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Medicaid PA Changes Eff 10.15.24

Date: 09/13/24

Medicaid Prior Authorization Changes Effective October 15, 2024

Arizona Complete Health Complete Care Plan (AzCH-CCP) requires prior authorization (PA) as a condition of payment for certain services. This communication outlines Medicaid PA changes effective for dates of service October 15, 2024, and after.

It is the ordering/prescribing provider’s responsibility to request PA when required. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL SERVICES EXCEPT WHERE OTHERWISE INDICATED.

Please verify eligibility and benefits prior to rendering service. Payment, regardless of PA, is contingent on the member’s eligibility at the time service is rendered.

Although these changes are effective October 15, 2024, our system including our secure provider portal, will be updated in early October to allow you to submit PA requests for dates of service October 15, 2024, and forward well ahead of time.

For a complete CPT/HCPCS code listing, please use the Pre-Auth Check Tool on our website under For Providers > Pre-Auth Check. The Pre-Auth Check Tool will reflect the changes outlined in this communication on October 15, 2024. In the interim this communication serves as the best reference for the upcoming changes.

ADDITIONAL INFORMATION

If you have questions regarding the information contained in this update, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us: AzCHProviderEngagement@azcompletehealth.com

AzCH-CCP Medicaid PA Changes Effective 10/15/24

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

POS 99

Services provided in POS 99

PA required for Non-Par providers only

655

HOSPICE/IP RESPITE

PA required for Non-Par providers only

657

HOSPICE/PHYSICIAN

PA required for Non-Par providers only

659

HOSPICE/OTHER

PA required for Non-Par providers only

780

TELEMEDICINE

PA required for Non-Par providers only

905

BH/INTENS OP/PSYCH

PA required for All providers

915

BH/GROUP RX

PA required for ALL providers

00190

ANESTH FACE/SKULL BONE SURG

PA required for Non-Par providers only

00921

ANESTH VASECTOMY

PA required for Non-Par providers only

01962

ANESTH EMER HYSTERECTOMY

PA required for Non-Par providers only

01963

ANESTH CS HYSTERECTOMY

PA required for Non-Par providers only

01969

ANESTH/ANALG CS HYST ADD-ON

PA required for Non-Par providers only

11042

DEB SUBQ TISSUE 20 SQ CM/<

PA required after 12 wound care visits billed

11043

DEB MUSC/FASCIA 20 SQ CM/<

PA required after 12 wound care visits billed

11044

DEB BONE 20 SQ CM/<

PA required after 12 wound care visits billed

11960

INSERT TISSUE EXPANDER(S)

PA required if billed with gender dysphoria diagnosis

11970

REPLACEMENT TISSUE EXPANDER W/PERMANENT IMPLANT

PA required if billed with gender dysphoria diagnosis

14000

TIS TRNFR TRUNK 10 SQ CM/<

PA required if billed with gender dysphoria diagnosis

14001

TIS TRNFR TRUNK 10.1-30SQCM

PA required if billed with gender dysphoria diagnosis

15100

SKIN SPLT GRFT TRNK/ARM/LEG

PA required if billed with gender dysphoria diagnosis

15101

SKIN SPLT GRFT T/A/L ADD-ON

PA required if billed with gender dysphoria diagnosis

15120

SKN SPLT A-GRFT FAC/NCK/HF/G

PA required if billed with gender dysphoria diagnosis

15121

SKN SPLT A-GRFT F/N/HF/G ADD

PA required if billed with gender dysphoria diagnosis

15200

SKIN FULL GRAFT TRUNK

PA required if billed with gender dysphoria diagnosis

15271

SKIN SUB GRAFT TRNK/ARM/LEG

PA required for ALL providers

15272

SKIN SUB GRAFT T/A/L ADD-ON

PA required for ALL providers

15273

SKIN SUB GRFT T/ARM/LG CHILD

PA required for ALL providers

15274

SKN SUB GRFT T/A/L CHILD ADD

PA required for ALL providers

15275

SKIN SUB GRAFT FACE/NK/HF/G

PA required for ALL providers

15276

SKIN SUB GRAFT F/N/HF/G ADDL

PA required for ALL providers

15277

SKN SUB GRFT F/N/HF/G CHILD

PA required for ALL providers

15278

SKN SUB GRFT F/N/HF/G CH ADD

PA required for ALL providers

15570

SKIN PEDICLE FLAP TRUNK

PA required if billed with gender dysphoria diagnosis

15574

PEDCLE FH/CH/CH/M/N/AX/G/H/F

PA required if billed with gender dysphoria diagnosis

15600

DELAY FLAP TRUNK

PA required if billed with gender dysphoria diagnosis

15620

DELAY FLAP F/C/C/N/AX/G/H/F

PA required if billed with gender dysphoria diagnosis

15734

MUSCLE-SKIN GRAFT TRUNK

PA required for Non-Par providers only

15736

MUSCLE-SKIN GRAFT ARM

PA required for Non-Par providers only

15738

MUSCLE-SKIN GRAFT LEG

PA required for Non-Par providers only

15757

FREE SKIN FLAP MICROVASC

PA required if billed with gender dysphoria diagnosis

15758

FREE FASCIAL FLAP MICROVASC

PA required if billed with gender dysphoria diagnosis

15769

GRAFTING OF AUTOLOGOUS SOFT TISS BY DIRECT EXC

PA required if billed with gender dysphoria diagnosis

15771

GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS

PA required if billed with gender dysphoria diagnosis

15772

GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC

PA required if billed with gender dysphoria diagnosis

15773

GRAFTING OF AUTOLOGOUS FAT BY LIPO 25 CC OR LESS

PA required if billed with gender dysphoria diagnosis

15774

GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 25 CC

PA required if billed with gender dysphoria diagnosis

15840

NERVE PALSY FASCIAL GRAFT

PA required for Non-Par providers only

15841

NERVE PALSY MUSCLE GRAFT

PA required for Non-Par providers only

15842

NERVE PALSY MICROSURG GRAFT

PA required for Non-Par providers only

15845

SKIN AND MUSCLE REPAIR FACE

PA required for Non-Par providers only

19301

PARTIAL MASTECTOMY

PA required for Non-Par providers only

19303

MAST SIMPLE COMPLETE

PA required if billed with gender dysphoria diagnosis

19330

RMVL RUPTURED BREAST IMPLANT W/IMPLANT CONTENTS

No PA required if billed with breast cancer diagnosis

19340

INSERTION BREAST IMPLANT SAME DAY OF MASTECTOMY

No PA required if billed with breast cancer diagnosis

19342

INSJ/RPLCMT BREAST IMPLANT SEP DAY MASTECTOMY

No PA required if billed with breast cancer diagnosis

19350

BREAST RECONSTRUCTION

No PA required if billed with breast cancer diagnosis

19355

CORRECT INVERTED NIPPLE(S)

