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 |