No Authorization Required List — Surgical and non-surgical CPT/HCPCS Codes (outpatient)
A list of outpatient surgical and non-surgical CPT/HCPCS codes that do not require prior authorization for AvMed; applies to outpatient procedures and includes referral and out-of-network verification guidance.
Policy Summary
PayerAvMed
PolicyNo Authorization Required List — Surgical and non-surgical CPT/HCPCS Codes (outpatient)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionVerify referral requirements and member network status prior to rendering outpatient services; call Provider Service Center at 1-800-452-8633 for out-of-network benefit verification.
No material clinical or coverage changes in this revision.
Outpatient onlyApplies to setting
200+Codes in document (approx)
Aug 23, 2022Last update
severalAdmin codes annotated
Coverage criteria and authorization notes
No Prior Authorization Required — outpatient procedure codes
The listed CPT/HCPCS codes do not require prior authorization when performed in the outpatient setting; providers must verify referral requirements and member benefits as indicated.
ALL of the following
Procedure is performed in an outpatient setting (applies to out‑patient procedures only).
The CPT/HCPCS code appears on AvMed's 'No Authorization Required' list.
Providers should verify whether the member's plan requires a PCP referral prior to specialist services and confirm member network status before rendering services (call Provider Service Center at 1-800-452-8633 for out-of-network verification).
Operational: referral and network verification are provider responsibilities prior to service.
Codes listed in AvMed's 'No Authorization Required' listing (example entries include, but are not limited to: 10004, 10005, 10006, 10007, 10008, 10009, 10010, 11102, 11104, 11401, 11600, 12001, 13100, 17000, 19000, 19100, 20610).Applies when code is billed for an outpatient procedure.
Coverage information not present in these chunks
This portion of the document is a code listing and does not include explicit coverage criteria or payment rules in these chunks.
Chunks in this section provide CPT/HCPCS codes and short descriptions only; no explicit coverage determinations, prior authorization rules, or payment criteria are specified in these entries.
Example entries from these chunks include CPT codes such as 49656, 49657, 50200 and related short descriptions; comment fields are present but not populated.
Authorization exceptions
Authorization/coverage exceptions applicable to select cardiology and ECG-related codes are noted.
ALL of the following
For the listed cardiology/electrocardiogram and cardioversion codes (examples: 92960, 93000, 93005, 93010, 93015, 93016, 93017, 93018), the document includes the comment: 'Contact NCH for Medicare only - No auth for Commercial.'
Operational: contact NCH for Medicare inquiries; no prior authorization required for commercial lines per the comment.
Other diagnostic and ultrasound cardiac codes (e.g., 93040, 93303, 93306, 93307) appear in the same section without that comment; verify individual code handling if needed.
Authorization and coverage notes (partial)
Assorted authorization notes in this section address administration (J-/A-/Q-/G‑) codes and other HCPCS entries.
ALL of the following
Multiple drug and administration HCPCS/J‑codes are annotated with the comment 'No auth for admin codes', indicating that administration codes for these items do not require prior authorization per this listing (examples: A9606; J1071; J1437; J1439; J1443; J1444; J1652; J1756; J2916; J3489; J7030; J7040; J7042; J7050; J7060; J7100; J7110; J7120; J7121; J7131; J7191; J7296; J7297; J7298; J7324; J7325; J9035; J9045; J9267; Q5107; Q5118).
Operational: the 'No auth for admin codes' comment applies specifically to administration/infusion/admin codes listed; verify billing practice for associated drug/procurement codes separately.
Several HCPCS entries for wound matrices, skin substitutes, and other supply codes are listed with short descriptions but without explicit coverage determinations in these chunks; confirm coverage or authorization requirements via standard AvMed channels if needed.
CPT / HCPCS code lists (No Authorization Required)
Sample codes from No Authorization Required listCPTCovered
10004
Fine needle aspiration biopsy, without imaging guidance; each additional lesion
10005
Fine needle aspiration biopsy, including ultrasound guidance; first lesion
10006
Fine needle aspiration biopsy, including ultrasound guidance;
10007
Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion
10008
Fine needle aspiration biopsy, including fluoroscopic guidance;
10009
Fine needle aspiration biopsy, including ct guidance; first lesion
10010
Fine needle aspiration biopsy, including ct guidance; each additional lesion
11102
Tangential biopsy of skin; single lesion
11104
Punch biopsy of skin; single lesion
11401
Excision, benign lesion including margins, except skin tag
1–10 of 17
1/2
Sample musculoskeletal and soft tissue CPT codesCPT
21931
Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater.
22902
Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm.
22903
Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater.
23030
Incision and drainage, shoulder area; deep abscess or hematoma.
23031
Incision and drainage, shoulder area; infected bursa.
23065
Biopsy, soft tissue of shoulder area; superficial.
23066
Biopsy, soft tissue of shoulder area; deep.
23071
Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater.
23073
Excision, tumor, soft tissue of shoulder area, subfascial.
23075
Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm.
Cystourethroscopy, with dilation of bladder for interstitial cystitis
52353
Cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy
54150
Circumcision, using clamp or other device with regional dorsal penile
1–10 of 19
1/2
Radiology and ultrasound codesCPT
75710
Venography, extremity, unilateral, radiological supervision and interpretation
75820
Venography, extremity, unilateral, radiological supervision and interpre.