No PA required if billed with breast cancer diagnosis

19357

TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION

PA required for Non-Par providers only

19364

BREAST RECONSTRUCTION W/FREE FLAP

No PA required if billed with breast cancer diagnosis

19370

REVISION PERI-IMPLANT CAPSULE BREAST

No PA required if billed with breast cancer diagnosis

19371

PERI-IMPLANT CAPSULECTOMY BREAST COMPLETE

No PA required if billed with breast cancer diagnosis

19380

REVISION OF RECONSTRUCTED BREAST

No PA required if billed with breast cancer diagnosis

19396

DESIGN CUSTOM BREAST IMPLANT

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

19499

BREAST SURGERY PROCEDURE

No PA required if billed with breast cancer diagnosis

20552

INJ TRIGGER POINT 1/2 MUSCL

PA required for Non-Par providers only

20553

INJECT TRIGGER POINTS 3/>

PA required for Non-Par providers only

20680

REMOVAL OF SUPPORT IMPLANT

PA required for Non-Par providers only

21010

INCISION OF JAW JOINT

PA required for Non-Par providers only

21050

REMOVAL OF JAW JOINT

PA required for Non-Par providers only

21060

REMOVE JAW JOINT CARTILAGE

PA required for Non-Par providers only

21070

REMOVE CORONOID PROCESS

PA required for Non-Par providers only

21073

MNPJ OF TMJ W/ANESTH

PA required for Non-Par providers only

21081

PREPARE FACE/ORAL PROSTHESIS

PA required for Non-Par providers only

21085

PREPARE FACE/ORAL PROSTHESIS

PA required for Non-Par providers only

21100

MAXILLOFACIAL FIXATION

PA required for Non-Par providers only

21116

INJECTION JAW JOINT X-RAY

PA required for Non-Par providers only

21141

LEFORT I-1 PIECE W/O GRAFT

PA required for Non-Par providers only

21142

LEFORT I-2 PIECE W/O GRAFT

PA required for Non-Par providers only

21143

LEFORT I-3/> PIECE W/O GRAFT

PA required for Non-Par providers only

21145

LEFORT I-1 PIECE W/ GRAFT

PA required for Non-Par providers only

21146

LEFORT I-2 PIECE W/ GRAFT

PA required for Non-Par providers only

21147

LEFORT I-3/> PIECE W/ GRAFT

PA required for Non-Par providers only

21154

LEFORT III W/O LEFORT I

PA required for Non-Par providers only

21159

LEFORT III W/FHDW/O LEFORT I

PA required for Non-Par providers only

21172

RECONSTRUCT ORBIT/FOREHEAD

PA required for Non-Par providers only

21175

RECONSTRUCT ORBIT/FOREHEAD

PA required for Non-Par providers only

21179

RECONSTRUCT ENTIRE FOREHEAD

PA required for Non-Par providers only

21180

RECONSTRUCT ENTIRE FOREHEAD

PA required for Non-Par providers only

21181

CONTOUR CRANIAL BONE LESION

PA required for Non-Par providers only

21182

RECONSTRUCT CRANIAL BONE

PA required for Non-Par providers only

21183

RECONSTRUCT CRANIAL BONE

PA required for Non-Par providers only

21188

RECONSTRUCTION OF MIDFACE

PA required for Non-Par providers only

21193

RECONST LWR JAW W/O GRAFT

PA required for Non-Par providers only

21194

RECONST LWR JAW W/GRAFT

PA required for Non-Par providers only

21195

RECONST LWR JAW W/O FIXATION

PA required for Non-Par providers only

21196

RECONST LWR JAW W/FIXATION

PA required for Non-Par providers only

21198

RECONSTR LWR JAW SEGMENT

PA required for Non-Par providers only

21199

RECONSTR LWR JAW W/ADVANCE

PA required for Non-Par providers only

21206

RECONSTRUCT UPPER JAW BONE

PA required for Non-Par providers only

21256

RECONSTRUCTION OF ORBIT

PA required for Non-Par providers only

21263

REVISE EYE SOCKETS

PA required for Non-Par providers only

21267

REVISE EYE SOCKETS

PA required for Non-Par providers only

21275

REVISION ORBITOFACIAL BONES

PA required for Non-Par providers only

21480

RESET DISLOCATED JAW

PA required for Non-Par providers only

21485

RESET DISLOCATED JAW

PA required for Non-Par providers only

21490

REPAIR DISLOCATED JAW

PA required for Non-Par providers only

21499

HEAD SURGERY PROCEDURE

PA required for ALL providers

21899

TREAT STERNUM FRACTURE

PA required for ALL providers

22999

ABDOMEN SURGERY PROCEDURE

PA required for ALL providers

23929

SHOULDER SURGERY PROCEDURE

PA required for ALL providers

25447

REPAIR WRIST JOINTS

PA required for Non-Par providers only

25449

REMOVE WRIST JOINT IMPLANT

PA required for Non-Par providers only

26530

REVISE KNUCKLE JOINT

PA required for Non-Par providers only

26531

REVISE KNUCKLE WITH IMPLANT

PA required for Non-Par providers only

26535

REVISE FINGER JOINT

PA required for Non-Par providers only

26536

REVISE/IMPLANT FINGER JOINT

PA required for Non-Par providers only

27096

INJECT SACROILIAC JOINT

PA required for ALL providers

29800

JAW ARTHROSCOPY/SURGERY

PA required for Non-Par providers only

29804

JAW ARTHROSCOPY/SURGERY

PA required for Non-Par providers only

29828

SURGICAL ARTHROSCOPY SHOULDER BICEPS TENODESIS

PA required for Non-Par providers only

31599

LARYNX SURGERY PROCEDURE

PA required if billed with gender dysphoria diagnosis

31899

AIRWAYS SURGICAL PROCEDURE

PA required if billed with gender dysphoria diagnosis

32672

THORACOSCOPY FOR LVRS

PA required for Non-Par providers only

32701

THORAX STEREO RAD TARGETW/TX

PA required for Non-Par providers only

32855

PREPARE DONOR LUNG SINGLE

PA required for Non-Par providers only

32856

PREPARE DONOR LUNG DOUBLE

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

33254

ABLATE ATRIA LMTD

PA required for Non-Par providers only

33255

ABLATE ATRIA W/O BYPASS EXT

PA required for Non-Par providers only

33256

ABLATE ATRIA W/BYPASS EXTEN

PA required for Non-Par providers only

33257

ABLATE ATRIA LMTD ADD-ON

PA required for Non-Par providers only

33258

ABLATE ATRIA X10SV ADD-ON

PA required for Non-Par providers only

33259

ABLATE ATRIA W/BYPASS ADD-ON

PA required for Non-Par providers only

33265

ABLATE ATRIA LMTD ENDO

PA required for Non-Par providers only

33266

ABLATE ATRIA X10SV ENDO

PA required for Non-Par providers only

33406

REPLACEMENT AORTIC VALVE OPN

PA required for Non-Par providers only

33410

REPLACEMENT AORTIC VALVE OPN

PA required for Non-Par providers only

33411

REPLACEMENT OF AORTIC VALVE

PA required for Non-Par providers only

33412

REPLACEMENT OF AORTIC VALVE

PA required for Non-Par providers only

33413

REPLACEMENT OF AORTIC VALVE

PA required for Non-Par providers only

33542

REMOVAL OF HEART LESION

PA required for Non-Par providers only

33930

REMOVAL OF DONOR HEART/LUNG

PA required for Non-Par providers only

33933

PREPARE DONOR HEART/LUNG

PA required for Non-Par providers only

33940

REMOVAL OF DONOR HEART

PA required for Non-Par providers only

33944

PREPARE DONOR HEART

PA required for Non-Par providers only

33999

CARDIAC SURGERY PROCEDURE

PA required for ALL providers

38204

BL DONOR SEARCH MANAGEMENT

PA required for Non-Par providers only

38205

HARVEST ALLOGENEIC STEM CELL

PA required for Non-Par providers only

38206

HARVEST AUTO STEM CELLS

PA required for Non-Par providers only

38207

CRYOPRESERVE STEM CELLS

PA required for Non-Par providers only

38208

THAW PRESERVED STEM CELLS

PA required for Non-Par providers only

38210

T-CELL DEPLETION OF HARVEST

PA required for Non-Par providers only

38212

RBC DEPLETION OF HARVEST

PA required for Non-Par providers only

38213

PLATELET DEPLETE OF HARVEST

PA required for Non-Par providers only

38214

VOLUME DEPLETE OF HARVEST

PA required for Non-Par providers only

38215

HARVEST STEM CELL CONCENTRTE

PA required for Non-Par providers only

38230

BONE MARROW HARVEST ALLOGEN

PA required for Non-Par providers only

38232

BONE MARROW HARVEST AUTOLOG

PA required for Non-Par providers only

38243

TRANSPLJ HEMATOPOIETIC BOOST

PA required for Non-Par providers only

38999

BLOOD/LYMPH SYSTEM PROCEDURE

PA required for ALL providers

39499

CHEST PROCEDURE

PA required for ALL providers

40650

REPAIR LIP

PA required for Non-Par providers only

40652

REPAIR LIP

PA required for Non-Par providers only

40654

REPAIR LIP

PA required for Non-Par providers only

40700

REPAIR CLEFT LIP/NASAL

PA required for Non-Par providers only

40701

REPAIR CLEFT LIP/NASAL

PA required for Non-Par providers only

40702

REPAIR CLEFT LIP/NASAL

PA required for Non-Par providers only

42200

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42205

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42210

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42215

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42220

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42225

RECONSTRUCT CLEFT PALATE

PA required for Non-Par providers only

42820

REMOVE TONSILS AND ADENOIDS

PA required for Non-Par providers only

42821

REMOVE TONSILS AND ADENOIDS

PA required for Non-Par providers only

42825

REMOVAL OF TONSILS

PA required for Non-Par providers only

42826

REMOVAL OF TONSILS

PA required for Non-Par providers only

42830

REMOVAL OF ADENOIDS

PA required for Non-Par providers only

42831

REMOVAL OF ADENOIDS

PA required for Non-Par providers only

42835

REMOVAL OF ADENOIDS

PA required for Non-Par providers only

42836

REMOVAL OF ADENOIDS

PA required for Non-Par providers only

43648

LAP REVISE/REMV ELTRD ANTRUM

PA required for Non-Par providers only

43771

LAP REVISE GASTR ADJ DEVICE

PA required for Non-Par providers only

43772

LAP RMVL GASTR ADJ DEVICE

PA required for Non-Par providers only

43773

LAP REPLACE GASTR ADJ DEVICE

PA required for Non-Par providers only

43774

LAP RMVL GASTR ADJ ALL PARTS

PA required for Non-Par providers only

43882

REVISE/REMOVE ELECTRD ANTRUM

PA required for Non-Par providers only

43886

REVISE GASTRIC PORT OPEN

PA required for Non-Par providers only

43887

REMOVE GASTRIC PORT OPEN

PA required for Non-Par providers only

43888

CHANGE GASTRIC PORT OPEN

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

44715

PREPARE DONOR INTESTINE

PA required for Non-Par providers only

44720

PREP DONOR INTESTINE/VENOUS

PA required for Non-Par providers only

44721

PREP DONOR INTESTINE/ARTERY

PA required for Non-Par providers only

44799

UNLISTED PX SMALL INTESTINE

PA required for ALL providers

44899

BOWEL SURGERY PROCEDURE

PA required for ALL providers

45399

UNLISTED PROCEDURE COLON

PA required for ALL providers

45499

LAPAROSCOPE PROC RECTUM

PA required for ALL providers

45999

RECTUM SURGERY PROCEDURE

PA required for ALL providers

46999

ANUS SURGERY PROCEDURE

PA required for ALL providers

47133

REMOVAL OF DONOR LIVER

PA required for Non-Par providers only

47140

PARTIAL REMOVAL DONOR LIVER

PA required for Non-Par providers only

47142

PARTIAL REMOVAL DONOR LIVER

PA required for Non-Par providers only

47143

PREP DONOR LIVER WHOLE

PA required for Non-Par providers only

47144

PREP DONOR LIVER 3-SEGMENT

PA required for Non-Par providers only

47145

PREP DONOR LIVER LOBE SPLIT

PA required for Non-Par providers only

47146

PREP DONOR LIVER/VENOUS

PA required for Non-Par providers only

47147

PREP DONOR LIVER/ARTERIAL

PA required for Non-Par providers only

47370

LAPARO ABLATE LIVER TUMOR RF

PA required for Non-Par providers only

47380

OPEN ABLATE LIVER TUMOR RF

PA required for Non-Par providers only

47382

PERCUT ABLATE LIVER RF

PA required for Non-Par providers only

47383

PERQ ABLTJ LVR CRYOABLATION

PA required for Non-Par providers only

47399

LIVER SURGERY PROCEDURE

PA required for ALL providers

47999

BILE TRACT SURGERY PROCEDURE

PA required for ALL providers

48550

DONOR PANCREATECTOMY

PA required for Non-Par providers only

48551

PREP DONOR PANCREAS

PA required for Non-Par providers only

48552

PREP DONOR PANCREAS/VENOUS

PA required for Non-Par providers only

48556

REMOVAL ALLOGRAFT PANCREAS

PA required for Non-Par providers only

48999

PANCREAS SURGERY PROCEDURE

PA required for ALL providers

49999

ABDOMEN SURGERY PROCEDURE

PA required for ALL providers

50323

PREP CADAVER RENAL ALLOGRAFT

PA required for Non-Par providers only

50325

PREP DONOR RENAL GRAFT

PA required for Non-Par providers only

50327

PREP RENAL GRAFT/VENOUS

PA required for Non-Par providers only

50328

PREP RENAL GRAFT/ARTERIAL

PA required for Non-Par providers only

50329

PREP RENAL GRAFT/URETERAL

PA required for Non-Par providers only

50547

LAPARO REMOVAL DONOR KIDNEY

PA required for Non-Par providers only

50548

LAPARO REMOVE W/URETER

PA required for Non-Par providers only

50549

LAPAROSCOPE PROC RENAL

PA required for ALL providers

51925

HYSTERECTOMY/BLADDER REPAIR

No PA for All providers

51992

LAPARO SLING OPERATION

No PA for All providers

51999

LAPAROSCOPE PROC BLA

PA required for ALL providers

53410

RECONSTRUCTION OF URETHRA

PA required if billed with gender dysphoria diagnosis

53415

RECONSTRUCTION OF URETHRA

PA required if billed with gender dysphoria diagnosis

53420

RECONSTRUCT URETHRA STAGE 1

PA required if billed with gender dysphoria diagnosis

53425

RECONSTRUCT URETHRA STAGE 2

PA required if billed with gender dysphoria diagnosis

53430

RECONSTRUCTION OF URETHRA

PA required if billed with gender dysphoria diagnosis

53460

REVISION OF URETHRA

PA required if billed with gender dysphoria diagnosis

53899

UROLOGY SURGERY PROCEDURE

PA required for ALL providers

54125

REMOVAL OF PENIS

PA required if billed with gender dysphoria diagnosis

54406

REMOVE MUTI-COMP PENIS PROS

PA required if billed with gender dysphoria diagnosis

54408

REPAIR MULTI-COMP PENIS PROS

PA required if billed with gender dysphoria diagnosis

54410

REMOVE/REPLACE PENIS PROSTH

PA required if billed with gender dysphoria diagnosis

54411

REMOV/REPLC PENIS PROS COMP

PA required if billed with gender dysphoria diagnosis

54415

REMOVE SELF-CONTD PENIS PROS

PA required if billed with gender dysphoria diagnosis

54416

REMV/REPL PENIS CONTAIN PROS

PA required if billed with gender dysphoria diagnosis

54420

REVISION OF PENIS

PA required if billed with gender dysphoria diagnosis

54520

REMOVAL OF TESTIS

PA required if billed with gender dysphoria diagnosis

54660

REVISION OF TESTIS

PA required if billed with gender dysphoria diagnosis

54680

RELOCATION OF TESTIS(ES)

PA required for Non-Par providers only

54690

LAPAROSCOPY ORCHIECTOMY

PA required if billed with gender dysphoria diagnosis

54692

LAPAROSCOPY ORCHIOPEXY

No PA for All providers

54699

LAPAROSCOPE PROC TESTIS

PA required for ALL providers

54860

REMOVAL OF EPIDIDYMIS

PA required for Non-Par providers only

54861

REMOVAL OF EPIDIDYMIS

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

55175

REVISION OF SCROTUM

PA required if billed with gender dysphoria diagnosis

55180

REVISION OF SCROTUM

PA required if billed with gender dysphoria diagnosis

55866

LAPARO RADICAL PROSTATECTOMY

PA required if billed with gender dysphoria diagnosis

55870

ELECTROEJACULATION

PA required if billed with gender dysphoria diagnosis

55899

GENITAL SURGERY PROCEDURE

PA required for ALL providers

56625

COMPLETE REMOVAL OF VULVA

PA required if billed with gender dysphoria diagnosis

56800

REPAIR OF VAGINA

PA required if billed with gender dysphoria diagnosis

56805

REPAIR CLITORIS

PA required if billed with gender dysphoria diagnosis

56810

REPAIR OF PERINEUM

PA required if billed with gender dysphoria diagnosis

57106

REMOVE VAGINA WALL PARTIAL

PA required if billed with gender dysphoria diagnosis

57107

REMOVE VAGINA TISSUE PART

PA required if billed with gender dysphoria diagnosis

57110

REMOVE VAGINA WALL COMPLETE

PA required if billed with gender dysphoria diagnosis

57111

REMOVE VAGINA TISSUE COMPL

PA required if billed with gender dysphoria diagnosis

57292

CONSTRUCT VAGINA WITH GRAFT

PA required if billed with gender dysphoria diagnosis

57295

REVISE VAG GRAFT VIA VAGINA

PA required if billed with gender dysphoria diagnosis

57335

REPAIR VAGINA

PA required if billed with gender dysphoria diagnosis

57426

REVISE PROSTH VAG GRAFT LAP

PA required if billed with gender dysphoria diagnosis

58150

TOTAL HYSTERECTOMY

PA required if billed with gender dysphoria diagnosis

58152

TOTAL HYSTERECTOMY

PA required for Non-Par providers only

58180

PARTIAL HYSTERECTOMY

PA required if billed with gender dysphoria diagnosis

58200

EXTENSIVE HYSTERECTOMY

No PA for All providers

58210

EXTENSIVE HYSTERECTOMY

PA required for Non-Par providers only

58240

REMOVAL OF PELVIS CONTENTS

No PA for All providers

58260

VAGINAL HYSTERECTOMY

PA required if billed with gender dysphoria diagnosis

58262

VAG HYST INCLUDING T/O

PA required if billed with gender dysphoria diagnosis

58263

VAG HYST W/T/O AND VAG REPAIR

PA required if billed with gender dysphoria diagnosis

58267

VAG HYST W/URINARY REPAIR

No PA for All providers

58270

VAG HYST W/ENTEROCELE REPAIR

PA required if billed with gender dysphoria diagnosis

58275

HYSTERECTOMY/REVISE VAGINA

PA required if billed with gender dysphoria diagnosis

58280

HYSTERECTOMY/REVISE VAGINA

No PA for All providers

58285

EXTENSIVE HYSTERECTOMY

No PA for All providers

58290

VAG HYST COMPLEX

PA required if billed with gender dysphoria diagnosis

58291

VAG HYST INCL T/O COMPLEX

PA required if billed with gender dysphoria diagnosis

58292

VAG HYST T/O AND REPAIR COMPL

PA required if billed with gender dysphoria diagnosis

58294

VAG HYST W/ENTEROCELE COMPL

PA required if billed with gender dysphoria diagnosis

58541

LSH UTERUS 250 G OR LESS

PA required if billed with gender dysphoria diagnosis

58542

LSH W/T/O UT 250 G OR LESS

PA required if billed with gender dysphoria diagnosis

58543

LSH UTERUS ABOVE 250 G

PA required if billed with gender dysphoria diagnosis

58544

LSH W/T/O UTERUS ABOVE 250 G

PA required if billed with gender dysphoria diagnosis

58548

LAP RADICAL HYST

PA required for Non-Par providers only

58550

LAPARO-ASST VAG HYSTERECTOMY

PA required if billed with gender dysphoria diagnosis

58552

LAPARO-VAG HYST INCL T/O

PA required if billed with gender dysphoria diagnosis

58553

LAPARO-VAG HYST COMPLEX

PA required if billed with gender dysphoria diagnosis

58554

LAPARO-VAG HYST W/T/O COMPL

PA required if billed with gender dysphoria diagnosis

58570

TLH UTERUS 250 G OR LESS

PA required if billed with gender dysphoria diagnosis

58571

TLH W/T/O 250 G OR LESS

PA required if billed with gender dysphoria diagnosis

58572

TLH UTERUS OVER 250 G

PA required if billed with gender dysphoria diagnosis

58573

TLH W/T/O UTERUS OVER 250 G

PA required if billed with gender dysphoria diagnosis

58575

LAPS TOT HYST RESJ MAL

PA required for Non-Par providers only

58661

LAPAROSCOPY REMOVE ADNEXA

PA required if billed with gender dysphoria diagnosis

58720

REMOVAL OF OVARY/TUBE(S)

