Arthroscopy procedure codes — prior authorization

Prior Authorization is required for many arthroscopy procedures listed below. Submit authorization requests via the secure provider portal. Prior authorization does not guarantee payment; benefits and coverage vary by plan.

• Arthroscopy shoulder codes (examples): 29805–29828 (diagnostic and multiple surgical shoulder arthroscopy codes).
• Arthroscopy hip codes (examples): 29860–29916 (diagnostic and surgical hip arthroscopy codes, including femoroplasty, acetabuloplasty, labral repair).
• Arthroscopy knee codes (examples): 29885–29889 (osteochondritis dissecans drilling, ACL/PCL repair/reconstruction).

Mixed specialty interventional codes — authorization list (partial)

Mixed-specialty interventional and endovenous procedures require prior authorization/notification as indicated. Provide clinical documentation supporting indication and laterality where applicable.

• Endovenous ablation and sclerotherapy codes: 36465, 36466, 36470, 36471, 36473–36478, 36483 (effective dates vary; some entries list 7/1/2025 updates).
• Injection/sclerosant and foam procedures: 36465–36471 grouped with imaging guidance and monitoring.
• Other interventional codes requiring review: 33289 (wireless pulmonary artery pressure sensor), 33361–33366 (TAVR), 33477, 364xx-series and related vascular/interventional codes.

Prior authorization / notification entries (partial list)

Certain surgical, device, and procedural entries require prior authorization or notification. Check the member’s benefits and include operative reports, device implants, and justification for medical necessity with requests.

• Spinal instrumentation and arthroplasty/implantation examples: 22843–22846 (posterior/anterior segmental instrumentation by vertebral segments).
• Neurostimulator implantation and related spinal procedures: 61863, 61867, 61885, 63650, 63655, 63685.
• Major cardiac and endovascular device procedures: 33361–33366 (TAVR approaches), 33477.
• Selected complex laparoscopic and bariatric revisions and implant removals: 43775, 43845–43848, 43881.

Surgical and device procedure entries — examples

Procedural codes that commonly require prior authorization/notification include many surgical, neurostimulation, and injection procedures. Submit documentation and device details for implants and neurostimulators.

• Spine and neuromodulation: 63057, 63075–63082, 63650, 63655, 63685.
• Injections with imaging guidance: 64484 (transforaminal epidural with imaging).
• Hysterectomy and adnexal procedures when combined with additional removals: 58661, 58720.

Procedural codes requiring authorization/notification (partial)

A broad set of procedures require prior authorization or notification; providers should verify requirements and submit necessary clinical information prior to scheduling.

• Radiation oncology delivery codes: 77402, 77407, 77412, 77470 and proton delivery: 77520, 77522, 77523, 77525 (prior auth required).
• Special procedures: 77470 (total body irradiation), and special dosimetry 77331 when applicable.
• Pain management and neuromodulation related injections and implant procedures listed elsewhere also require authorization.

Imaging and Angiography Codes (partial)

Advanced imaging and angiography CPT codes frequently require prior authorization. Confirm service-specific requirements and include clinical indication and prior imaging when applicable.

• CT head/brain and related: 70450–70482, 70486–70498 (various head/neck/maxillofacial CT codes).
• CT angiography / CTA and advanced CT: 70496, 70498, 75572–75574 (cardiac CT mappings).
• MR and MR angiography: 70540–70552 and corresponding MRA codes (70544–70549).
• Vascular/angiography and advanced post-processing: 75635, 75572–75574 and related CTA/MRA mappings.

MR Elastography and Breast MRI Codes (partial)

MR elastography and breast MRI codes are included on the prior authorization/notification list. Verify indications, laterality, and whether unilateral or bilateral imaging is requested.

• MR elastography / related unlisted mapping: 76497–76498 (MR elastography unlisted CT/MR procedure mappings).
• Breast MRI and elastography sequences: 77046–77049 (breast MRI without and with contrast, unilateral/bilateral).
• MR spectroscopy and specialized MRI: 0611T–0612T (discogenic pain spectroscopy), and other MRI add-on codes (0697T–0698T) where applicable.

Radiation Treatment Delivery Codes (partial)

Radiation therapy delivery codes (photon and proton) and special procedure delivery levels require prior authorization. Provide treatment intent, simulation details, and planning information with requests.

• Radiation treatment delivery levels: 77402 (Level 1), 77407 (Level 2), 77412 (Level 3).
• Special treatment and dosimetry: 77470 (special treatment), 77331 (special dosimetry).
• Proton therapy delivery: 77520 (simple without compensation), 77522 (simple with compensation), 77523 (intermediate), 77525 (complex).

PET / PET-CT Codes (partial)

PET, SPECT, and radiopharmaceutical imaging codes require prior authorization/notification. Include clinical indication, prior imaging, and relevant lab results when requesting authorization.

• Planar and tomographic nuclear medicine: 78801–78804 (planar localization, multi-day imaging).
• SPECT and tomographic studies: 78803, 78831, 78832 (SPECT with and without CT).
• PET and PET/CT codes: 78811–78816 (PET limited area, skull base to mid-thigh, whole body, PET/CT with CT for attenuation correction).

