Required Authorization Required No Authorization Required
78481 Advanced Radiology HEART FIRST PASS SINGLE Authorization Required Authorization Required No Authorization Required
78483 Advanced Radiology CARDIAC BLOOD POOL IMAGING, MULTI
MYOCARDIAL IMAGING, POSITRON EMISSION
Authorization Required Authorization Required No Authorization Required
78491 Cardiology TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT
REST OR STRESS
MYOCARDIAL IMAGING, POSITRON EMISSION
Authorization Required Authorization Required No Authorization Required
78492 Cardiology TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES
AT REST AND/OR STRESS
Authorization Required Authorization Required No Authorization Required
78494 Advanced Radiology CARDIAC BLOOD POOL IMAGING, SPECT Authorization Required Authorization Required No Authorization Required
78496 Advanced Radiology
CARDIAC BLOOD POOL IMAGING, SINGLE AT REST (Use
with 78472)
Authorization Required Authorization Required No Authorization Required
78499 Advanced Radiology UNLISTED CARDIOVASCULAR PROCEDURE Authorization Required Authorization Required No Authorization Required
78579 Advanced Radiology
PULMONARY VENTILATION IMAGING (EG, AEROSOL
OR GAS)
Authorization Required Authorization Required No Authorization Required
Updated March 2012 25 of 36 Authorization Requirements

PROCEDURE
CODE
78580 Advanced Radiology
78582 Advanced Radiology
78584 Advanced Radiology
78585 Advanced Radiology
78586 Advanced Radiology
78587 Advanced Radiology
78588 Advanced Radiology
78591 Advanced Radiology
78593 Advanced Radiology
78594 Advanced Radiology
78596 Advanced Radiology
78597 Advanced Radiology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
PULMONARY PERFUSION IMAGING (EG,
PARTICULATE);
PULMONARY VENTILATION (EG, AEROSOL OR GAS)
AND PERFUSION IMAGING
PULMONARY PERFUSION IMAGING, PARTICULATE,
WITH VENTILATION; SINGLE BREATH
PULMONARY PERFUSION IMAGING, PARTICULATE,
WITH VENTILATION; REBREATHING AND WASHOUT,
WITH OR WITHOUT SINGLE BREATH
PULMONARY VENTILATION IMAGING, AEROSOL;
SINGLE PROJECTION
MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR,
LATERAL VIEWS)
PULMONARY PERFUSION IMAGING, PARTICULATE,
WITH VENTILATION IMAGING, AEROSOL, 1 OR
MULTIPLE PROJECTIONS;
PULMONARY VENTILATION IMAGING, GASEOUS,
SINGLE BREATH, SINGLE PROJECTION;
PULMONARY VENTILATION IMAGING, GASEOUS, WITH
REBREATHING AND WASHOUT WITH OR WITHOUT
SINGLE BREATH; SINGLE PROJECTION
MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR,
LATERAL VIEWS)
PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION
(VENTILATION/PERFUSION) STUDY;
QUANTITATIVE DIFFERENTIAL PULMONARY
PERFUSION, INCLUDING IMAGING WHEN PERFORMED
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
78598 Advanced Radiology
QUANTITATIVE DIFFERENTIAL PULMONARY
PERFUSION AND VENTILATION (EG, AEROSOL OR GAS),
INCLUDING IMAGING WHEN PERFORMED
Authorization Required Authorization Required No Authorization Required
78599 Advanced Radiology UNLISTED RESPIRATORY PROCEDURE Authorization Required Authorization Required No Authorization Required
78600 Advanced Radiology BRAIN IMAGING LTD STATIC Authorization Required Authorization Required No Authorization Required
78601 Advanced Radiology BRAIN LTD IMAGING AND FLOW Authorization Required Authorization Required No Authorization Required
78605 Advanced Radiology BRAIN IMAGING COMPLETE Authorization Required Authorization Required No Authorization Required
78606 Advanced Radiology BRAIN IMAGING COMPLETE W FLOW Authorization Required Authorization Required No Authorization Required
78607 Advanced Radiology BRAIN IMAGING SPECT Authorization Required Authorization Required No Authorization Required
78608 Advanced Radiology
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY
(PET) METABOLIC EVALUATION
Authorization Required Authorization Required No Authorization Required
78609 Advanced Radiology
BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY
(PET) , PERFUSION EVALUATION
Authorization Required Authorization Required No Authorization Required
78610 Advanced Radiology BRAIN FLOW IMAGING ONLY Authorization Required Authorization Required No Authorization Required
78630 Advanced Radiology CISTERNOGRAM (Cerebrospinal Fluid Flow) Authorization Required Authorization Required No Authorization Required
78635 Advanced Radiology CEREBROSPINAL VENTRICULOGRAPHY Authorization Required Authorization Required No Authorization Required
78645 Advanced Radiology CSF SHUNT EVALUATION Authorization Required Authorization Required No Authorization Required
78647 Advanced Radiology CEREBROSPINAL FLUID SCAN SPECT Authorization Required Authorization Required No Authorization Required
78650 Advanced Radiology CSF LEAKAGE DETECTION AND LOCALIZATION Authorization Required Authorization Required No Authorization Required
78660 Advanced Radiology RADIOPHARMACEUTICAL DACRYOCYSTORGRAPHY Authorization Required Authorization Required No Authorization Required
78699 Advanced Radiology UNLISTED NUCLEAR MEDICINE PROCEDURE Authorization Required Authorization Required No Authorization Required
78700 Advanced Radiology KIDNEY IMAGING MORPHOLOGY Authorization Required Authorization Required No Authorization Required
78701 Advanced Radiology KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW Authorization Required Authorization Required No Authorization Required
78707 Advanced Radiology
78708 Advanced Radiology
KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW
AND FUNCTION STUDY
KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW
AND FUNCTION, SINGLE W PHARM INTERVENTION
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
78709 Advanced Radiology
KIDNEY IMAGING MORPHOLOGY W VASCULAR FLOW,
MULTI, W/O AND W PHARM INTERVENTION
Authorization Required Authorization Required No Authorization Required
78710 Advanced Radiology KIDNEY IMAGING, SPECT Authorization Required Authorization Required No Authorization Required
78725 Advanced Radiology
KIDNEY FUNCTION STUDY, NON-IMAGE
RADIOISOTROPIC
Authorization Required Authorization Required No Authorization Required
78730 Advanced Radiology URINARY BLADDER RESIDUAL STUDY Authorization Required Authorization Required No Authorization Required