PA required if billed with gender dysphoria diagnosis

58940

REMOVAL OF OVARY(S)

PA required if billed with gender dysphoria diagnosis

58951

RESECT OVARIAN MALIGNANCY

No PA for All providers

58952

RESECT OVARIAN MALIGNANCY

No PA for All providers

58953

TAH RAD DISSECT FOR DEBULK

PA required for Non-Par providers only

58954

TAH RAD DEBULK/LYMPH REMOVE

PA required for Non-Par providers only

58956

BSO OMENTECTOMY W/TAH

PA required for Non-Par providers only

58999

GENITAL SURGERY PROCEDURE

PA required if billed with gender dysphoria diagnosis

59525

REMOVE UTERUS AFTER CESAREAN

PA required for Non-Par providers only

59812

TREATMENT OF MISCARRIAGE

PA required for Non-Par providers only

59820

CARE OF MISCARRIAGE

PA required for Non-Par providers only

59821

TREATMENT OF MISCARRIAGE

PA required for Non-Par providers only

59830

TREAT UTERUS INFECTION

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

59840

ABORTION

PA required for Non-Par providers only

59841

ABORTION

PA required for Non-Par providers only

59850

ABORTION

PA required for Non-Par providers only

59851

ABORTION

PA required for Non-Par providers only

59855

ABORTION

PA required for Non-Par providers only

59856

ABORTION

PA required for Non-Par providers only

59899

MATERNITY CARE PROCEDURE

PA required for ALL providers

60699

ENDOCRINE SURGERY PROCEDURE

PA required for ALL providers

61796

SRS CRANIAL LESION SIMPLE

PA required for Non-Par providers only

61797

SRS CRAN LES SIMPLE ADDL

PA required for Non-Par providers only

61798

SRS CRANIAL LESION COMPLEX

PA required for Non-Par providers only

61800

APPLY SRS HEADFRAME ADD-ON

PA required for Non-Par providers only

61867

IMPLANT NEUROELECTRODE

PA required for Non-Par providers only

61880

REVISE/REMOVE NEUROELECTRODE

PA required for Non-Par providers only

62263

EPIDURAL LYSIS MULT SESSIONS

PA required for ALL providers

62264

EPIDURAL LYSIS ON SINGLE DAY

PA required for ALL providers

62280

TREAT SPINAL CORD LESION

PA required for Non-Par providers only

62281

TREAT SPINAL CORD LESION

PA required for ALL providers

62282

TREAT SPINAL CANAL LESION

PA required for ALL providers

62321

NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN

PA required for ALL providers

62323

NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN

PA required for ALL providers

62324

NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN

PA required for Non-Par providers only

62325

NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN

PA required for Non-Par providers only

62326

NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN

PA required for Non-Par providers only

62327

NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN

PA required for Non-Par providers only

63620

SRS SPINAL LESION

PA required for Non-Par providers only

63621

SRS SPINAL LESION ADDL

PA required for Non-Par providers only

64405

INJECTION AA AND /STRD GREATER OCCIPITAL NERVE

PA required for ALL providers

64483

NJX AA AND /STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL

PA required for ALL providers

64484

NJX AA AND /STRD TFRML EPI LUMBAR/SACRAL EA ADDL

PA required for Non-Par providers only

64486

TAP BLOCK UNIL BY INJECTION

PA required for Non-Par providers only

64487

TAP BLOCK UNI BY INFUSION

PA required for Non-Par providers only

64488

TAP BLOCK BI INJECTION

PA required for Non-Par providers only

64489

TAP BLOCK BI BY INFUSION

PA required for Non-Par providers only

64490

INJ PARAVERT F JNT C/T 1 LEV

PA required for ALL providers

64491

INJ PARAVERT F JNT C/T 2 LEV

PA required for Non-Par providers only

64493

INJ PARAVERT F JNT L/S 1 LEV

PA required for ALL providers

64494

INJ PARAVERT F JNT L/S 2 LEV

PA required for ALL providers

64505

N BLOCK SPENOPALATINE GANGL

PA required for Non-Par providers only

64568

OPEN IMPLANTATION CRANIAL NERVE NEA AND PULSE GEN

PA required for Non-Par providers only

64575

OPEN IMPLANTATION NEA PERIPHERAL NERVE

PA required for ALL providers

64581

OPEN IMPLANTATION NEA SACRAL NERVE

PA required for ALL providers

64590

INSRT/REDO PN/GASTR STIMUL

PA required for ALL providers

64600

INJECTION TREATMENT OF NERVE

PA required for ALL providers

64620

INJECTION TREATMENT OF NERVE

PA required for Non-Par providers only

64624

DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG

PA required for ALL providers

64630

INJECTION TREATMENT OF NERVE

PA required for Non-Par providers only

64632

N BLOCK INJ COMMON DIGIT

PA required for Non-Par providers only

64633

DESTROY CERV/THOR FACET JNT

PA required for ALL providers

64634

DESTROY C/TH FACET JNT ADDL

PA required for ALL providers

64635

DESTROY LUMB/SAC FACET JNT

PA required for ALL providers

64636

DESTROY L/S FACET JNT ADDL

PA required for ALL providers

64640

INJECTION TREATMENT OF NERVE

PA required for ALL providers

64650

CHEMODENERV ECCRINE GLANDS

PA required for ALL providers

64653

CHEMODENERV ECCRINE GLANDS

PA required for ALL providers

64680

INJECTION TREATMENT OF NERVE

PA required for Non-Par providers only

64681

INJECTION TREATMENT OF NERVE

PA required for Non-Par providers only

66999

EYE SURGERY PROCEDURE

PA required for ALL providers

67299

EYE SURGERY PROCEDURE

PA required for ALL providers

67399

EYE MUSCLE SURGERY PROCEDURE

PA required for ALL providers

67599

ORBIT SURGERY PROCEDURE

PA required for ALL providers

67912

CORRECTION EYELID W/IMPLANT

PA required for ALL providers

67999

REVISION OF EYELID

PA required for ALL providers

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

68899

TEAR DUCT SYSTEM SURGERY

PA required for ALL providers

69399

OUTER EAR SURGERY PROCEDURE

PA required for ALL providers

69714

IMPLTJ OI IMPLT SKULL PERQ ATTACHMENT ESP

PA required for ALL providers

69799

MIDDLE EAR SURGERY PROCEDURE

PA required for ALL providers

76975

GI ENDOSCOPIC ULTRASOUND

PA required for ALL providers

77301

RADIOTHERAPY DOSE PLAN IMRT

PA required for Non-Par providers only

77338

DESIGN MLC DEVICE FOR IMRT

PA required for Non-Par providers only

77432

STEREOTACTIC RADIATION TRMT

PA required for Non-Par providers only

77435

SBRT MANAGEMENT

PA required for Non-Par providers only

78999

NUCLEAR DIAGNOSTIC EXAM

PA required for ALL providers

81246

FLT3 GENE ANALYSIS

PA required for Non-Par providers only

81250

G6PC GENE

PA required for Non-Par providers only

81252

GJB2 GENE FULL SEQUENCE

PA required for Non-Par providers only

81253

GJB2 GENE KNOWN FAM VARIANTS

PA required for Non-Par providers only

81254

GJB6 GENE COM VARIANTS

PA required for Non-Par providers only

81258

HBA1/HBA2 GENE FAM VRNT

PA required for Non-Par providers only

81263

IGH VARI REGIONAL MUTATION

PA required for Non-Par providers only

81270

JAK2 GENE

PA required for Non-Par providers only

81331

SNRPN/UBE3A GENE

PA required for Non-Par providers only

81332

SERPINA1 GENE

PA required for Non-Par providers only

81333

TGFBI GENE ANALYSIS COMMON VARIANTS

PA required for Non-Par providers only

81370

HLA I AND II TYPING LR

PA required for Non-Par providers only

81371

HLA I AND II TYPE VERIFY LR

PA required for Non-Par providers only

81372

HLA I TYPING COMPLETE LR

PA required for Non-Par providers only

81373

HLA I TYPING 1 LOCUS LR

PA required for Non-Par providers only

81374

HLA I TYPING 1 ANTIGEN LR

PA required for Non-Par providers only

81375

HLA II TYPING AG EQUIV LR

PA required for Non-Par providers only

81376

HLA II TYPING 1 LOCUS LR

PA required for Non-Par providers only

81377

HLA II TYPE 1 AG EQUIV LR

PA required for Non-Par providers only

81378

HLA I AND II TYPING HR

PA required for Non-Par providers only

81379

HLA I TYPING COMPLETE HR

PA required for Non-Par providers only

81380

HLA I TYPING 1 LOCUS HR

PA required for Non-Par providers only

81383

HLA II TYPING 1 ALLELE HR

PA required for Non-Par providers only

81519

ONCOLOGY BREAST MRNA

PA required for Non-Par providers only

86812

HLA TYPING A B OR C

PA required for Non-Par providers only

86813

HLA TYPING A B OR C

PA required for Non-Par providers only

86816

HLA TYPING DR/DQ

PA required for Non-Par providers only

86817

HLA TYPING DR/DQ

PA required for Non-Par providers only

86821

LYMPHOCYTE CULTURE MIXED

PA required for Non-Par providers only

86825

HLA X-MATH NON-CYTOTOXIC

PA required for Non-Par providers only

86826

HLA X-MATCH NONCYTOTOXC ADDL

PA required for Non-Par providers only

86828

HLA CLASS IANDII ANTIBODY QUAL

PA required for Non-Par providers only

86829

HLA CLASS I/II ANTIBODY QUAL

PA required for Non-Par providers only

86830

HLA CLASS I PHENOTYPE QUAL

PA required for Non-Par providers only

86831

HLA CLASS II PHENOTYPE QUAL

PA required for Non-Par providers only

86832

HLA CLASS I HIGH DEFIN QUAL

PA required for Non-Par providers only

86833

HLA CLASS II HIGH DEFIN QUAL

PA required for Non-Par providers only

86834

HLA CLASS I SEMIQUANT PANEL

PA required for Non-Par providers only

86835

HLA CLASS II SEMIQUANT PANEL

PA required for Non-Par providers only

87483

CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25

PA required for Non-Par providers only

87999

MICROBIOLOGY PROCEDURE

PA required for ALL providers

88230

TISSUE CULTURE LYMPHOCYTE

PA required for Non-Par providers only

88233

TISSUE CULTURE SKIN/BIOPSY

PA required for Non-Par providers only

88235

TISSUE CULTURE PLACENTA

PA required for Non-Par providers only

88240

CELL CRYOPRESERVE/STORAGE

PA required for Non-Par providers only

88245

CHROMOSOME ANALYSIS 20-25

PA required for Non-Par providers only

88248

CHROMOSOME ANALYSIS 50-100

PA required for Non-Par providers only

88249

CHROMOSOME ANALYSIS 100

PA required for Non-Par providers only

88261

CHROMOSOME ANALYSIS 5

PA required for Non-Par providers only

88262

CHROMOSOME ANALYSIS 15-20

PA required for Non-Par providers only

88263

CHROMOSOME ANALYSIS 45

PA required for Non-Par providers only

88264

CHROMOSOME ANALYSIS 20-25

PA required for Non-Par providers only

88267

CHROMOSOME ANALYS PLACENTA

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

88269

CHROMOSOME ANALYS AMNIOTIC

PA required for Non-Par providers only

88271

CYTOGENETICS DNA PROBE

PA required for Non-Par providers only

88272