Molecular and Genomic Testing Codes — prior authorization required

Many molecular and genomic tests require prior authorization. For molecular/genomic testing, include the clinical indication, family history, prior test results, and exact specimen type. Prior authorization is required to determine coverage and medical necessity for complex genomic panels and certain multigene tests.

• Selected molecular/genomic CPT codes (examples): 81162–81164 (BRCA1/BRCA2 full sequence/duplication analysis).
• Genomic panels and high-level molecular pathology: 81407–81408 (molecular pathology levels), 81410–81414 (heritable disorders panels), 81416, 81418 (exome/pharmacogenomics).
• Neoplasm panels and tumor profiling: 81449–81455, 81458–81464 (solid organ and hematolymphoid neoplasm panels; some entries effective 7/1/2025).
• Cytogenomic and microarray analyses: 81277, 81228–81229 (cytogenomic microarray and CGH analyses).
• Proprietary and U-code genomic services: 0320U, 0326U, 0327U, 0332U, 0334U and other temporary codes (see portal for full list).

Prior authorization / notification requirement (molecular/genomic tests)

Prior authorization / notification is required for many genomic and molecular diagnostics to determine medical necessity and coverage. Always submit detailed clinical rationale, testing methodology, and prior relevant results.

• High-complexity panels (exome/genome): 81415, 81425, 81416, 81426 (exome/genome sequence analyses) — some effective dates noted 7/1/2025.
• Tumor and cell-free assays: 81458–81463 (solid organ neoplasm panels, including cell-free/plasma assays; several entries 7/1/2025).
• Proprietary U-codes and algorithmic assays: 0320U–0334U (tests with algorithmic risk scores or multianalyte assessments).

Genomic and molecular diagnostics (selected)

Selected genomic and molecular diagnostics and service codes are on the list; this is a sample and not exhaustive. Use the provider portal for the complete, current list and to submit requests.

• Selected U-codes and proprietary tests: 0320U, 0326U, 0327U, 0332U, 0334U (examples related to gene expression profiling and pan-tumor tests).
• T-codes and emerging imaging/genomics: 0611T–0698T, 0633T–0638T (specialty MR spectroscopy and breast CT/MRI descriptors).
• Cytogenomic and genome-wide panels: 81228–81229, 81277, 81349 (cytogenomic microarray and low-pass sequencing entries).

Drugs, biologics, J-code listing and effective dates

Many injectable drugs, biologics, and specialty products require prior authorization. Effective dates and therapeutic equivalence mappings are provided for several J-codes; check the portal for plan-specific coverage, biosimilar handling, and effective dates.

• Selected J-codes (examples): J0129, J0174, J0179, J0180, J0185, J0202 (functional neuromuscular stimulation / drug mappings).
• Specialty product examples and effective dates: J0217–J0225, J0256–J0257, J0491, J0517, J0567, J0584, J0638, J0641–J0642.
• Gene therapies and high-cost biologics: J1411, J1412 (gene therapy entries such as onasemnogene abeparvovec) and other J-codes requiring review.
• See mappings and therapeutic equivalence notes for J9294–J9296, J9298 and numerous pemetrexed-related mapping entries (J9294–J9600 series) for non-equivalence and mapping guidance.

J-code mappings (sample)

Some J-code mappings and equivalence notes are shown here as examples — therapeutic equivalence or non-equivalence and effective dates are important for billing and prior authorization decisions.

• J9294–J9296: amivantamab-vmjw mappings and comments (effective 1/1/2024).
• Pemetrexed and related mappings: numerous entries (J9298, J9301–J9325, J9332–J9348, J9353, J9355, others) indicating non-equivalence or mapped product relationships; effective dates 1/1/2024 (see portal).
• Biosimilar and therapeutic equivalence notes: many J- and Q-code mappings (Q5xxx series) showing biosimilar relationships and effective dates — verify per-product.

J-code mappings (expanded)

Expanded J-code mapping details and biosimilar/non-equivalence relationships are included in the full list. Use the provider portal to confirm the correct J-code to request and any required clinical documentation.

• Extensive pemetrexed-related mappings across J93xx series illustrating non-therapeutic equivalence relationships and mapped agent substitutions.
• Entries indicating effective dates and special handling for novel biologics and unclassified drugs (J3490, J3590) and implantable biologic products.
• Many mappings include notes on which products are considered therapeutically equivalent or not — these affect prior authorization and billing.

Durable medical equipment / prosthesis mappings

Durable medical equipment (DME), prosthesis, and K-/L-code items require prior authorization. Provide supporting documentation of medical necessity, functional status, and device specifications when submitting requests.

• Power wheelchair group mappings and DME examples: K0848–K0891 (power wheelchair groups 3 with varying weight capacities and configurations).
• Crosswalks and equivalency mappings to higher group power wheelchairs and group 4/5 examples (K0868–K0885, K0890–K0891).
• Prosthesis and L-code entries: L6026 (transcarpal/metacarpal or partial hand prosthesis, myoelectric components).
• Provide model/device details and clinical justification for custom or heavy-duty power mobility devices.