78740 Advanced Radiology URETERAL REFLUX STUDY Authorization Required Authorization Required No Authorization Required
78761 Advanced Radiology TESTICULAR IMAGING W VASCULAR FLOW Authorization Required Authorization Required No Authorization Required
78799 Advanced Radiology UNLISTED GENITOURINARY PROCEDURE Authorization Required Authorization Required No Authorization Required
78800 Advanced Radiology
RADIOPHARM LOCALIZATION OF TUMOR, LIMITED
AREA
Authorization Required Authorization Required No Authorization Required
78801 Advanced Radiology
RADIOPHARM LOCALIZATION OF TUMOR, MULTI
AREAS
Authorization Required Authorization Required No Authorization Required
78802 Advanced Radiology
RADIOPHARM LOCALIZATION OF TUMOR, WHOLE
BODY
Authorization Required Authorization Required No Authorization Required
78803 Advanced Radiology RADIOPHARM LOCALIZATION OF TUMOR, SPECT Authorization Required Authorization Required No Authorization Required
Updated March 2012 26 of 36 Authorization Requirements

PROCEDURE
CODE
78804 Advanced Radiology
78805 Advanced Radiology
78806 Advanced Radiology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR
OR DISTRIBUTION OF RADIOPHARMACEUTICAL
AGENT(S); WHOLE BODY, REQUIRING 2 OR MORE DAYS
IMAGING
RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED
AREA
RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE
BODY
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
78807 Advanced Radiology RADIOPHARM LOCALIZATION OF ABSCESS, SPECT Authorization Required Authorization Required No Authorization Required
78811 Advanced Radiology
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING;
LIMITED AREA (EG, CHEST, HEAD/NECK)
Authorization Required Authorization Required No Authorization Required
78812 Advanced Radiology
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING;
SKULL BASE TO MID-THIGH
Authorization Required Authorization Required No Authorization Required
78813 Advanced Radiology
POSITRON EMISSION TOMOGRAPHY (PET) IMAGING;
WHOLE BODY
POSITRON EMISSION TOMOGRAPHY (PET) WITH
CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY
Authorization Required Authorization Required No Authorization Required
78814 Advanced Radiology (CT) FOR ATTENUATION CORRECTION AND
ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA
(EG CHEST, HEAD/NECK)
POSITRON EMISSION TOMOGRAPHY (PET) WITH
CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY
Authorization Required Authorization Required No Authorization Required
78815 Advanced Radiology (CT) FOR ATTENUATION CORRECTION AND
ANATOMICAL LOCALIZATION IMAGING; SKULL BASE
TO MID-THIGH
Authorization Required Authorization Required No Authorization Required
78816 Advanced Radiology
POSITRON EMISSION TOMOGRAPHY (PET) WITH
CONCURRENTLY ACQUIRED COMPUTER TOMOGRAPHY
(CT) FOR ATTENUATION CORRECTION AND
ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY
Authorization Required Authorization Required No Authorization Required
78999 Advanced Radiology
UNLISTED MISC.PROCEDURE DIAGNOSTIC NUCLEAR
MED
Authorization Required Authorization Required No Authorization Required
83890 Molecular Diagnostics MOLECULE ISOLATE Authorization Required Authorization Required No Authorization Required
83891 Molecular Diagnostics MOLECULE ISOLATE NUCLEIC Authorization Required Authorization Required No Authorization Required
83892 Molecular Diagnostics MOLECULAR DIAGNOSTICS Authorization Required Authorization Required No Authorization Required
83893 Molecular Diagnostics MOLECULE DOT/SLOT/BLOT Authorization Required Authorization Required No Authorization Required
83894 Molecular Diagnostics MOLECULE GEL ELECTROPHOR Authorization Required Authorization Required No Authorization Required
83896 Molecular Diagnostics MOLECULAR DIAGNOSTICS Authorization Required Authorization Required No Authorization Required
83897 Molecular Diagnostics MOLECULE NUCLEIC TRANSFER Authorization Required Authorization Required No Authorization Required
83898 Molecular Diagnostics MOLECULE NUCLEIC AMPLI, EACH Authorization Required Authorization Required No Authorization Required
83900 Molecular Diagnostics MOLECULE NUCLEIC AMPLI 2 SEQ Authorization Required Authorization Required No Authorization Required
83901 Molecular Diagnostics MOLECULE NUCLEIC AMPLI ADDON Authorization Required Authorization Required No Authorization Required
83902 Molecular Diagnostics MOLECULAR DIAGNOSTICS Authorization Required Authorization Required No Authorization Required
83903 Molecular Diagnostics MOLECULE MUTATION SCAN Authorization Required Authorization Required No Authorization Required
83904 Molecular Diagnostics MOLECULE MUTATION IDENTIFY Authorization Required Authorization Required No Authorization Required
83905 Molecular Diagnostics MOLECULE MUTATION IDENTIFY Authorization Required Authorization Required No Authorization Required
83906 Molecular Diagnostics MOLECULE MUTATION IDENTIFY Authorization Required Authorization Required No Authorization Required
83907 Molecular Diagnostics LYSE CELLS FOR NUCLEIC EXT Authorization Required Authorization Required No Authorization Required
83908 Molecular Diagnostics NUCLEIC ACID, SIGNAL AMPLI Authorization Required Authorization Required No Authorization Required
83909 Molecular Diagnostics NUCLEIC ACID, HIGH RESOLUTE Authorization Required Authorization Required No Authorization Required
83912 Molecular Diagnostics GENETIC EXAMINATION Authorization Required Authorization Required No Authorization Required
83913 Molecular Diagnostics MOLECULAR, RNA STABILIZATION Authorization Required Authorization Required No Authorization Required
83914 Molecular Diagnostics MUTATION IDENT OLA/SBCE/ASPE Authorization Required Authorization Required No Authorization Required
88230 Cytogenetics
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS;
LYMPHOCYTE
Authorization Required Authorization Required No Authorization Required
88233 Cytogenetics
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS;
SKIN OR OTHER SOLID TISSUE BIOPSY
Authorization Required Authorization Required No Authorization Required
88235 Cytogenetics
TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS;
AMNIOTIC FLUID OR CHORIONIC VILLUS CELLS
Authorization Required Authorization Required No Authorization Required
88237 Cytogenetics
TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE
MARROW, BLOOD CELLS
Authorization Required Authorization Required No Authorization Required
88239 Cytogenetics
TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID
TUMOR
Authorization Required Authorization Required No Authorization Required
88240 Cytogenetics
CRYOPRESERVATION, FREEZING AND STORAGE OF
CELLS, EACH CELL LINE
Authorization Required Authorization Required No Authorization Required
88241 Cytogenetics
THAWING AND EXPANSION OF FROZEN CELLS, EACH
ALIQUOT
CHROMOSOME ANALYSIS FOR BREAKAGE
Authorization Required Authorization Required No Authorization Required
88245 Cytogenetics
SYNDROMES; BASELINE SISTER CHROMATID
EXCHANGE (SCE), 20-25 CELLS
CHROMOSOME ANALYSIS FOR BREAKAGE
Authorization Required Authorization Required No Authorization Required
88248 Cytogenetics SYNDROMES; BASELINE BREAKAGE, SCORE 50-100
CELLS, COUNT 20 CELLS, 2 KARYOTYPES (EG, FOR A
Authorization Required Authorization Required No Authorization Required
Updated March 2012 27 of 36 Authorization Requirements

PROCEDURE
CODE
88249 Cytogenetics
88261 Cytogenetics
88262 Cytogenetics
88263 Cytogenetics
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
CHROMOSOME ANALYSIS FOR BREAKAGE
SYNDROMES; SCORE 100 CELLS, CLASTOGEN STRESS
(EG, DIEPOXYBUTANE, MITOMYCIN C, IONIZING RA
CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1
KARYOTYPE, WITH BANDING
CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2
KARYOTYPES, WITH BANDING
CHROMOSOME ANALYSIS; COUNT 45 CELLS FOR
MOSAICISM, 2 KARYOTYPES, WITH BANDING
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
88264 Cytogenetics CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS
CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR
Authorization Required Authorization Required No Authorization Required
88267 Cytogenetics CHORIONIC VILLUS, COUNT 15 CELLS, 1 KARYOTYPE,
WITH BANDING
CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC
Authorization Required Authorization Required No Authorization Required
88269 Cytogenetics FLUID CELLS, COUNT CELLS FROM 6-12 COLONIES, 1
KARYOTYPE, WITH BANDING
Authorization Required Authorization Required No Authorization Required
88271 Cytogenetics
MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG,
FISH)
MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU
Authorization Required Authorization Required No Authorization Required
88272 Cytogenetics
HYBRIDIZATION, ANALYZE 3-5 CELLS (EG, FOR
DERIVATIVES AND MARKERS)
MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU
Authorization Required Authorization Required No Authorization Required
88273 Cytogenetics HYBRIDIZATION, ANALYZE 10-30 CELLS (EG, FOR
MICRODELETIONS)
Authorization Required Authorization Required No Authorization Required
88274 Cytogenetics
MOLECULAR CYTOGENETICS; INTERPHASE IN SITU
HYBRIDIZATION, ANALYZE 25-99 CELLS
Authorization Required Authorization Required No Authorization Required
88275 Cytogenetics
MOLECULAR CYTOGENETICS; INTERPHASE IN SITU
HYBRIDIZATION, ANALYZE 100-300 CELLS
Authorization Required Authorization Required No Authorization Required
88280 Cytogenetics
CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES,
EACH STUDY
Authorization Required Authorization Required No Authorization Required
88283 Cytogenetics
CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED
BANDING TECHNIQUE (EG, NOR, C-BANDING)
Authorization Required Authorization Required No Authorization Required
88285 Cytogenetics
CHROMOSOME ANALYSIS; ADDITIONAL CELLS
COUNTED, EACH STUDY
Authorization Required Authorization Required No Authorization Required
88289 Cytogenetics
CHROMOSOME ANALYSIS; ADDITIONAL HIGH
RESOLUTION STUDY
Authorization Required Authorization Required No Authorization Required
88291 Cytogenetics
CYTOGENETICS AND MOLECULAR CYTOGENETICS,
INTERPRETATION AND REPORT
Authorization Required Authorization Required No Authorization Required
88299 Cytogenetics UNLISTED CYTOGENETIC STUDY Authorization Required Authorization Required No Authorization Required
89250 Reproductive Medicine
CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4
DAYS;
Authorization Required Authorization Required No Authorization Required
89251 Reproductive Medicine
CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4
DAYS; WITH CO-CULTURE OF OOCYTE(S)/EMBRYOS
Authorization Required Authorization Required No Authorization Required
89253 Reproductive Medicine
ASSISTED EMBRYO HATCHING, MICROTECHNIQUES
(ANY METHOD)
Authorization Required Authorization Required No Authorization Required
89254 Reproductive Medicine OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID Authorization Required Authorization Required No Authorization Required
89255 Reproductive Medicine
PREPARATION OF EMBRYO FOR TRANSFER (ANY
METHOD)
Authorization Required Authorization Required No Authorization Required
89257 Reproductive Medicine
SPERM IDENTIFICATION FROM ASPIRATION (OTHER
THAN SEMINAL FLUID)
Authorization Required Authorization Required No Authorization Required
89258 Reproductive Medicine CRYOPRESERVATION; EMBRYO(S) Authorization Required Authorization Required No Authorization Required
89259 Reproductive Medicine CRYOPRESERVATION; SPERM
SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH
Authorization Required Authorization Required No Authorization Required
89260 Reproductive Medicine AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS
WITH SEMEN ANALYSIS
Authorization Required Authorization Required No Authorization Required
89261 Reproductive Medicine
SPERM ISOLATION; COMPLEX PREP (EG, PERCOLL
GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION
OR DIAGNOSIS WITH SEMEN ANALYSIS
Authorization Required Authorization Required No Authorization Required
89264 Reproductive Medicine
SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH
OR CRYOPRESERVED
Authorization Required Authorization Required No Authorization Required
89268 Reproductive Medicine INSEMINATION OF OOCYTES Authorization Required Authorization Required No Authorization Required