CYTOGENETICS 3-5

PA required for Non-Par providers only

88273

CYTOGENETICS 10-30

PA required for Non-Par providers only

88274

CYTOGENETICS 25-99

PA required for Non-Par providers only

88275

CYTOGENETICS 100-300

PA required for Non-Par providers only

88280

CHROMOSOME KARYOTYPE STUDY

PA required for Non-Par providers only

88283

CHROMOSOME BANDING STUDY

PA required for Non-Par providers only

88285

CHROMOSOME COUNT ADDITIONAL

PA required for Non-Par providers only

88289

CHROMOSOME STUDY ADDITIONAL

PA required for Non-Par providers only

88291

CYTO/MOLECULAR REPORT

PA required for Non-Par providers only

89240

PATHOLOGY LAB PROCEDURE

PA required for Non-Par providers only

90867

TCRANIAL MAGN STIM TX PLAN

PA required for ALL providers

90868

TCRANIAL MAGN STIM TX DELI

PA required for ALL providers

90869

TCRAN MAGN STIM REDETEMINE

PA required for ALL providers

90945

DIALYSIS ONE EVALUATION

PA required for Non-Par providers only

91110

GI TRC IMG INTRALUMINAL ESOPHAGUS-ILEUM W/I AND R

PA required for Non-Par providers only

91299

GASTROENTEROLOGY PROCEDURE

PA required for ALL providers

92508

SPEECH/HEARING THERAPY

PA required for Non-Par providers only

92512

NASAL FUNCTION STUDIES

PA required for Non-Par providers only

92516

FACIAL NERVE FUNCTION TEST

PA required for Non-Par providers only

92520

LARYNGEAL FUNCTION STUDIES

PA required for Non-Par providers only

92610

EVALUATE SWALLOWING FUNCTION

PA required for Non-Par providers only

92611

MOTION FLUOROSCOPY/SWALLOW

PA required for Non-Par providers only

92612

ENDOSCOPY SWALLOW (FEES) VID

PA required for Non-Par providers only

92613

ENDOSCOPY SWALLOW (FEES) IANDR

PA required for Non-Par providers only

92614

LARYNGOSCOPIC SENSORY VID

PA required for Non-Par providers only

92616

FEES W/LARYNGEAL SENSE TEST

PA required for Non-Par providers only

92617

FEES W/LARYNGEAL SENSE IANDR

PA required for Non-Par providers only

93653

COMPRE EP EVAL ABLTJ 3D MAPG TX SVT

PA required for Non-Par providers only

93656

COMPRE EP EVAL ABLTJ ATR FIB PULM VEIN ISOLATION

PA required for Non-Par providers only

93799

CARDIOVASCULAR PROCEDURE

PA required for ALL providers

94799

PULMONARY SERVICE/PROCEDURE

PA required for ALL providers

95783

POLYSOM <6 YRS CPAP/BILVL

PA required for Non-Par providers only

96112

DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR

PA required for Non-Par providers only

96113

DEVELOPMENTAL TST ADMIN PHYS/QHP EA ADDL 30 MIN

PA required for Non-Par providers only

96125

COGNITIVE TEST BY HC PRO

PA required for Non-Par providers only

96130

PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR

PA required for Non-Par providers only

96131

PSYCHOLOGICAL TST EVAL SVC PHYS/EA ADD'L HR

PA required for Non-Par providers only

96931

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96932

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96933

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96934

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96935

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96936

RCM CELULR SUBCELULR IMG SKN

PA required for Non-Par providers only

96999

DERMATOLOGICAL PROCEDURE

PA required for ALL providers

97014

ELECTRIC STIMULATION THERAPY

No PA for All providers

97763

ORTHC/PROSTC MGMT SBSQ ENC

PA required for Non-Par providers only

99183

HYPERBARIC OXYGEN THERAPY

PA required for Non-Par providers only

99184

HYPOTHERMIA ILL NEONATE

PA required for Non-Par providers only

99199

SPECIAL SERVICE/PROC/REPORT

PA required for ALL providers

99377

HOSPICE CARE SUPERVISION

PA required for Non-Par providers only

99378

HOSPICE CARE SUPERVISION

PA required for Non-Par providers only

99601

HOME INFUSION/VISIT 2 HRS

PA required for Non-Par providers only

99602

HOME INFUSION EACH ADDTL HR

PA required for Non-Par providers only

0174U

ONC SOLID TUM MASS SPECTROMETRIC 30 PROTEIN TRGT

PA required for Non-Par providers only

0219U

NFCT AGENT HIV TRGT VIRAL NEXT-GNRJ SEQ ALYS ALG

PA required for Non-Par providers only

0437T

IMPLTJ SYNTH RNFCMT ABDL WAL

PA required for ALL providers

0444T

1ST PLMT DRUG ELUT OC INS

PA required for ALL providers

0483T

TMVI PERCUTANEOUS APPROACH

PA required for ALL providers

A0999

UNLISTED AMBULANCE SERVICE

PA required for ALL providers

A4210

NEEDLE-FREE INJECTION DEVICE EACH

PA required for Non-Par providers only

A6507

COMPRS BRN GARMNT FT KNEE LEN CSTM

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

A6511

COMPRS BRN GARMNT LW TRNK LEG OPN

PA required for Non-Par providers only

A8003

HELMET PROTECTIVE HARD CUSTOM FAB

PA required for Non-Par providers only

A9277

TRANSMITTER EXT USE WITH NONDME INTRSTL CGM

PA required for Non-Par providers only

A9278

RECEIVER EXT USE NONDME INTRSTL SYSTEM CGM

PA required for Non-Par providers only

A9542

IN-111 IBRITUMAB TIUXTN DX TO 5 MCI

PA required for Non-Par providers only

A9606

RADIUM RA223 DICHLORIDE THER

PA required for Non-Par providers only

B4034

ENTERAL FEED SPL KIT SYRINGE DAY

PA required for Non-Par providers only

B4035

ENTERAL FEED SPL KIT PUMP FED-DAY

PA required for Non-Par providers only

B4036

ENTERAL FD SPL KIT GRAVITY FED-DAY

PA required for Non-Par providers only

B4081

NASOGASTRIC TUBING WITH STYLET

PA required for Non-Par providers only

B4082

NASOGASTRIC TUBING WITHOUT STYLET

PA required for Non-Par providers only

B4083

STOMACH TUBE - LEVINE TYPE

PA required for Non-Par providers only

B4087

GASTROSTOMY/J-TUBE STANDARD EACH

PA required for Non-Par providers only

B4088

GASTROSTOMY/J-TUBE LOW-PROFILE EA

PA required for Non-Par providers only

B4164

PARNTRAL NUT SOL CARBS 50%/< HOM

PA required for Non-Par providers only

B4168

PARNTRAL NUT SOL AMINO ACID 3.5%

PA required for Non-Par providers only

B4172

PARNTRAL NUT SOL AMINO ACID 5.5-7%

PA required for Non-Par providers only

B4176

PARNTRAL NUT SOL AMINO ACID 7-8.5%

PA required for Non-Par providers only

B4178

PARNTRAL NUT SOL AMINO ACID > 8.5%

PA required for Non-Par providers only

B4180

PARNTRAL NUT SOL CARBS > 50% HOM

PA required for Non-Par providers only

B4185

PARENTERAL NUTRITION SOL NOS 10 GRAMS LIPIDS

PA required for Non-Par providers only

B4189

PARNTRAL NUT AMINOACIDANDCARB 10-51GM

PA required for Non-Par providers only

B4193

PARNTRAL NUT AMINOACIDANDCARB 52-73GM

PA required for Non-Par providers only

B4197

PARNTRL NUT AMINOACIDANDCARB 74-100GM

PA required for Non-Par providers only

B4199

PARNTRAL NUT AMINO ACIDANDCARB >100GM

PA required for Non-Par providers only

B4216

PARNTRAL NUT ADDITIVES-HOM MIX-DAY

PA required for Non-Par providers only

B4220

PARNTRAL NUTRIT SPL KIT PREMIX-DAY

PA required for Non-Par providers only

B4222

PARNTRAL NUT SPL KIT HOM MIX-DAY

PA required for Non-Par providers only

B4224

PARNTRAL NUTRITION ADMIN KIT-DAY

PA required for Non-Par providers only

B5000

PARENTERAL SOL RENAL-AMIROSY

PA required for Non-Par providers only

B5100

PARENTERAL SOLUTION HEPATIC

PA required for Non-Par providers only

B9002

ENTERAL NUTR INFUSION PUMP ANY TYPE

PA required for Non-Par providers only

B9004

PARNTRAL NUTRIT INFUS PUMP PRTBLE

PA required for Non-Par providers only

B9006

PARNTRAL NUTRIT INFUS PUMP STATION

PA required for Non-Par providers only

B9998

NOC FOR ENTERAL SUPPLIES

PA required for Non-Par providers only

B9999

NOC FOR PARENTERAL SUPPLIES

PA required for Non-Par providers only

C1734

ORTHOPEDIC/DEVC/DX MATRIX OPP BTB/SFT TISS-TO BN

PA required for Non-Par providers only

C1813

PROSTHESIS PENILE INFLATABLE

PA required for ALL providers

C1899

LEAD PACEMKR/CARDIOVERT-DEFIB COMB

PA required for ALL providers

C2596

PROBE IMAGE GUIDED ROBOTIC WATERJET ABLATION

PA required for Non-Par providers only

C9765

REV EVAR LE AA IV LITHOTRIPSY AND TL STENT PLCMT

PA required for ALL providers

E0147

WALKR HEVY DUTY MX BRAKE VARIBL WHL

PA required for Non-Par providers only

E0255

HOS BED VARIBL HT W/RAIL W/MATTRSS

PA required for Non-Par providers only

E0260

HOS BED SEMI-ELEC W/RAIL W/MATTRSS

PA required for Non-Par providers only

E0261

HOS BED SEMI-ELEC W/RAIL NO MATTRSS

PA required for Non-Par providers only

E0265

HOS BED TOT ELEC W/RAIL W/MATTRSS

PA required for Non-Par providers only

E0266

HOS BED TOT ELEC W/RAIL W/O MATTRSS

PA required for Non-Par providers only

E0292

HOS BED VARIBL HT NO RAIL W/MATTRSS

PA required for Non-Par providers only

E0293

HOS BED VARIBL HT W/O RAIL/MATTRSS

PA required for Non-Par providers only

E0294

HOS BED SEMI-ELEC NO RAIL W/MATTRSS

PA required for Non-Par providers only

E0295

HOS BED SEMI-ELEC W/O RAIL/MATTRSS

PA required for Non-Par providers only

E0296

HOS BED TOT ELEC W/O RAIL W/MATTRSS

PA required for Non-Par providers only

E0301

HOS BED HEVY DUTY W/WT CAP >350 PDS

PA required for Non-Par providers only

E0302

HOS BED WT CAP>600 W/O MATTRESS

PA required for Non-Par providers only

E0303

HOS BED HEVY DUTY WT CAP >350<=600

PA required for Non-Par providers only

E0304

HOS BED XTRA HD WT CAP>600 MTTRSS

PA required for Non-Par providers only

E0371

NONPWR PRSS RDUC OVRLAY MATTRSS STD

PA required for Non-Par providers only

E0372

PWR AIR OVRLAY MATTRSS STD LENANDWDTH

PA required for Non-Par providers only

E0373

NONPWR ADVD PRESS REDUCING MATTRSS

PA required for Non-Par providers only

E0470

RESP ASST DEVC BI-LEVL PRSS CAPABIL

PA required for ALL providers

E0471

RESP ASST DEVC BI-LEVL PRSS CAPABIL

PA required for ALL providers

E0500

IPPB MACH BUILT-IN NEBULZ VALVS PWR

PA required for Non-Par providers only

E0575

NEBULIZER ULTRASONIC LARGE VOLUME

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

E0600

RESP SUCTN PUMP HOME MODEL ELEC

PA required for Non-Par providers only

E0619

APNEA MONITOR W/RECORDING FEATURE

PA required for Non-Par providers only

E0620

SKN PIERC DEVC CLCT CAPLRY BLD LASR

PA required for Non-Par providers only

E0621

SLING/SEAT PT LIFT CANVAS/NYLON

PA required for Non-Par providers only

E0635

PATIENT LIFT ELECTRIC W/SEAT/SLING

PA required for Non-Par providers only

E0636

MX PSTN PT SUPP SYS LIFT PT CNTRL

PA required for Non-Par providers only

E0639

PT LIFT MOVEABLE DISASSMBLANDREASSMBL

PA required for ALL providers

E0667

SEG PNEUMAT APPLINC COMPRS FULL LEG