76801
Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus
HCPCS supplies and drugsHCPCS
A2001
Innovamatrix ac, per square centimeter
A9595
Piflufolastat f-18, diagnostic, 1 millicurie
C9088
Instillation, bupivacaine, and meloxicam, 1 mg/0.03 mg
Selected HCPCS/Codes with notesHCPCS
A2001-A2010
Various wound matrices, per square centimeter
A4436-A4437
Irrigation supply; sleeve (reusable/disposable), per month
A9595
Piflufolastat F-18, diagnostic, 1 millicurie
Q4199
Cygnus matrix, per square centimeter
J1437, J1439, J1443, J1444
Various intravenous iron products (noted 'No auth for admin codes')
J3489
Zoledronic acid (No auth for admin codes)
Comment fields presence — coding
Comment field presenceComment fields are present for each code but are empty (Comment = .)
OccurrenceAppears after each Short Description in code listings (e.g., '21931, Comment = .')
ImplicationNo supplemental notes provided for most CPT entries in these chunks
Document update date
Document update date2022-08-23
Where shown'AvMed Last Update: August 23, 2022' appears in chunk headers throughout the document
Policy metadataLast review date in brief: 2022-08-23
Commercial prior auth note
Commercial prior authorization noteContact NCH for Medicare only - No auth for Commercial.
Applies toSelect cardiology/ECG and cardioversion CPT entries listed in the document
Action for providersContact NCH for Medicare cases; no prior auth required for Commercial plans per listing
What providers must do / important billing notes
Note
No Authorization Required — Outpatient
No Authorization Required List Surgical and non-surgical CPT/HCPCS Codes. Applies to outpatient procedures only.
Applies to outpatient procedures only — inpatient services may have different requirements.
Verify PCP referral and member network status prior to rendering services.
Out-of-Network Providers: verify member benefits prior to rendering service by calling the Provider Service Center at 1-800-452-8633.
Billing Rule
Endoscopy CPT Entries (partial)
Endoscopy CPT codes listed below are included in the No Authorization Required outpatient list. Providers should confirm outpatient status before billing.
43220 — Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation.
43226 — Esophagoscopy, flexible, transoral; with insertion of guide wire.
43227 — (If present in full list) other related esophagoscopy procedures (partial list shown in source).
Billing Rule
No Authorization Required — Administration / Supply Codes
Selected administration (J-, A-, Q-, C- series) codes are included on the No Authorization Required list for administration/supplies. These entries are specific to administration or low-cost supply items; confirm outpatient context and billing rules when submitting claims.
A9606 — Xofigo radium ra-223 dichloride, therapeutic, per microcurie. (No auth for admin codes)
J1071 — Injection, testosterone cypionate, 1 mg. (No auth for admin codes)
J1094 — Injection, dexamethasone acetate, 1 mg. (No auth for admin codes)
J1100 — Injection, dexamethasone sodium phosphate, 1 mg. (No auth for admin codes)
J1437 — Ferric derisomaltose. (No auth for admin codes)
J1439 — Injectafer injection, ferric carboxymaltose, 1 mg. (No auth for admin codes)
J1443 — Triferic injection, ferric pyrophosphate citrate solution, 0.1 mg of iron. (No auth for admin codes)
J1444 — Ferric pyrophosphate citrate. (No auth for admin codes)
J1652 — Arixtra injection, fondaparinux sodium, 0.5 mg. (No auth for admin codes)
J1756 — Venofer injection, iron sucrose, 1 mg. (No auth for admin codes)
J2916 — Sodium ferric gluconate. (No auth for admin codes)
Definitions and field meanings
Outpatient — scope definition
ScopeApplies to out‑patient procedures only
Document purposeNo Authorization Required list for surgical and non‑surgical CPT/HCPCS codes in the outpatient setting
Provider reminderVerify referral requirements and network status prior to rendering services
Short Description field meaning
Field meaningShort Description contains a brief procedure description following each CPT code
Format example'21931, Short Description = Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater.'
PurposeProvides a concise label for the CPT/HCPCS code in the payer's list
Comment field presence
Presence of Comment fieldA 'Comment' field appears after the Short Description for each code entry and is often empty (Comment = .)
ImplicationSpecific J‑codes and infusion codes are annotated to exempt administration codes from prior auth
Short Description — esophagoscopy bleeding control
Short Description example43227 = Esophagoscopy, flexible, transoral; with control of bleeding, any method
LocationListed with other esophagoscopy entries in AvMed's CPT list
PurposeProvides concise procedure label for billing/reference
Comment — 'No auth for admin codes' (administration codes)
Comment example ('No auth for admin codes')J7030, J7040, J7042, J7050, J7060, J7100, J7110, J7120, J7121, J7191 are annotated 'No auth for admin codes'
ScopeApplies to infusion and administration codes listed in the HCPCS/J‑code sections
Provider actionNo prior authorization required for administration codes per the comment annotation
Policy Summary
PayerAvMed
PolicyNo Authorization Required List — Surgical and non-surgical CPT/HCPCS Codes (outpatient)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionVerify referral requirements and member network status prior to rendering outpatient services; call Provider Service Center at 1-800-452-8633 for out-of-network benefit verification.