89272 Reproductive Medicine
EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7
DAYS
Authorization Required Authorization Required No Authorization Required
89280 Reproductive Medicine
89281 Reproductive Medicine
89290 Reproductive Medicine
ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE;
LESS THAN OR EQUAL TO 10 OOCYTES
ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE;
GREATER THAN 10 OOCYTES
BIOPSY, OOCYTE POLAR BODY OR EMBRYO
BLASTOMERE, MICROTECHNIQUE (FOR PRE-
IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR
EQUA
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 28 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
BIOPSY, OOCYTE POLAR BODY OR EMBRYO
POS 11 POS 22 POS 24
89291 Reproductive Medicine
BLASTOMERE, MICROTECHNIQUE (FOR PRE-
IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN
5 EM
Authorization Required Authorization Required No Authorization Required
89300 Reproductive Medicine
SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF
SPERM INCLUDING HUHNER TEST (POST COITAL)
Authorization Required Authorization Required No Authorization Required
89310 Reproductive Medicine
SEMEN ANALYSIS; MOTILITY AND COUNT (NOT
INCLUDING HUHNER TEST)
Authorization Required Authorization Required No Authorization Required
89320 Reproductive Medicine
SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND
DIFFERENTIAL
Authorization Required Authorization Required No Authorization Required
89321
SEMEN ANALYSIS; SPERM PRESENCE AND MOTILITY OF
Reproductive Medicine
SPERM, IF PERFORMED
SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND
Authorization Required Authorization Required No Authorization Required
89322 Reproductive Medicine DIFFERENTIAL USING STRICT MORPHOLOGIC CRITERIA
(EG, KRUGER)
Authorization Required Authorization Required No Authorization Required
89325 Reproductive Medicine SPERM ANTIBODIES Authorization Required Authorization Required No Authorization Required
89329 Reproductive Medicine SPERM EVALUATION; HAMSTER PENETRATION TEST Authorization Required Authorization Required No Authorization Required
89330 Reproductive Medicine
SPERM EVALUATION; CERVICAL MUCUS PENETRATION
TEST, WITH OR WITHOUT SPINNBARKEIT TEST
Authorization Required Authorization Required No Authorization Required
89331 Reproductive Medicine
SPERM EVALUATION, FOR RETROGRADE EJACULATION,
URINE (SPERM CONCENTRATION, MOTILITY, AND
MORPHOLOGY, AS INDICATED)
Authorization Required Authorization Required No Authorization Required
89335 Reproductive Medicine
CRYOPRESERVATION, REPRODUCTIVE TISSUE,
TESTICULAR
Authorization Required Authorization Required No Authorization Required
89342 Reproductive Medicine STORAGE (PER YEAR); EMBRYO(S) Authorization Required Authorization Required No Authorization Required
89343 Reproductive Medicine STORAGE (PER YEAR); SPERM/SEMEN Authorization Required Authorization Required No Authorization Required
89344 Reproductive Medicine
STORAGE (PER YEAR); REPRODUCTIVE TISSUE,
TESTICULAR/OVARIAN
Authorization Required Authorization Required No Authorization Required
89346 Reproductive Medicine STORAGE (PER YEAR); OOCYTE(S) Authorization Required Authorization Required No Authorization Required
89352 Reproductive Medicine THAWING OF CRYOPRESERVED; EMBRYO(S) Authorization Required Authorization Required No Authorization Required
89353 Reproductive Medicine
THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH
ALIQUOT
Authorization Required Authorization Required No Authorization Required
89354 Reproductive Medicine
THAWING OF CRYOPRESERVED; REPRODUCTIVE
TISSUE, TESTICULAR/OVARIAN
Authorization Required Authorization Required No Authorization Required
89356 Reproductive Medicine
THAWING OF CRYOPRESERVED; OOCYTES, EACH
Authorization Required Authorization Required No Authorization Required
89398 Reproductive Medicine
ALIQUOT
UNLISTED REPRODUCTIVE MEDICINE LABORATORY
PROCEDURE
Authorization Required Authorization Required No Authorization Required
90801 Behavioral Health PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION Authorization Required Authorization Required No Authorization Required
90802 Behavioral Health
90804 Behavioral Health
90805 Behavioral Health
90806 Behavioral Health
90807 Behavioral Health
90808 Behavioral Health
90809 Behavioral Health
90810 Behavioral Health
90811 Behavioral Health
90812 Behavioral Health
INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW
EXAMINATION USING PLAY EQUIPMENT, PHYSICAL
DEVICES, LANGUAGE INTERPRETER, OR
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
OFFICE OR OUTPATIENT FACILITY, APP
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 29 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
POS 11 POS 22 POS 24
90813 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90814 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90815 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90816 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90817 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90818 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90819 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90821 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED,
Authorization Required Authorization Required No Authorization Required
90822 Behavioral Health BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN
INPATIENT HOSPITAL, PARTIAL HOSPIT
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90823 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90824 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90826 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90827 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90828 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING
Authorization Required Authorization Required No Authorization Required
90829 Behavioral Health PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE
INTERPRETER, OR OTHER MECHANISMS O
Authorization Required Authorization Required No Authorization Required
90845 Behavioral Health PSYCHOANALYSIS Authorization Required Authorization Required No Authorization Required