PA required for Non-Par providers only

E0668

SEG PNEUMAT APPLINC COMPRS FULL ARM

PA required for Non-Par providers only

E0670

SEG PNEU APPL P C INT 2 F LEG TRNK

PA required for Non-Par providers only

E0731

FORM FIT CONDUCT GARM TENS/NMES

PA required for ALL providers

E0765

FDA APPRVD NRV STIM TX NAUSAANDVOMIT

PA required for Non-Par providers only

E0769

ESTIM/ELECMAGNET WOUND TX DEVC NOC

PA required for Non-Par providers only

E0781

AMB INFUS PUMP 1/MX CHANNL W/ADMIN

PA required for Non-Par providers only

E0784

EXTERNAL AMB INFUSION PUMP INSULIN

PA required for Non-Par providers only

E0791

PAR INFUS PUMP STAT SINGLE/MXCHANEL

PA required for Non-Par providers only

E0849

TRAC EQP CERV FREESTND FRME PNEUMAT

PA required for Non-Par providers only

E0958

MNL WC ACCESS 1-ARM DRIVE ATTCH EA

PA required for Non-Par providers only

E0983

MNL WC ACSS PWR ADD-ON CNVRT MNL WC

PA required for ALL providers

E1003

WC ACSS RECLINE ONLY NO SHEAR RDUC

PA required for Non-Par providers only

E1030

WHLCHAIR ACCESS VENT TRAY GIMBALED

PA required for Non-Par providers only

E1031

ROLLABOUT CHAIR W/CASTRS 5 IN/GT

PA required for Non-Par providers only

E1037

TRANSPORT CHAIR PEDIATRIC SIZE

PA required for Non-Par providers only

E1050

FULL RECLINE WC FIX ARM DETACH LEGS

PA required for Non-Par providers only

E1060

FULL RECLN WHLCHAR DTACH ARM LEGRST

PA required for Non-Par providers only

E1070

FULL RECLN WHLCHR DTACH ARM FOOTRST

PA required for Non-Par providers only

E1084

HEMI-WHLCHAIR DTACHBLE ARMS LEGRST

PA required for Non-Par providers only

E1086

HEMI-WHLCHAIR DTACHBL ARMS FOOTRST

PA required for Non-Par providers only

E1087

HI-STRGTH WHLCHAIR FIX ARMS LEGRST

PA required for Non-Par providers only

E1089

HI-STRGTH WHLCHAIR FIX ARM FOOTRST

PA required for Non-Par providers only

E1090

HI-STRGTH WHLCHAR DTACH ARM FOOTRST

PA required for Non-Par providers only

E1092

WIDE HEVY-DUT WHLCHR DTACH ARM LEG

PA required for Non-Par providers only

E1093

WIDE HEVY-DUT WHLCHR DTACH ARM FOOT

PA required for Non-Par providers only

E1140

WHLCHAIR DTACHBLE ARMS FOOTRESTS

PA required for Non-Par providers only

E1150

WHLCHAIR DTACHBLE ARMS LEGRESTS

PA required for Non-Par providers only

E1160

WHLCHAIR FIX ARMS DTACHBL LEGRESTS

PA required for Non-Par providers only

E1195

HVY DUT WHLCHR FIX ARM DTACH LEGRST

PA required for Non-Par providers only

E1222

WHEELCHAIR W/FIX ARM ELEV LEGRESTS

PA required for Non-Par providers only

E1224

WHLCHAIR W/DTACHBL ARMS ELEV LEGRST

PA required for Non-Par providers only

E1225

WC ACCESS MNL SEMIRECLINING BACK EA

PA required for Non-Par providers only

E1226

WC ACCESS MNL FULL RECLIN BACK EA

PA required for Non-Par providers only

E1240

LGHTWT WHLCHAIR DTACH ARMS LEGRSTS

PA required for Non-Par providers only

E1250

LGHTWT WHLCHR FIX ARM DTACH FOOTRST

PA required for Non-Par providers only

E1260

LGHTWT WHLCHAIR DTACH ARMS FOOTRST

PA required for Non-Par providers only

E1280

HEVY-DUTY WHLCHR DTACH ARMS LEGRST

PA required for Non-Par providers only

E1285

HEVY-DUTY WHLCHR FIX ARM DTACH FOOT

PA required for Non-Par providers only

E1290

HEVY-DUTY WHLCHR DTACH ARM FOOTRST

PA required for Non-Par providers only

E1295

HEVY-DUTY WHLCHAIR FIX ARMS LEGRST

PA required for Non-Par providers only

E1296

SPECIAL WHEELCHAIR SEAT HT FROM FLR

PA required for Non-Par providers only

E1801

STATIC PROGRESSV STRETCH ELBOW DEVC

PA required for Non-Par providers only

E1806

STATIC PROGRESSV STRETCH WRIST DEVC

PA required for Non-Par providers only

E1811

STATIC PROGRESSV STRETCH KNEE DEVC

PA required for Non-Par providers only

E1818

STATIC PROGRSV STRETCH FOREARM DEVC

PA required for Non-Par providers only

E1830

DYN ADJUSTABLE TOE EXT/FLX DEVC

PA required for ALL providers

E1841

STATIC PROGRS STRETCH SHOULDER DEVC

PA required for Non-Par providers only

E2000

GASTR SUCTN PUMP HOME MODEL ELEC

PA required for Non-Par providers only

E2120

PULSE GEN SYS TYMPANIC TX INNR EAR

PA required for Non-Par providers only

E2201

MNL WC ACSS SEAT WDTH >/=20 IN AND<24

PA required for Non-Par providers only

E2202

MNL WC ACSS SEAT WIDTH 24-27 IN

PA required for Non-Par providers only

E2203

MNL WC ACSS SEAT DEPTH 20 < 11 IN

PA required for Non-Par providers only

E2204

MNL WC ACSS SEAT DEPTH 22-25 IN

PA required for Non-Par providers only

E2228

MNL WC WHL BRAKE SYSANDLOCK COMPL EA

PA required for Non-Par providers only

E2291

BACK PLANR PED WC FIX ATTCH HARDWRE

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

E2292

SEAT PLANR PED WC FIX ATTCH HARDWRE

PA required for Non-Par providers only

E2293

BACK CONTRD PED WC ATTCH HARDWARE

PA required for Non-Par providers only

E2294

SEAT CONTRD PED WC ATTCH HARDWARE

PA required for Non-Par providers only

E2359

PWR WC GRP 34 SEALED LA BATT EA

PA required for Non-Par providers only

E2366

PWR WC ACSS BATTRY CHARGER 1 MODE

PA required for Non-Par providers only

E2368

PWR WC CMPNT DR WHEEL MTR REPL ONLY

PA required for Non-Par providers only

E2378

POWER WC CMPNT ACTUATOR REPL ONLY

PA required for Non-Par providers only

E2402

NEG PRSS WND TX PUMP STATN/PRTBL

PA required for Non-Par providers only

E2611

GEN WC BACK CUSHN WIDTH < 22 IN HT

PA required for Non-Par providers only

E2612

GEN WC BACK CUSHN WIDTH 22 IN/GT HT

PA required for Non-Par providers only

E2620

PSTN WC BACK CUSHN PLANAR WD <22 IN

PA required for Non-Par providers only

E2628

WC SHLDR ELB MOBIL SUPP RECLINING

PA required for Non-Par providers only

G0182

PHYS SUPV PT UND MCR-APPRVD HOSPICE

PA required for Non-Par providers only

G0219

PET BDY MELANOMA NON-COVR INDICAT

PA required for ALL providers

G0235

PET IMAGING ANY SITE NOS

PA required for ALL providers

G0259

INJECTION PROC SI JNT ARTHROGRAPY

PA required for ALL providers

G0260

INJ SI JNT ANES AND/TX AGT ANDARTHROG

PA required for Non-Par providers only

G0293

NONCOVR SURG SEDAT ANES-MCR QUAL

PA required for Non-Par providers only

G0294

NONCOVR PROC NO ANES/LOC-MCR QUAL

PA required for Non-Par providers only

G0302

PRE-OP PULM SURG SRVC PREP LVRS CMP

PA required for Non-Par providers only

G0303

PRE-OP PULM SURG PREP LVRS 10-15 DA

PA required for Non-Par providers only

G0304

PRE-OP PULM SURG PREP LVRS 1-9 DA

PA required for Non-Par providers only

G0305

POST-D/C PULM SURG SRVC AFTER LVRS

PA required for Non-Par providers only

G2169

SERVICES PRFRM BY OT ASST HH SETTING EA 15 MIN

PA required for Non-Par providers only

G6015

RADIATION TX DELIVERY IMRT

PA required for Non-Par providers only

G6016

DELIVERY COMP IMRT

PA required for Non-Par providers only

G6017

INTRAFRACTION TRACK MOTION

PA required for Non-Par providers only

G9473

SRVC PERF CHAPLN HOSPICE EA 15 MIN

PA required for Non-Par providers only

G9474

SRVC PRF DIET CNSLR HOSPICE EA 15 M

PA required for Non-Par providers only

G9475

SRVC PERF OTH COUNS HSPCE EA 15 MIN

PA required for Non-Par providers only

G9476

SRVC PRF VOLUNTEER HOSPICE EA15 MIN

PA required for Non-Par providers only

G9477

SRVC PRF CARE COORD HOSPICE EA 15 M

PA required for Non-Par providers only

G9478

SRVC PRF OTH QUAL TH HOSPCE EA 15 M

PA required for Non-Par providers only

G9479

SRVC PRF QUAL PHARM HOSPICE EA 15 M

PA required for Non-Par providers only

H0014

ALCOHL AND/ RX SRVC AMB DTOXFICATION

PA required for Non-Par providers only

H0035

MENTAL HEALTH PART HOSP TX < 24 HR

PA required for ALL providers

H0036

CMTY PSYC SUPP TX FCE-TO-FCE-15 MIN

PA required for ALL providers

H0037

CMTY PSYC SUPPORTIVE TX PROGM-DIEM

PA required for ALL providers

H2012

BEHAVIORAL HEALTH DAY TX PER HOUR

PA required for ALL providers

H2014

SKILLS TRAINING & DEVELOPMENT, PER 15 MIN

PA required for > 8 units/day for members 18 yr and older

H2017

PYSCHOSOCIAL REHABILITATION, PER 15 MIN

PA required for > 8 units/day for members 18 yr and older

H2019

THERAPEUTIC BEHAVIORAL SRVC 15 MIN

PA required for ALL providers

H2020

THERAPEUTIC BEHAVIORAL SRVC DIEM

PA required for ALL providers

J0121

INJECTION OMADACYCLINE 1 MG

PA required for Non-Par providers only

J0205

INJECTION ALGLUCERASE PER 10 UNITS

PA required for Non-Par providers only

J0742

INJ IMP 4 MG CILASTATIN 4 MG AND RELEBACTAM 2 MG

PA required for Non-Par providers only

J0875

INJECTION DALBAVANCIN 5MG

PA required for Non-Par providers only

J1190

INJ DEXRAZOXANE HCL PER 250 MG

PA required for ALL providers

J2315

INJ NALTREXONE DEPOT FORM 1 MG

PA required for ALL providers

J2791

INJ RHO D IG HUMAN RHOPHYLAC 100 IU

PA required for Non-Par providers only

J3095

INJECTION TELAVANCIN 10 MG

PA required for Non-Par providers only

J7310

GANCICLOVIR 4.5 MG LONG-ACT IMPLANT

PA required for Non-Par providers only

J7315

MITOMYCIN OPTHALMIC 0. 2 MG

PA required for Non-Par providers only

J7342

CIPROFLOXACIN OTIC SUSP 6 MG

PA required for Non-Par providers only

J7500

AZATHIOPRINE ORAL 50 MG

PA required for Non-Par providers only

J7513

DACLIZUMAB PARENTERAL 25 MG

PA required for Non-Par providers only

J7517

MYCOPHENOLATE MOFETIL ORAL 250 MG

PA required for Non-Par providers only

J7518

MYCOPHENOLIC ACID ORAL 180 MG

PA required for Non-Par providers only

J7525

TACROLIMUS PARENTERAL 5 MG

PA required for Non-Par providers only

J7999

COMPOUNDED DRUG NOC

PA required for Non-Par providers only

J8562

FLUDARABINE PHOSPHATE ORAL 10 MG

PA required for Non-Par providers only

J9020

INJECTION ASPARAGINASE 10000 UNITS

PA required for ALL providers

J9151

INJ DAUNORUBICIN CITRATE LIP 10 MG

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

J9175

INJECTION ELLIOTTS B SOLUTION 1 ML

PA required for Non-Par providers only

K0001

STANDARD WHEELCHAIR

PA required for Non-Par providers only

K0004

HIGH STRENGTH LIGHTWEIGHT WHLCHAIR

PA required for Non-Par providers only

K0730

CNTRL DOSE INHAL RX DEL ERY SYS

PA required for Non-Par providers only

K0900

CUSTOMIZED DME OTH THAN WHEELCHAIR

PA required for ALL providers

L0112

CRANIL CERV ORTHOT CONGN TORTICOLLI

PA required for Non-Par providers only

L0170

CERV COLLAR MOLDED PATIENT MODEL

PA required for Non-Par providers only

L0190

CERV MX POST COLLR ADJ CERV BARS

PA required for Non-Par providers only

L0200

CERV COLLR ADJ CERV BARSANDTHOR EXT

PA required for Non-Par providers only

L0456

TLSO FLEX SC SCAP SPN PRFAB CUSTOM

PA required for Non-Par providers only

L0457

TLSO FLX SC JUNC TRM INF SCAP SPINE

PA required for Non-Par providers only

L0458

TLSO TRIPLANR 2 SHELL ANT-XIPHOID

PA required for Non-Par providers only

L0460

TLSO TRIPLANR 2 SHELL ANT-STERNL

PA required for Non-Par providers only

L0462

TLSO TRIPLANR 3 SHELL ANT-STERNL

PA required for Non-Par providers only

L0464

TLSO TRIPLANR 4 SHELL ANT-STERNL

PA required for Non-Par providers only

L0467

TLSO SAGITTAL CONTROL RIGD PREFAB

PA required for Non-Par providers only

L0468

TLSO SAGITTAL-CORONAL PREFAB CUSTOM

PA required for Non-Par providers only

L0469

TLSO SAGITTAL-CORONAL CONTRL PREFAB

PA required for Non-Par providers only

L0470

TLSO TRIPLANAR FRMEANDAPRON W/STRAP

PA required for Non-Par providers only

L0480

TLSO TRIPLANR 1 PC NO INTERFCE CSTM

PA required for Non-Par providers only

L0488

TLSO TRIPLANR 1 PC W/INTERFCE PRFAB

PA required for Non-Par providers only

L0490

TLSO SAGIT-CORONAL REINFORCE PRFAB

PA required for Non-Par providers only

L0491

TLSO 2 RIGID PLASTIC SHELLS PREFAB

PA required for Non-Par providers only

L0492

TLSO 3 RIGID PLASTIC SHELLS PREFAB

PA required for Non-Par providers only

L0631

LSO SAGIT CNTRL RIGID POST CUSTOM

PA required for Non-Par providers only

L0635

LSO SAG-COR CNTRL LUMB FLEX PREFAB

PA required for Non-Par providers only

L0637

LSO SAG-COR CNTRL RIGID AANDP PREFAB

PA required for Non-Par providers only

L0639

LSO SAG-COR CNTRL RIGD SHELL PREFAB

PA required for Non-Par providers only

L0650

LSO SAGIT-CORNL CNTRL ANT PST PANL

PA required for Non-Par providers only

L0651

LSO SAGIT-CORNL CNTRL RIGD SHLL/PNL

PA required for Non-Par providers only

L1001

CTLS IMMOBILIZER INFANT SZ PREFAB

PA required for Non-Par providers only

L1200

TLSO INCL FURNISH INIT ORTHOTC ONLY

PA required for Non-Par providers only

L1230

ADD TLSO MLWAKEE TYPE SUPERSTRCT

PA required for Non-Par providers only

L1300

OTH SCOLIOS PROC BDY JACKT MOLD PT

PA required for Non-Par providers only

L1640

HIP ORTHOTIC-PELV BAND/SPRDR BAR

PA required for Non-Par providers only

L1680

HIP ORTHOT DYN PELV CNTRL THI CSTM

PA required for Non-Par providers only

L1686

HIP ORTHOT POSTOP HIP ABDCT PRFAB

PA required for Non-Par providers only

L1690

COMB BIL LUMBO-SAC HIP FEM ORTHOT

PA required for Non-Par providers only

L1730

LEGG PERTHES ORTHOTIC SCOTTISH RITE

PA required for Non-Par providers only

L1832

KNEE ORTHOS IMMOBLZR ADJUST PREFAB

PA required for Non-Par providers only

L1844

KNEE ORTHOS 1 UPRT THIANDCALF CUSTOM

PA required for Non-Par providers only

L1907

ANKLE ORTHOS SUPRAMALLEOLAR CUSTOM

No PA required if member < 21 yr on DOS

L1932

AFO RIGD ANT TIBL CARB FIBR/= PRFAB

No PA required if member < 21 yr on DOS

L1940

ANK FT ORTHOT PLSTC/OTH MATL CSTM

No PA required if member < 21 yr on DOS

L1945

AFO MOLD PLSTC RIGD ANT TIBL CSTM

No PA required if member < 21 yr on DOS

L1950

AFO SPIRAL PLASTIC CUSTOM FAB

No PA required if member < 21 yr on DOS

L1951

ANK FT ORTHOT SPIRAL PLSTC/OTH MATL

No PA required if member < 21 yr on DOS

L1960

AFO POST SOLID ANK PLSTC CSTM FAB

No PA required if member < 21 yr on DOS

L1970

AFO PLASTIC W/ANK JOINT CUSTOM FAB

No PA required if member < 21 yr on DOS

L1971

ANK FT ORTHOT PLSTC/OTH MATL PREFAB

No PA required if member < 21 yr on DOS

L1990

AFO DBL UPRT DORSIFLX STIRUP CSTM

No PA required if member < 21 yr on DOS

L2035

KAFO FULL PLSTC STAT PED SZ PRFAB

PA required for Non-Par providers only

L2106

AFO TIB FX CAST THERMOPLSTC CSTM

PA required for Non-Par providers only

L2108

AFO TIB FX CAST ORTHT CSTM

PA required for Non-Par providers only

L2114

AFO TIBL FX ORTHOS SEMI-RIGD PRFAB

PA required for Non-Par providers only

L2116

AFO TIB FX ORTHOT RIGD PRFAB FIT

PA required for Non-Par providers only

L2136

KAFO FEM FX CAST ORTHOT RIGD PRFAB

PA required for Non-Par providers only

L2330

ADD LOW EXT LACER MOLD PT CSTM ONLY

PA required for Non-Par providers only

L2340

ADD LW EXTRM PRETIBL SHELL MOLD PT

PA required for Non-Par providers only

L2350

ADD LW EXT PROSTH TYPE SCKT MOLD PT

PA required for Non-Par providers only

L2510

ADD LW EXTRM THI/WT BEAR MOLD PT

PA required for Non-Par providers only

L2520

ADD LW EXTRM THI/WT BEAR CSTM

PA required for Non-Par providers only

L2525

ADD LW EXT ISCH M-L BRIM MOLD PT

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

L2526

ADD LW EXTRM ISCH M-L BRIM CSTM FIT

PA required for Non-Par providers only

L2540

ADD LW EXT THI/WT BEAR LACR MOLD PT

PA required for Non-Par providers only

L2570

ADD LW EXT PELV HIP JNT CLEVIS

PA required for Non-Par providers only

L2580

ADD LOW EXTRM PELV CNTRL PELV SLING

PA required for Non-Par providers only

L2628

ADD LW EXT PELV METL FRME-CABLES

PA required for Non-Par providers only

L3230

ORTHO FTWEAR CSTM SHOE DEPTH INLAY

PA required for Non-Par providers only

L3330

LIFT ELEVATION METAL EXTENSION

PA required for Non-Par providers only

L3760

EO ADJ POS LOCKING JNT PREFAB ITEM

PA required for Non-Par providers only

L3915

WH ORTHOS 1/>NONTRSN PRFAB CSTM FIT

PA required for Non-Par providers only

L3916

WH ORTHOS 1/> NONTORSN JOINT PREFAB

PA required for Non-Par providers only

L3960

SEWHO ABDUCT PSTN AIRPLANE DESIGN

PA required for Non-Par providers only

L3962

SEWHO ABDUCT PSTN ERBS PALS DESIGN

PA required for Non-Par providers only

L3967

SEWHO ABDUCT PSTN W/O JNTS CSTM FAB

PA required for Non-Par providers only

L3981

UE FX ORTH SHOUL CAP FOREARM

PA required for Non-Par providers only

L4000

REPLACE GIRDLE FOR SPINAL ORTHOSIS

PA required for Non-Par providers only

L4130

REPLACE PRETIBIAL SHELL

PA required for Non-Par providers only

L4205

REPR ORTHOT DEVC LABR CMPNT 15 MIN

PA required for Non-Par providers only

L5150

KNEE DISRTC MOLD SCKT EXT KNEE JNT

PA required for Non-Par providers only

L5400

IMMED POSTSURG RIGD DRSG W/1 CHG BK

PA required for Non-Par providers only

L5410

IMMED POSTSURG RIGD DRS BK-EA CAST

PA required for Non-Par providers only

L5430

IMMED POSTSURG RIGD DRSG AK EA CAST

PA required for Non-Par providers only

L5450

IMMED POSTSURG NONWT BEAR RIGD BK

PA required for Non-Par providers only

L5460

IMMED POSTSURG NONWT BEAR RIGD AK

PA required for Non-Par providers only

L5616

ADD LW EXT AK UNIVRSL MXPLX FRICT

PA required for Non-Par providers only

L5617

ADD LW EXTREM QUICK CHANGE AK/BK EA

PA required for Non-Par providers only

L5626

ADD LW EXTRM TST SOCKT HIP DISARTIC

PA required for Non-Par providers only

L5628

ADD LOW EXTRM TST SOCKT HEMIPELVECT

PA required for Non-Par providers only

L5630

ADD LW EXT SYMS TYPE XPND WALL SCKT

PA required for Non-Par providers only

L5631

ADD LW EXT ABVE KNEE/DISARTC ACRYLC

PA required for Non-Par providers only

L5632

ADD LW EXT SYMS PTB BRIM DESN SOCKT

PA required for Non-Par providers only

L5638

ADD LW EXTRM BELW KNEE LEATHR SOCKT

PA required for Non-Par providers only

L5640

ADD LW EXT KNEE DISARTC LEATHR SCKT

PA required for Non-Par providers only

L5642

ADD LW EXTRM ABVE KNEE LEATHR SOCKT

PA required for Non-Par providers only

L5643

ADD LW EXT HIP DISRTC FLX EXT FRAME

PA required for Non-Par providers only

L5644

ADD LOW EXTREM ABVE KNEE WOOD SOCKT

PA required for Non-Par providers only

L5645

ADD LW EXTRM BK FLX INNR EXT FRME

PA required for Non-Par providers only

L5646

ADD LOW EXT BELOW KNEE CUSHN SOCKT

PA required for Non-Par providers only

L5647

ADD LOW EXTRM BELW KNEE SUCTN SOCKT

PA required for Non-Par providers only

L5648

ADD LOW EXT ABOVE KNEE CUSHN SOCKT

PA required for Non-Par providers only

L5650

ADD LW EXTRM TOT CONTACT AK/DISARTC

PA required for Non-Par providers only

L5651

ADD LW EXTRM AK FLX INNR EXT FRME

PA required for Non-Par providers only

L5652

ADD LW EXTRM SUCTN SUSP AK/DISARTC

PA required for Non-Par providers only

L5653

ADD LW EXT KNEE DISRTC XPNDABL WALL

PA required for Non-Par providers only

L5661

ADD LW EXT INSRT MXIDUROMETER SYMES

PA required for Non-Par providers only

L5665

ADD LW EXT INSRT MXDROMTR BELW KNEE

PA required for Non-Par providers only

L5666

ADD LOW EXTREM BELOW KNEE CUFF SUSP

PA required for Non-Par providers only

L5671

ADD LW EXTRM BK/AK SUSP LOCK MECH

PA required for Non-Par providers only

L5673

ADD LW EXT BK/AK CSTM FAB XST MOLD

PA required for Non-Par providers only

L5677

ADD LW EXT BK KNEE JNT POLYCNTRC PR

PA required for Non-Par providers only

L5679

ADD LW EXT BK/AK CSTM FAB XST MOLD

PA required for Non-Par providers only

L5681

ADD LW EXT INSRT CONGN/AMPUTEE INIT

PA required for Non-Par providers only

L5682

ADD LW EXT BK THIGH LACER MOLD

PA required for Non-Par providers only

L5683

ADD LW EXT INSRT NO CONGN/AMP INIT

PA required for Non-Par providers only

L5714

ADD EXO KNEE-SHIN VARBL FRICT SWING

PA required for Non-Par providers only

L5716

ADD EXO KNEE-SHIN MECH STANCE LOCK

PA required for Non-Par providers only

L5785

ADD EXOSKEL BELW KNEE ULTRA-LT MATL

PA required for Non-Par providers only

L5790

ADD EXOSKEL ABVE KNEE ULTRA-LT MATL

PA required for Non-Par providers only

L5810

ADD ENDOSKEL KNEE-SHIN MANUAL LOCK

PA required for Non-Par providers only

L5811

ADD ENDO KNEE-SHIN MNL LCK ULTRA-LT

PA required for Non-Par providers only

L5812

ADD ENDO KNEE-SHIN FRICT SWNG CNTRL

PA required for Non-Par providers only

L5816

ADD ENDO KNEE-SHIN MECH STANCE LOCK

PA required for Non-Par providers only

L5818

ADD ENDO KNEE-SHIN FRICT SWNGANDSTANC

PA required for Non-Par providers only

L5822

ADD ENDO KNEE-SHIN PNEUMATIC FRICT

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

L5828

ADD ENDO KNEE-SHIN FL SWINGANDSTANCE

PA required for Non-Par providers only

L5920

ADD ENDOSKEL AK/HIP DISRTC ALIGNBL

PA required for Non-Par providers only

L5940

ADD ENDOSKEL BELW KNEE ULTRA-LGHT

PA required for Non-Par providers only

L5950

ADD ENDOSKEL ABVE KNEE ULTRA-LGHT

PA required for Non-Par providers only

L5960

ADD ENDOSKL HIP DISARTC ULTRA-LGHT

PA required for Non-Par providers only

L5962

ADD ENDO BK FLEX PROTVE OUTER COVER

PA required for Non-Par providers only

L5964

ADD ENDO AK FLXBL PROTVE OUTR COVR

PA required for Non-Par providers only

L5975

ALL LW EXTRM PROSTH COMB 1 AXIS ANK