90846 Behavioral Health
FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT
PRESENT)
Authorization Required Authorization Required No Authorization Required
90847 Behavioral Health
FAMILY PSYCHOTHERAPY (CONJOINT
PSYCHOTHERAPY) (WITH PATIENT PRESENT)
Authorization Required Authorization Required No Authorization Required
90849 Behavioral Health MULTIPLE-FAMILY GROUP PSYCHOTHERAPY Authorization Required Authorization Required No Authorization Required
90853 Behavioral Health
GROUP PSYCHOTHERAPY (OTHER THAN OF A
MULTIPLE-FAMILY GROUP)
Authorization Required Authorization Required No Authorization Required
90857 Behavioral Health INTERACTIVE GROUP PSYCHOTHERAPY Authorization Required Authorization Required No Authorization Required
90862 Behavioral Health
90865 Behavioral Health
90867 Behavioral Health
90868 Behavioral Health
90869 Behavioral Health
90870 Behavioral Health
PHARMACOLOGIC MANAGEMENT, INCLUDING
PRESCRIPTION, USE, AND REVIEW OF MEDICATION
WITH NO MORE THAN MINIMAL MEDICAL PSYCHOTH
NARCOSYNTHESIS FOR PSYCHIATRIC DIAGNOSTIC AND
THERAPEUTIC PURPOSES (EG, SODIUM AMOBARBITAL
(AMYTAL) INTERVIEW)
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC
STIMULATION TREATMENT; PLANNING
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC
STIMULATION TREATMENT; DELIVERY AND
MANAGEMENT, PER SESSION
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC
STIMULATION (TMS) TREATMENT; SUBSEQUENT
MOTOR THRESHOLD RE-DETERMINATION WITH
DELIVER
ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY
MONITORING)
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 30 of 36 Authorization Requirements

PROCEDURE
CODE
PROGRAM DESCRIPTION
INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY
POS 11 POS 22 POS 24
90875 Behavioral Health INCORPORATING BIOFEEDBACK TRAINING BY ANY
MODALITY (FACE-TO-FACE WITH THE PATIENT),
INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY
Authorization Required Authorization Required No Authorization Required
90876 Behavioral Health INCORPORATING BIOFEEDBACK TRAINING BY ANY
MODALITY (FACE-TO-FACE WITH THE PATIENT),
Authorization Required Authorization Required No Authorization Required
90880 Behavioral Health HYPNOTHERAPY
ENVIRONMENTAL INTERVENTION FOR MEDICAL
Authorization Required Authorization Required No Authorization Required
90882 Behavioral Health MANAGEMENT PURPOSES ON A PSYCHIATRIC
PATIENT'S BEHALF WITH AGENCIES, EMPLOYERS, OR
PSYCHIATRIC EVALUATION OF HOSPITAL RECORDS,
Authorization Required Authorization Required No Authorization Required
90885 Behavioral Health OTHER PSYCHIATRIC REPORTS, PSYCHOMETRIC
AND/OR PROJECTIVE TESTS, AND OTHER ACC
INTERPRETATION OR EXPLANATION OF RESULTS OF
Authorization Required Authorization Required No Authorization Required
90887 Behavioral Health PSYCHIATRIC, OTHER MEDICAL EXAMINATIONS AND
PROCEDURES, OR OTHER ACCUMULATED D
Authorization Required Authorization Required No Authorization Required
90889 Behavioral Health
PREPARATION OF REPORT OF PATIENT'S PSYCHIATRIC
STATUS, HISTORY, TREATMENT, OR PROGRESS (OTHER
THAN FOR LEGAL OR CONSULTATI
Authorization Required Authorization Required No Authorization Required
90899 Behavioral Health UNLISTED PSYCHIATRIC SERVICE OR PROCEDURE Authorization Required Authorization Required No Authorization Required
92506 Skilled Therapy
92507 Skilled Therapy
92508 Skilled Therapy
92526 Skilled Therapy
93015
93016
93017
93018
93303 Cardiology
93304 Cardiology
93306 Cardiology
93307 Cardiology
93308 Cardiology
93320 Cardiology
93321 Cardiology
93325 Cardiology
EVALUATION OF SPEECH, LANGUAGE, VOICE,
COMMUNICATION, AND/OR AUDITORY PROCESSING
TREATMENT OF SPEECH, LANGUAGE, VOICE,
COMMUNICATION, AND/OR AUDITORY PROCESSING
DISORDER; INDIVIDUAL
TREATMENT OF SPEECH, LANGUAGE, VOICE,
COMMUNICATION, AND/OR AUDITORY PROCESSING
DISORDER; GROUP, 2 OR MORE INDIVIDUALS
TREATMENT OF SWALLOWING DYSFUNCTION AND/OR
ORAL FUNCTION FOR FEEDING
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR
SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE,
CONTINUOUS ELECTROCARDIOGRAPHIC MONI
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR
SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE,
CONTINUOUS ELECTROCARDIOGRAPHIC MONI
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR
SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE,
CONTINUOUS ELECTROCARDIOGRAPHIC MONI
CARDIOVASCULAR STRESS TEST USING MAXIMAL OR
SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE,
CONTINUOUS ELECTROCARDIOGRAPHIC MONI
TRANSTHORACIC ECHOCARDIOGRAPHY FOR
CONGENITAL CARDIAC ANOMALIES; COMPLETE
TRANSTHORACIC ECHOCARDIOGRAPHY FOR
CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR
LIMITED STUDY
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME
WITH IMAGE DOCUMENTATION (2D), INCLUDES M-
MODE RECORDING, WHEN PERFORMED, COMPLETE,
WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND
WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR
WITHOUT M-MODE RECORDING; COMPLETE
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME
WITH IMAGE DOCUMENTATION (2D) WITH OR
WITHOUT M-MODE RECORDING; FOLLOW-UP OR
LIMITED STUDY
DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE
AND/OR CONTINUOUS WAVE WITH SPECTRAL
DISPLAY; COMPLETE
DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE
AND/OR CONTINUOUS WAVE WITH SPECTRAL
DISPLAY; FOLLOW-UP OR LIMITED STUDY
DOPPLER ECHOCARDIOGRAPHY COLOR FLOW
VELOCITY MAPPING
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
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Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 31 of 36 Authorization Requirements

PROCEDURE
CODE
93350 Cardiology
93351 Cardiology
93352 Cardiology
93452 Cardiology
93453 Cardiology
93454 Cardiology
93455 Cardiology
93456 Cardiology
93457 Cardiology
93458 Cardiology
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME
WITH IMAGE DOCUMENTATION (2D), WITH OR
WITHOUT M-MODE RECORDING, DURING REST AND
CARDIOVASCULAR STRESS TEST, WITH
INTERPRETATION AND REPORT
ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME
WITH IMAGE DOCUMENTATION (2D), INCLUDES M-
MODE RECORDING, WHEN PERFORMED, DURING REST
AND CARDIOVASCULAR STRESS TEST USING