PA required for Non-Par providers only

L5976

ALL LW EXTRM PROSTH ENERGY STOR FT

PA required for Non-Par providers only

L5982

ALL EXOSKEL LW EXT PROS AXIAL ROTAT

PA required for Non-Par providers only

L5984

ALL ENDOSKEL LW EXT PRSTH AXL ROTAT

PA required for Non-Par providers only

L5985

ALL ENDOSKL LW XTRM PROSTH DYNAMIC

PA required for Non-Par providers only

L5986

ALL LW EXTRM PROSTH MX-AXIAL ROT U

PA required for Non-Par providers only

L5990

ADD LW EXTRM PROSTH USE ADJ HEEL HT

PA required for Non-Par providers only

L6388

IMMED POSTSURG RIGID DRSG ONLY

PA required for Non-Par providers only

L6623

UP EXT ADD ROTATL WRST W/LATCH RLSE

PA required for Non-Par providers only

L6625

UP EXT ADD ROTAT WRST W/CABLE LOCK

PA required for Non-Par providers only

L6628

UP EXTRM ADD QUICK DISCNCT HOOK

PA required for Non-Par providers only

L6647

UP EXT ADD SHLDR LOCK MECH BDY PWR

PA required for Non-Par providers only

L6650

UP EXTRM ADD SHLDR UNIVERSAL JNT EA

PA required for Non-Par providers only

L6686

UPPER EXTREM ADDITION SUCTION SOCKT

PA required for Non-Par providers only

L6687

UP EXT ADD FRME TYPE SCKT BELW ELB

PA required for Non-Par providers only

L6688

UP EXT ADD FRME TYPE SOCKT ABVE ELB

PA required for Non-Par providers only

L6689

UP EXT ADD FRAME SCKT SHLDR DISARTC

PA required for Non-Par providers only

L6692

UP EXTREM ADD SILCON GEL INSRT/=EA

PA required for Non-Par providers only

L6693

UP EXT ADD LOCK ELB FORARM CNTRBAL

PA required for Non-Par providers only

L6698

ADD UP EXT PROS LOCK MECH EXC INSRT

PA required for Non-Par providers only

L6706

TERMINAL DEVC HOOK MECH VOL OPENING

PA required for Non-Par providers only

L6707

TERMINAL DEVC HOOK MECH VOL CLOSING

PA required for Non-Par providers only

L6708

TERMINAL DEVC HAND MECH VOL OPENING

PA required for Non-Par providers only

L6711

TERM DVC HOOK MECH VOL OPN PED

PA required for Non-Par providers only

L6712

TERM DVC HOOK MECH VOL CLOS PED

PA required for Non-Par providers only

L6713

TERM DVC HAND MECH VOL OPN PED

PA required for Non-Par providers only

L6714

TERM DEVC HAND MECH VOL CLOS PED

PA required for Non-Par providers only

L6721

TERM DEVC HOOK/HAND HD MECH VOL OPN

PA required for Non-Par providers only

L6722

TERM DEVC HOOK/HND HD MECH VOL CLOS

PA required for Non-Par providers only

L6883

REPL SOCKET BE/WD MOLDED TO PT MDL

PA required for Non-Par providers only

L6884

REPL SOCKT ABOVE ELB DISART MOLD PT

PA required for Non-Par providers only

L6885

REPL SOCKT SD/INTRSCAP THOR MOLD PT

PA required for Non-Par providers only

L6895

ADD UP EXT PROSTH GLOV TERM CSTM

PA required for Non-Par providers only

L6905

HND REST PART HND W/GLOV MX FNGR

PA required for Non-Par providers only

L6940

ELB DISRTC OTTO BOCK/=SWITCH CNTRL

PA required for Non-Par providers only

L6945

ELB DISRTC OTTO BOCK/=MYOELC CNTRL

PA required for Non-Par providers only

L7360

SIX VOLT BATTERY EACH

PA required for Non-Par providers only

L7366

BATTERY CHARGER TWELVE VOLT EACH

PA required for Non-Par providers only

L7367

LITHIUM ION BATTERY REPLACEMENT

PA required for Non-Par providers only

L7368

LITHIUM ION BATT CHARGER REPL ONLY

PA required for Non-Par providers only

L7404

ADD UP EXT PROS ABVE ED ACRYLC MATL

PPA required for Non-Par providers only

L7405

ADD UP EXT PROS SD/INTERSCAP THOR

PA required for Non-Par providers only

L8040

NASL PROSTH PROVIDED NON-PHYSICIAN

PA required for Non-Par providers only

L8041

MIDFCE PROSTH PROV NON-PHYSICIAN

PA required for Non-Par providers only

L8042

ORB PROSTH PROVIDED NON-PHYSICIAN

PA required for Non-Par providers only

L8043

UPPER FCE PROSTH PROV NON-PHYSICIAN

PA required for Non-Par providers only

L8044

HEMI-FCE PROSTH PROV NON-PHYSICIAN

PA required for Non-Par providers only

L8045

AURICULAR PROSTH PROV NON-PHYSICIAN

PA required for Non-Par providers only

L8046

PART FCE PROSTH PROV NON-PHYSICIAN

PA required for Non-Par providers only

L8047

NASL SEPTAL PROSTH PROV NON-PHYS

PA required for Non-Par providers only

L8610

OCULAR IMPLANT

PA required for Non-Par providers only

L8612

AQUEOUS SHUNT

PA required for Non-Par providers only

L8615

HEADSET/HEADPIECE COCHLR IMPL REPL

PA required for Non-Par providers only

L8616

MICROPHONE COCHLEAR IMPL DEVC REPL

PA required for ALL providers

L8617

TRNSMTTING COIL COCHLEAR IMPL REPL

PA required for ALL providers

L8618

TX CBL U CI/AUD OSSEOINTG DVC REPL

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

L8621

REPL ZINC AIR BATTERY

PA required for ALL providers

L8622

ALKALIN BATT COCHLR IMPL ANY SZ RPL

PA required for ALL providers

L8623

LITH ION BATT NOT EAR LEVEL REPL EA

PA required for ALL providers

L8624

LIB CI/AO DVC SP EAR LEVEL REPL EA

PA required for ALL providers

L8625

EXT RECHRG BATT CI/AO DEVC REPL EA

PA required for ALL providers

L8628

COCHLR IMPL EXT CONTRLLR CMPNT REPL

PA required for Non-Par providers only

L8629

TRANSMIT COIL CABLE COCHLR DEV RPL

PA required for Non-Par providers only

L8631

MPJ REPLCMT TWO/MORE PECES METL CER

PA required for Non-Par providers only

L8659

IP FNGR JNT REPLCMT 2/MORE PECES ME

PA required for Non-Par providers only

L8670

VASC GRAFT MATERIAL SYNTH IMPLANT

PA required for Non-Par providers only

L8684

RF TRNSMT BOWEL BLADDR MGMT REPL

PA required for Non-Par providers only

L8691

AO D EXT SP EXCL TRNDCR/ACTR RPL EA

PA required for Non-Par providers only

L8693

AUD OSSEOINTEGRATED DEVC ABUT REPL

PA required for Non-Par providers only

Q4100

SKIN SUBSTITUTE NOT OTHERWISE SPECI

PA required for ALL providers

Q4101

APLIGRAF PER SQ CM

PA required for ALL providers

Q4103

OASIS BURN MATRIX PER SQ CM

PA required for ALL providers

Q4104

INTEGRA BMWD PER SQ CM

PA required for ALL providers

Q4105

INTGRA DRT/OMNIGR DERM RGN MTX P SC

PA required for ALL providers

Q4106

DERMAGRAFT PER SQ CM

PA required for ALL providers

Q4107

GRAFTJACKET PER SQ CM

PA required for ALL providers

Q4108

INTEGRA MATRIX PER SQ CM

PA required for ALL providers

Q4110

PRIMATRIX PER SQ CM

PA required for ALL providers

Q4112

CYMETRA INJECTABLE 1 CC

PA required for ALL providers

Q4115

ALLOSKIN PER SQ CM

PA required for ALL providers

Q4116

ALLODERM PER SQ CM

PA required for ALL providers

Q4117

HYALOMATRIX PER SQ CM

PA required for ALL providers

Q4118

MATRISTEM MICROMATRIX 1 MG

PA required for ALL providers

Q4121

THERASKIN PER SQ CM

PA required for ALL providers

Q4132

GRAFIX CORE AND GRAFIXPL CORE-SQ CM

PA required for ALL providers

Q4137

AMNIOEXCEL AMNIOEXCEL PLUS/BIODEXCEL PER SQ CM

PA required for ALL providers

Q4150

ALLOWRAP DS OR DRY 1 SQ CM

PA required for ALL providers

Q4151

AMNIOBAND, GUARDIAN 1 SQ CM

PA required for ALL providers

Q4152

Dermapure 1 square cm

PA required for ALL providers

Q4155

NEOXFLO OR CLARIXFLO 1 MG

PA required for ALL providers

Q4158

KERECIS OMEGA3 PER SQUARE CM

PA required for ALL providers

Q4160

NUSHIELD 1 SQUARE CM

PA required for ALL providers

Q4205

MEMBRANE GRAFT OR MEMBRANE WRAP PER SQ CM

PA required for ALL providers

Q4208

NOVAFIX PER SQ CM

PA required for ALL providers

Q4209

SURGRAFT PER SQ CM

PA required for ALL providers

Q4211

AMNION BIO OR AXOBIOMEMBRANE PER SQ CM

PA required for ALL providers

Q4212

ALLOGEN PER CC

PA required for ALL providers

Q4213

ASCENT 0.5 MG

PA required for ALL providers

Q4214

CELLESTA CORD PER SQ CM

PA required for ALL providers

Q4215

AXOLOTL AMBIENT OR AXOLOTL CRYO 0.1 MG

PA required for ALL providers

Q4216

ARTACENT CORD PER SQ CM

PA required for ALL providers

Q4217

WNDFIX BIOWND WNDFIX+BIOWND+WNDFIX X+/X+ P SC

PA required for ALL providers

Q4218

SURGICORD PER SQ CM

PA required for ALL providers

Q4219

SURGIGRAFT-DUAL PER SQ CM

PA required for ALL providers

Q4220

BELLACELL HD OR SUREDERM PER SQ CM

PA required for ALL providers

Q4221

AMNIO WRAP2 PER SQ CM

PA required for ALL providers

Q4222

PROGENAMATRIX PER SQ CM

PA required for ALL providers

Q4226

MYOWN SKIN INCL HARVEST AND PREP PROC PER SQ CM

PA required for ALL providers

Q4230

COGENEX FLOWABLE AMNION PER 0.5 CC

PA required for ALL providers

Q5002

HOSPICE/HHC PROV ASSTD LIVING FACL

PA required for Non-Par providers only

Q5003

HOSPICE CARE PRVO LTC/NON-SKILL NF

PA required for Non-Par providers only

Q5007

HOSPICE CARE PROV IN LTC FACL

PA required for Non-Par providers only

Q5008

HOSPICE CARE PROV IP PSYCH FACILITY

PA required for Non-Par providers only

Q5009

HOSPICE/HOME HLTH CARE IN PLACE NOS

PA required for Non-Par providers only

Q5010

HOSPICE HOME CARE PROV HOSPICE FACL

PA required for Non-Par providers only

S0190

MIFEPRISTONE ORAL 200 MG

PA required for Non-Par providers only

S0191

MISOPROSTOL ORAL 200 MCG

PA required for Non-Par providers only

S0271

PHYS MGT PT HM CARE HOSPICE MO RATE

PA required for Non-Par providers only

S2083

ADJ GASTRIC BAND DIAM SUBQ PORT

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

S5140

FOSTER CARE ADULT PER DIEM

PA required for ALL providers

S5165

HOME MODIFICATIONS PER SERVICE

PA required for ALL providers

S9110

TELEMON PT HOME ALL EQUIP PER MTH

PA required for ALL providers

S9123

NRS CARE HOM REGISTERED NURSE-HOUR

PA required for ALL providers

S9124

NURSING CARE THE HOME LPN PER HOUR

PA required for ALL providers

S9208

HOME MGMT PRETERM LABOR PER DIEM

PA required for ALL providers

S9209

HOME MANGEMENT PPROM DIEM

PA required for ALL providers

S9211

HOME MGMT GESTATIONAL HTN DIEM

PA required for ALL providers

S9213

HOME MANAGEMENT PREECLAMPSIA DIEM

PA required for ALL providers

S9214

HOME MGMT GESTATIONAL DIABETES DIEM

PA required for ALL providers

S9365

HIT TPN 1 LITER PER DAY PER DIEM

PA required for Non-Par providers only

S9434

MOD SOLID FOOD SUP INBORN ERR METAB

PA required for Non-Par providers only

S9480

INTENSIVE OP PSYC SERVICES PER DIEM

PA required for ALL providers

S9975

TPLNT REL LODG MEALS AND TRNSPRT DIEM

PA required for Non-Par providers only

T1021

HOME HLTH AIDE/CERT NURSE ASST VST

PA required for ALL providers

V2020

FRAMES PURCHASES

PA required for Non-Par providers only

V2100

SPHER 1 VISN PLANO +/- 4.00-LENS

PA required for Non-Par providers only

V2101

SPHER 1 VISN +/- 4.12 +/- 7.00D EA

PA required for Non-Par providers only

V2102