TREADMILL, BICYCLE EXERCISE AND/OR
PHARMACOLOGICALLY INDUCED STRESS, WITH
INTERPRETATION
USE OF ECHOCARDIOGRAPHIC CONTRAST AGENT
DURING STRESS ECHOCARDIOGRAPHY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
LEFT HEART CATHETERIZATION INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR LEFT
VENTRICULOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION, WHEN PERFORMED
COMBINED RIGHT AND LEFT HEART CATHETERIZATION
INCLUDING INTRAPROCEDURAL INJECTION(S) FOR
LEFT VENTRICULOGRAPHY, IMAGING SUPERVISION
AND INTERPRETATION, WHEN PERFORMED
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH CATHETER PLACEMENT(S) IN
BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE
ARTERIAL VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH RIGHT HEART
CATHETERIZATION
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH CATHETER PLACEMENT(S) IN
BYPASS GRAFT(S) (INTERNAL MAMMARY, FREE
ARTERIAL, VENOUS GRAFTS) INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR BYPASS GRAFT
ANGIOGRAPHY AND RIGHT HEART CATHETERIZATION
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
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Authorization Required Authorization Required No Authorization Required
Updated March 2012 32 of 36 Authorization Requirements

PROCEDURE
CODE
93459 Cardiology
93460 Cardiology
93461 Cardiology
93462 Cardiology
93720
93721
93722
93880
93882
93886
93890
93892
93922
93923
93924
93925
93926
93930
93931
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS
GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL,
VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH RIGHT AND LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED
CATHETER PLACEMENT IN CORONARY ARTERY(S) FOR
CORONARY ANGIOGRAPHY, INCLUDING
INTRAPROCEDURAL INJECTION(S) FOR CORONARY
ANGIOGRAPHY, IMAGING SUPERVISION AND
INTERPRETATION; WITH RIGHT AND LEFT HEART
CATHETERIZATION INCLUDING INTRAPROCEDURAL
INJECTION(S) FOR LEFT VENTRICULOGRAPHY, WHEN
PERFORMED, CATHETER PLACEMENT(S) IN BYPASS
GRAFT(S) (INTERNAL MAMMARY, FREE ARTERIAL,
VENOUS GRAFTS) WITH BYPASS GRAFT ANGIOGRAPHY
LEFT HEART CATHETERIZATION BY TRANSSEPTAL
PUNCTURE THROUGH INTACT SEPTUM OR BY
TRANSAPICAL PUNCTURE (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROCEDURE)
PLETHYSMOGRAPHY, TOTAL BODY; WITH
INTERPRETATION AND REPORT
PLETHYSMOGRAPHY, TOTAL BODY; TRACING ONLY,
WITHOUT INTERPRETATION AND REPORT
PLETHYSMOGRAPHY, TOTAL BODY; INTERPRETATION
AND REPORT ONLY
DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE
BILATERAL STUDY
DUPLEX SCAN OF EXTRACRANIAL ARTERIES;
UNILATERAL OR LIMITED STUDY
TRANSCRANIAL DOPPLER STUDY OF THE
INTRACRANIAL ARTERIES; COMPLETE STUDY
TRANSCRANIAL DOPPLER STUDY OF THE
INTRACRANIAL ARTERIES; VASOREACTIVITY STUDY
TRANSCRANIAL DOPPLER STUDY OF THE
INTRACRANIAL ARTERIES; EMBOLI DETECTION
WITHOUT INTRAVENOUS MICROBUBBLE INJECTION
NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR
LOWER EXTREMITY ARTERIES, SINGLE LEVEL,
BILATERAL (EG, ANKLE/BRACHIAL INDICES,
NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR
LOWER EXTREMITY ARTERIES, MULTIPLE LEVELS OR
WITH PROVOCATIVE FUNCTIONAL MANEU
NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER
EXTREMITY ARTERIES, AT REST AND FOLLOWING
TREADMILL STRESS TESTING, COMPLETE BILA
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR
ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL
STUDY
DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR
ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED
STUDY
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR
ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL
STUDY
DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR
ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED
STUDY
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
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No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 33 of 36 Authorization Requirements

PROCEDURE
CODE
93965
93970
93971
93975
93976
93978
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY
VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER
WAVEFORM ANALYSIS WITH RESPONSES
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING
RESPONSES TO COMPRESSION AND OTHER
MANEUVERS; COMPLETE BILATERAL STUDY
DUPLEX SCAN OF EXTREMITY VEINS INCLUDING
RESPONSES TO COMPRESSION AND OTHER
MANEUVERS; UNILATERAL OR LIMITED STUDY
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS
OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL
CONTENTS AND/OR RETROPERITONEAL ORGANS; CO
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS
OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL
CONTENTS AND/OR RETROPERITONEAL ORGANS; LI
DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC
VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
93979
DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC
VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR
LIMITED STUDY
No Authorization Required Authorization Required No Authorization Required
93980
DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS
No Authorization Required
OUTFLOW OF PENILE VESSELS; COMPLETE STUDY
DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING
Authorization Required No Authorization Required
93990
ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS
OUTFLOW)
SLEEP STUDY, UNATTENDED, SIMULTANEOUS
No Authorization Required Authorization Required No Authorization Required
95800 Sleep
RECORDING; HEART RATE, OXYGEN SATURATION,
RESPIRATORY ANALYSIS (EG, BY AIRFLOW OR
PERIPHERAL ARTERIAL TONE), AND SLEEP TIME
SLEEP STUDY, UNATTENDED, SIMULTANEOUS
Authorization Required Authorization Required No Authorization Required
95801 Sleep
RECORDING; MINIMUM OF HEART RATE, OXYGEN
SATURATION, AND RESPIRATORY ANALYSIS (EG, BY
AIRFLOW OR PERIPHERAL ARTERIAL TONE)
Authorization Required Authorization Required No Authorization Required
95805 Sleep
MULTIPLE SLEEP LATENCY TEST OR MAINTENANCE OF
WAKEFULNESS TEST
SLEEP STUDY, UNATTENDED, SIMULTANEOUS
Authorization Required Authorization Required No Authorization Required
95806 Sleep
RECORDING OF, HEART RATE, OXYGEN SATURATION,
RESPIRATORY AIRFLOW, AND RESPIRATORY EFFORT