SPHER 1 VISN +/- 7.12 +/- 20.00D EA

PA required for Non-Par providers only

V2103

1 VISN PLANO-+/-4.00D 0.12-2.00D EA

PA required for Non-Par providers only

V2104

1 VISN PLANO-+/-4.00D 2.12-4.00D EA

PA required for Non-Par providers only

V2105

1 VISN PLANO-+/-4.00D 4.25-6.00D EA

PA required for Non-Par providers only

V2106

1 VISN PLANO-+/-4.00D OVR 6.00D EA

PA required for Non-Par providers only

V2107

1 VISN +/-4.25-+/-7.00 0.12-2.00D

PA required for Non-Par providers only

V2108

1 VSN +/-4.25D-+/-7.00D 2.12-4.00D

PA required for Non-Par providers only

V2109

1 VISN+/- 4.25-+/- 7.00D 4.25-6.00D

PA required for Non-Par providers only

V2110

1 VISN +/- 4.25-7.00D OVER 6.00D

PA required for Non-Par providers only

V2111

1 VISN +/-7.25-+/-12.00D 0.25-2.25D

PA required for Non-Par providers only

V2112

1 VSN +/-7.25-+/-12.00D 2.25D-400D

PA required for Non-Par providers only

V2113

1 VISN +/-7.25-+/-12.00D 4.25-6.00D

PA required for Non-Par providers only

V2114

1 VISN SPHERE >+/-12.00D PER LENS

PA required for Non-Par providers only

V2115

LENTICULAR PER LENS SINGLE VISION

PA required for Non-Par providers only

V2118

ANISEIKONIC LENS SINGLE VISION

PA required for Non-Par providers only

V2121

LENTICULAR LENS PER LENS SINGLE

PA required for Non-Par providers only

V2199

NOC SINGLE VISION LENS

PA required for Non-Par providers only

V2200

SPHERE BIFOCL PLANO +/-4.00D LENS

PA required for Non-Par providers only

V2201

SPHERE BIFOCL +/-4.12-+/-7.00D LENS

PA required for Non-Par providers only

V2202

SPHERE BIFOCL +/-7.12-+/-20.00D EA

PA required for Non-Par providers only

V2203

BIFOCL PLANO +/-4.00D 0.12-2.00D EA

PA required for Non-Par providers only

V2204

BIFOCL PLANO +/-4.00D 2.12-4.00D EA

PA required for Non-Par providers only

V2205

BIFOCL PLANO +/-4.00D 4.25-6.00D EA

PA required for Non-Par providers only

V2206

BIFOCL PLANO +/-4.00D OVER 6.00D EA

PA required for Non-Par providers only

V2207

BIFOCL +/-4.25-+/-7.00D 0.12-2.00D

PA required for Non-Par providers only

V2208

BIFOCL +/-4.25-+/-7.00D 2.12-4.00D

PA required for Non-Par providers only

V2209

BIFOCL +/-4.25-+/-7.00D 4.25-6.00D

PA required for Non-Par providers only

V2210

BIFOCL +/-4.25-+/-7.00D OVER 6.00D

PA required for Non-Par providers only

V2211

BIFOCL +/-7.25-+/-12.00D 0.25-2.25D

PA required for Non-Par providers only

V2212

BIFOCL +/-7.25-+/-12.00D 2.25-4.00D

PA required for Non-Par providers only

V2213

BIFOCL +/-7.25-+/-12.00D 4.25-6.00D

PA required for Non-Par providers only

V2214

BIFOCL SPHER OVR +/-12.00D PER LENS

PA required for Non-Par providers only

V2215

LENTICULAR PER LENS BIFOCAL

PA required for Non-Par providers only

V2218

ANISEIKONIC PER LENS BIFOCAL

PA required for Non-Par providers only

V2219

BIFOCAL SEG WIDTH OVER 28MM

PA required for Non-Par providers only

V2220

BIFOCAL ADD OVER 3.25D

PA required for Non-Par providers only

V2221

LENTICULAR LENS PER LENS BIFOCAL

PA required for Non-Par providers only

V2299

SPECIALTY BIFOCAL

PA required for Non-Par providers only

V2300

SPHERE TRIFOCL PLANO/+/-4.00D LENS

PA required for Non-Par providers only

V2301

SPHERE TRIFOCL +/- 4.12-+/-7.00 LNS

PA required for Non-Par providers only

V2302

SPHER TRIFOCL +/- 7.12-+/-20.00 LNS

PA required for Non-Par providers only

V2303

TRIFOCL PLANO +/-4.00D 0.12-2.00D

PA required for Non-Par providers only

V2304

TRIFOCL PLANO +/-4.00D 2.25-4.00D

PA required for Non-Par providers only

V2305

TRIFOCL PLANO +/-4.00D 4.25-6.00

PA required for Non-Par providers only

V2306

TRIFOCL PLANO +/-4.00D OVR 6.00D

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

V2307

TRIFCL +/-4.25-+/-7.00D 0.12-2.00D

PA required for Non-Par providers only

V2308

TRIFOCL +/-4.25-+/-7.00D 2.12-4.00D

PA required for Non-Par providers only

V2309

TRIFOCL +/-4.25-+/-7.00D 4.25-6.00D

PA required for Non-Par providers only

V2310

TRIFOCL +/-4.25-+/-7.00D OVR 6.00D

PA required for Non-Par providers only

V2311

TRIFCL +/-7.25-+/-12.00D 0.25-2.25D

PA required for Non-Par providers only

V2312

TRIFCL +/-7.25-+/-12.00D 2.25-4.00D

PA required for Non-Par providers only

V2313

TRIFCL +/-7.25-+/-12.00D 4.25-6.00D

PA required for Non-Par providers only

V2314

TRIFOCL SPHER > +/-12.00D PER LENS

PA required for Non-Par providers only

V2315

LENTICULAR PER LENS TRIFOCAL

PA required for Non-Par providers only

V2318

ANISEIKONIC LENS TRIFOCAL

PA required for Non-Par providers only

V2319

TRIFOCAL SEG WIDTH OVER 28 MM

PA required for Non-Par providers only

V2320

TRIFOCAL ADD OVER 3.25D

PA required for Non-Par providers only

V2321

LENTICULAR LENS PER LENS TRIFOCAL

PA required for Non-Par providers only

V2399

SPECIALTY TRIFOCAL

PA required for Non-Par providers only

V2410

VARIBL ASPHRCITY 1 FULL FIELD-LENS

PA required for Non-Par providers only

V2430

VRIBL ASPHRC BIFOCL FULL FIELD-LENS

PA required for Non-Par providers only

V2499

VARIABLE SPHERICITY LENS OTHER TYPE

PA required for Non-Par providers only

V2500

CNTC LENS PMMA SPHERICAL PER LENS

PA required for Non-Par providers only

V2501

CNTC LENS PMMA/PRISM BALLST LENS

PA required for Non-Par providers only

V2502

CONTACT LENS PMMA BIFOCAL PER LENS

PA required for Non-Par providers only

V2503

CNTC LENS PMMA COLR VISN DEFIC LENS

PA required for Non-Par providers only

V2510

CNTC LENS GAS PRMEABL SPHERICL LENS

PA required for Non-Par providers only

V2511

CNTC LENS GAS PRMEABL PRSM BLLST EA

PA required for Non-Par providers only

V2512

CNTC LENS GAS PERMEABLE BIFOCL LENS

PA required for Non-Par providers only

V2513

CNTC LENS GAS PRMEABL EXT WEAR LENS

PA required for Non-Par providers only

V2520

CNTC LENS HYDROPHIL SPHERICAL LENS

PA required for Non-Par providers only

V2521

CNTC LENS HYDROPHL/PRISM BLLST LENS

PA required for Non-Par providers only

V2522

CNTC LENS HYDROPHIL BIFOCAL LENS

PA required for Non-Par providers only

V2523

CNTC LENS HYDROPHIL EXT WEAR LENS

PA required for Non-Par providers only

V2524

CONTACT LENS HPI SPH PC ADDITIVE PER LENS

PA required for Non-Par providers only

V2526

CONTACT LENS HPI W/BLUE-VIOLET FILTER PER LENS

PA required for Non-Par providers only

V2530

CNTC LENS SCLERAL GAS IMPERMEBL PER

PA required for Non-Par providers only

V2531

CNTC LENS SCLERAL GAS PERMEABLE PER

PA required for Non-Par providers only

V2599

CONTACT LENS OTHER TYPE

PA required for Non-Par providers only

V2600

HAND HELD LW VISNANDOTH NON SPEC AIDS

PA required for Non-Par providers only

V2610

SNGL LENS SPECT MOUNT LW VISION AID

PA required for Non-Par providers only

V2615

TELESCOPIC AND OTH COMPOUND LENS SYS

PA required for Non-Par providers only

V2623

PROSTHETIC EYE PLASTIC CUSTOM

PA required for Non-Par providers only

V2624

POLISHING/RESURFACING OCULR PROSTH

PA required for Non-Par providers only

V2625

ENLARGEMENT OF OCULAR PROSTHESIS

PA required for Non-Par providers only

V2626

REDUCTION OF OCULAR PROSTHESIS

PA required for Non-Par providers only

V2627

SCLERAL COVER SHELL

PA required for Non-Par providers only

V2628

FABRICATIONANDFIT OCULAR CONFORMER

PA required for Non-Par providers only

V2629

PROSTHETIC EYE OTHER TYPE

PA required for Non-Par providers only

V2700

BALANCE LENS PER LENS

PA required for Non-Par providers only

V2710

SLAB OFF PRISM GLASS/PLSTC PER LENS

PA required for Non-Par providers only

V2715

PRISM PER LENS

PA required for Non-Par providers only

V2718

PRESS-ON LENS FRESNELL PRISM P LENS

PA required for Non-Par providers only

V2730

SPCL BASE CURVE GLASS/PLSTC-LENS

PA required for Non-Par providers only

V2744

TINT PHOTOCHROMATIC PER LENS

PA required for Non-Par providers only

V2750

ANTIREFLECTIVE COATING PER LENS

PA required for Non-Par providers only

V2755

U-V LENS PER LENS

PA required for Non-Par providers only

V2760

SCRATCH RESISTANT COATING PER LENS

PA required for Non-Par providers only

V2770

OCCLUDER LENS PER LENS

PA required for Non-Par providers only

V2780

OVERSIZE LENS PER LENS

PA required for Non-Par providers only

V2781

PROGRESSIVE LENS PER LENS

PA required for Non-Par providers only

V2782

LNS I 1.54-1.65 PLST/1.60-1.79 GLA

PA required for Non-Par providers only

V2783

LNS INDX >/=1.66 PLSTC/>/=1.80 GLA

PA required for Non-Par providers only

V2784

LENS POLYCARBATE/EQUL ANY INDX-LENS

PA required for Non-Par providers only

V2787

ASTIGMATISM CORRECTING FUNCTION IOL

PA required for Non-Par providers only

V2790

AMNIOTIC MEMBRANE SURG RECNSTR-PROC

PA required for Non-Par providers only

V2799

VISION SERVICE MISCELLANEOUS

PA required for Non-Par providers only

V5011

FIT/ORIENTATION/CHECK HEARING AID

PA required for Non-Par providers only

 

Rev Code/ Procedure Code

Description

New PA Requirement Effective 10/15/24

V5014

REPAIR/MODIFICATION OF A HEARING AID

PA required for Non-Par providers only

V5090

DISPENSING FEE UNSPEC HEARING AID

PA required for Non-Par providers only

V5110

DISPENSING FEE BILATERAL

PA required for Non-Par providers only

V5150

BINAURAL GLASSES

PA required for Non-Par providers only

V5160

DISPENSING FEE BINAURAL

PA required for Non-Par providers only

V5190

HEARING AID CONTRALATERAL RTE MONAURAL GLASSES

PA required for Non-Par providers only

V5200

DISPENSING FEE CONTRALATERAL MONAURAL

PA required for Non-Par providers only

V5240

DISPENSING FEE CONTRALATERAL RTE SYSTEM BINAURAL

PA required for Non-Par providers only

V5241

DISPNS FEE MONAURL HEARING AID TYPE

PA required for Non-Par providers only

V5262

HEARING AID DISPBL TYPE MONAURAL

PA required for Non-Par providers only

V5263

HEARING AID DISPBL TYPE BINAURAL

PA required for Non-Par providers only

V5264

EAR MOLD/INSERT NOT DISPBL ANY TYPE

PA required for Non-Par providers only

V5265

EAR MOLD/INSERT DISPOSABLE ANY TYPE

PA required for Non-Par providers only

V5266

BATTERY FOR USE IN HEARING DEVICE

PA required for Non-Par providers only

V5267

HA/ALD/SUPP/ACCESS NOT O/W SPEC

PA required for Non-Par providers only

V5275

EAR IMPRESSION EACH

PA required for Non-Par providers only

V5298

HEARING AID NOC

PA required for ALL providers

V5362

SPEECH SCREENING

PA required for Non-Par providers only

V5363

LANGUAGE SCREENING

PA required for Non-Par providers only

V5364

DYSPHAGIA SCREENING

PA required for Non-Par providers only