(E.G. THORACOABDOMINAL MOVEMENT)
SLEEP STUDY, SIMULTANEOUS RECORDING OF
Authorization Required Authorization Required No Authorization Required
95807 Sleep
VENTILATION, RESPIRATORY EFFORT, ECG OR HEART
RATE, AND OXYGEN SATURATION, ATTENDED BY A
TECHNOLOGIST
POLYSOMNOGRAPHY, SLEEP STAGING WITH 1-3
Authorization Required Authorization Required No Authorization Required
95808 Sleep
ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A
TECHNOLOGIST
Authorization Required Authorization Required No Authorization Required
95810 Sleep POLYSOMNOGRAPHY, 4 OR MORE Authorization Required Authorization Required No Authorization Required
95811 Sleep POLYSOMNOGRAPHY W/CPAP Authorization Required Authorization Required No Authorization Required
95860
NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH
No Authorization Required
OR WITHOUT RELATED PARASPINAL AREAS
Authorization Required No Authorization Required
95861
NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES
No Authorization Required
WITH OR WITHOUT RELATED PARASPINAL AREAS
Authorization Required No Authorization Required
95863
NEEDLE ELECTROMYOGRAPHY; THREE EXTREMITIES
No Authorization Required
WITH OR WITHOUT RELATED PARASPINAL AREAS
Authorization Required No Authorization Required
95864
NEEDLE ELECTROMYOGRAPHY; FOUR EXTREMITIES
No Authorization Required
WITH OR WITHOUT RELATED PARASPINAL AREAS
NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF
Authorization Required No Authorization Required
95870
MUSCLES IN ONE EXTREMITY OR NON-LIMB (AXIAL)
MUSCLES (UNILATERAL OR BILATERAL),
NERVE CONDUCTION, AMPLITUDE AND
No Authorization Required Authorization Required No Authorization Required
95900
LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, No Authorization Required Authorization Required No Authorization Required
WITHOUT F-WAVE STUDY
NERVE CONDUCTION, AMPLITUDE AND
95903
LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, No Authorization Required Authorization Required No Authorization Required
95904
WITH F-WAVE STUDY
NERVE CONDUCTION, AMPLITUDE AND
No Authorization Required
LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY
TESTING OF AUTONOMIC NERVOUS SYSTEM
Authorization Required No Authorization Required
95921
FUNCTION; CARDIOVAGAL INNERVATION
(PARASYMPATHETIC FUNCTION), INCLUDING TWO OR
MORE OF
No Authorization Required Authorization Required No Authorization Required
Updated March 2012 34 of 36 Authorization Requirements

PROCEDURE
CODE
95922
95925
95926
95927
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
TESTING OF AUTONOMIC NERVOUS SYSTEM
FUNCTION; VASOMOTOR ADRENERGIC INNERVATION
(SYMPATHETIC ADRENERGIC FUNCTION), INCLUDIN
SHORT-LATENCY SOMATOSENSORY EVOKED
POTENTIAL STUDY, STIMULATION OF ANY/ALL
PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM
SHORT-LATENCY SOMATOSENSORY EVOKED
POTENTIAL STUDY, STIMULATION OF ANY/ALL
PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM
SHORT-LATENCY SOMATOSENSORY EVOKED
POTENTIAL STUDY, STIMULATION OF ANY/ALL
PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
No Authorization Required Authorization Required No Authorization Required
95930
VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL
No Authorization Required
NERVOUS SYSTEM, CHECKERBOARD OR FLASH
Authorization Required No Authorization Required
95934
H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD
No Authorization Required
GASTROCNEMIUS/SOLEUS MUSCLE
H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD
Authorization Required No Authorization Required
95936
MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS
MUSCLE
NEUROMUSCULAR JUNCTION TESTING (REPETITIVE
No Authorization Required Authorization Required No Authorization Required
95937
STIMULATION, PAIRED STIMULI), EACH NERVE, ANY
ONE METHOD
MONITORING FOR LOCALIZATION OF CEREBRAL
No Authorization Required Authorization Required No Authorization Required
95951
SEIZURE FOCUS BY CABLE OR RADIO, 16 OR MORE
CHANNEL TELEMETRY, COMBINED ELECTROENC
MONITORING FOR LOCALIZATION OF CEREBRAL
No Authorization Required Authorization Required No Authorization Required
95953
SEIZURE FOCUS BY COMPUTERIZED PORTABLE 16 OR
MORE CHANNEL EEG, ELECTROENCEPHALOGRA
MONITORING FOR LOCALIZATION OF CEREBRAL
No Authorization Required Authorization Required No Authorization Required
95956
SEIZURE FOCUS BY CABLE OR RADIO, 16 OR MORE
CHANNEL TELEMETRY, ELECTROENCEPHALOGRA
No Authorization Required Authorization Required No Authorization Required
95957
DIGITAL ANALYSIS OF ELECTROENCEPHALOGRAM
No Authorization Required
(EEG) (EG, FOR EPILEPTIC SPIKE ANALYSIS)
Authorization Required No Authorization Required
97001 Skilled Therapy PHYSICAL THERAPY EVALUATION Authorization Required Authorization Required No Authorization Required
97002 Skilled Therapy PHYSICAL THERAPY RE-EVALUATION Authorization Required Authorization Required No Authorization Required
97003 Skilled Therapy OCCUPATIONAL THERAPY EVALUATION Authorization Required Authorization Required No Authorization Required
97004 Skilled Therapy OCCUPATIONAL THERAPY RE-EVALUATION Authorization Required Authorization Required No Authorization Required
97005 Skilled Therapy ATHLETIC TRAINING EVALUATION Authorization Required Authorization Required No Authorization Required
97006 Skilled Therapy ATHLETIC TRAINING RE-EVALUATION Authorization Required Authorization Required No Authorization Required
97010 Skilled Therapy APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD Authorization PACKS Required Authorization Required No Authorization Required
97012 Skilled Therapy APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, MECHANICAL Authorization Required Authorization Required No Authorization Required
97014 APPLICATION Skilled Therapy OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION Authorization (UNATTENDED) Required Authorization Required No Authorization Required
97016 Skilled APPLICATION Therapy OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC Authorization DEVICES Required Authorization Required No Authorization Required
97018 Skilled Therapy APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH Authorization Required Authorization Required No Authorization Required
97022 Skilled TherapyAPPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL Authorization Required Authorization Required No Authorization Required
97024 Skilled APPLICATION Therapy OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (EG, MICROWAVE)
Authorization Required Authorization Required No Authorization Required
97026 Skilled TherapyAPPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED Authorization Required Authorization Required No Authorization Required
97028 Skilled Therapy APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET Authorization Required Authorization Required No Authorization Required
97032 APPLICATION Skilled OF Therapy A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), Authorization EACH 15 Required MINUTES Authorization Required No Authorization Required
97033 Skilled APPLICATION Therapy OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH Authorization 15 MINUTESRequired
Authorization Required No Authorization Required
97034 Skilled APPLICATION TherapyOF
A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH Authorization 15 MINUTES Required Authorization Required No Authorization Required
97035 Skilled APPLICATION Therapy OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH Authorization 15 MINUTES Required Authorization Required No Authorization Required
97036 Skilled APPLICATION Therapy OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH Authorization 15 MINUTESRequired
Authorization Required No Authorization Required
97039 Skilled Therapy UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT ATTENDANCE) Authorization Required
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS,
Authorization Required No Authorization Required
97110 Skilled Therapy EACH 15 MINUTES; THERAPEUTIC EXERCISES TO
DEVELOP STRENGTH AND ENDURANCE, RANGE
Authorization Required Authorization Required No Authorization Required
97112 Skilled Therapy
97113 Skilled Therapy
97116 Skilled Therapy
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS,
EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION
OF MOVEMENT, BALANCE, COORDINATION, K
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS,
EACH 15 MINUTES; AQUATIC THERAPY WITH
THERAPEUTIC EXERCISES
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS,
EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR
CLIMBING)
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 35 of 36 Authorization Requirements

PROCEDURE
CODE
97124 Skilled Therapy
PROGRAM DESCRIPTION POS 11 POS 22 POS 24
THERAPEUTIC PROCEDURE, ONE OR MORE AREAS,
EACH 15 MINUTES; MASSAGE, INCLUDING
EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (ST
Authorization Required Authorization Required No Authorization Required
97139 Skilled Therapy UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) Authorization Required Authorization Required No Authorization Required
97140 Skilled Therapy
97150 Skilled Therapy
97530 Skilled Therapy
97532 Skilled Therapy
97533 Skilled Therapy
97535 Skilled Therapy
97537 Skilled Therapy
97542 Skilled Therapy
MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/
MANIPULATION, MANUAL LYMPHATIC DRAINAGE,
MANUAL TRACTION), ONE OR MORE REGION
THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE
INDIVIDUALS)
THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE)
PATIENT CONTACT BY THE PROVIDER (USE OF
DYNAMIC ACTIVITIES TO IMPROVE FUNCTION
DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE
ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES
COMPENSATORY TRAINING), DIRECT (ON
SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE
SENSORY PROCESSING AND PROMOTE ADAPTIVE
RESPONSES TO ENVIRONMENTAL DEMANDS, DIRE
SELF-CARE/HOME MANAGEMENT TRAINING (EG,
ACTIVITIES OF DAILY LIVING (ADL) AND
COMPENSATORY TRAINING, MEAL PREPARATION,
SAFE
COMMUNITY/WORK REINTEGRATION TRAINING (EG,
SHOPPING, TRANSPORTATION, MONEY
MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR
WORK
WHEELCHAIR MANAGEMENT (EG, ASSESSMENT,
FITTING, TRAINING), EACH 15 MINUTES
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
97545 Skilled Therapy WORK HARDENING/CONDITIONING; INITIAL 2 HOURS Authorization Required Authorization Required No Authorization Required
97546 Skilled Therapy
97597 Skilled Therapy
97598 Skilled Therapy
97602 Skilled Therapy
97605 Skilled Therapy
97606 Skilled Therapy
97750 Skilled Therapy
97755 Skilled Therapy
97760 Skilled Therapy
97761 Skilled Therapy
97762 Skilled Therapy
97799 Skilled Therapy
WORK HARDENING/CONDITIONING; EACH
ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO
CODE FOR PRIMARY PROCEDURE)
REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S),
SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG,
HIGH PRESSURE WATERJET WITH/WI
REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S),
SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG,
HIGH PRESSURE WATERJET WITH/WI
REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S),
NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA
(EG, WET-TO-MOIST DRESSINGS, EN
NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM
ASSISTED DRAINAGE COLLECTION), INCLUDING
TOPICAL APPLICATION(S), WOUND ASSESSM
NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM
ASSISTED DRAINAGE COLLECTION), INCLUDING
TOPICAL APPLICATION(S), WOUND ASSESSM
PHYSICAL PERFORMANCE TEST OR MEASUREMENT
(EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY),
WITH WRITTEN REPORT, EACH 15 MINUTES
ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO
RESTORE, AUGMENT OR COMPENSATE FOR EXISTING
FUNCTION, OPTIMIZE FUNCTIONAL TASKS AN
ORTHOTIC(S) MANAGEMENT AND TRAINING
(INCLUDING ASSESSMENT AND FITTING WHEN NOT
OTHERWISE REPORTED), UPPER EXTREMITY(S), LO
PROSTHETIC TRAINING, UPPER AND/OR LOWER
EXTREMITY(S), EACH 15 MINUTES
CHECKOUT FOR ORTHOTIC/PROSTHETIC USE,
ESTABLISHED PATIENT, EACH 15 MINUTES
UNLISTED PHYSICAL MEDICINE/REHABILITATION
SERVICE OR PROCEDURE
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Authorization Required Authorization Required No Authorization Required
Updated March 2012 36 of 36 Authorization Requirements