Blue Cross Blue Shield - Maine Prior Auth Codes

36471 — Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg.

36901 — Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including imaging and report.

36902 — Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography; with transluminal balloon angioplasty, peripheral dialysis segment.

36905 — Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method; with transluminal balloon angioplasty, peripheral dialysis segment.

36906 — Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit; with transcatheter placement of intravascular stent(s), peripheral dialysis segment.

36907 — Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit (List separately).

36908 — Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit (List separately).

99183 — Physician or other qualified health care professional attendance and supervision for moderate sedation during pediatric procedures (example entry).

99509 — Home Visit, Assistance With Activities of Daily Living & Personal Care.

99511 — Home Visit, Fecal Impaction Management & Enema Administration.

99600 — Unlisted Home Visit Service/Procedure.

J3392 — Injection, exagamglogene autotemcel, per treatment.

A0430 — Fixed Wing Air Transport.

C9807 — Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components.

A0431 — Rotary Wing Air Transport.

J1414 — Injection, fidanacogene elaparvovec-dzkt, per therapeutic dose.

A0888 — Noncovered Ambulance Mileage.

A0435 — Fixed Wing Air Mileage.

A0436 — Rotary Wing Air Mileage.

A7025 — High Frequency Chest Wall Oscillation System Vest, Replacement For Use.

A9276 — Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day supply.

A9278 — (entry truncated in source) — sensor/accessory codes for CGM (see full policy list).

E2228 — Manual wheelchair accessory, wheel braking system and lock, complete, each.

E2291 — Planar back for pediatric size wheelchair.

E2293 — Contour back for pediatric size wheelchair.

E2292 — Planar seat for pediatric size wheelchair.

E2294 — Contour seat for pediatric size wheelchair.

E2295 — Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame.

E2310 — Power wheelchair accessory, electronic connection between wheelchair controller.

E2311 — Power wheelchair accessory, electronic connection between wheelchair controller.

E2312 — Power wheelchair accessory, hand or chin control interface, mini-proportional.

E2321 — Power wheelchair accessory, hand control interface, remote joystick.

E2322 — Power wheelchair accessory, hand control interface, multiple mechanical switches.

E2323 — Power wheelchair accessory, specialty joystick handle for hand control.

E2324 — Power wheelchair accessory, chin cup for chin control interface.

E2313 — Power wheelchair accessory, harness for upgrade to expandable controller.

E2326 — Power wheelchair accessory, breath tube kit for sip and puff interface.

E2327 — Power wheelchair accessory, head control interface, mechanical, proportional.

E2329 — Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional.

E2328 — Power wheelchair accessory, head control or extremity control interface, electronic, proportional.

E2340 — Power wheelchair accessory, nonstandard seat frame width, 20-23 inches.

E2341 — Power wheelchair accessory, nonstandard seat frame width, 24-27 inches.

E2342 — Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches.

E2343 — Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches.

E2351 — Power wheelchair accessory, electronic interface to operate speech generating device.

E2358 — Power wheelchair accessory, group 34 nonsealed lead acid battery, each.

E2362 — Power wheelchair accessory, group 24 non-sealed lead acid battery, each.

E2360 — Power wheelchair accessory, 22 nf non-sealed lead acid battery, each.

E2363 — Power wheelchair accessory, group 24 sealed lead acid battery, each.

E2364 — Power wheelchair accessory, u-1 non-sealed lead acid battery, each.

E2365 — Power wheelchair accessory, u-1 sealed lead acid battery, each.

E2367 — Power wheelchair accessory, battery charger, dual mode, for use with either battery type.

E2368 — Power wheelchair component, drive wheel motor, replacement only.

E2369 — Power wheelchair component, drive wheel gear box, replacement only.

E2370 — Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only.

E2371 — Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each.

L5999 — Lower Extremity Prosthesis, Not Otherwise Specified.

L6026 — Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, with myoelectric control components.

L6677 — Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow.

L6715 — Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement.

21086 — Impression & Custom Preparation; Auricular Prosthesis.

L6880 — Electric hand, switch or myoelectric controlled, independently articulating digits, includes motor(s).

L6881 — Automatic grasp feature, addition to upper limb electric prosthetic terminal.

L6882 — Microprocessor control feature, addition to upper limb prosthesis terminal device.

L6935 — Below Elbow Myoelectronic Component.

L7009 — Electric hook, switch or myoelectric controlled, adult.

54410 — Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session.

54411 — Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, With Irrigation & Debridement.

54440 — Plastic Operation, Penis, Injury.

54417 — Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infected, With Irrigation & Debridement.

55881 — Transurethral ablation of prostate tissue, using thermal ultrasound.

32850 — Donor pneumonectomy(s) (including cold preservation), from cadaver donor.

61630 — Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous.

61715 — MRI guided focused ultrasound high intensity stereotactic intracranial ablation.

61864 — Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, without Intraoperative Microelectrode Recording; each additional array.

61867 — Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, with Intraoperative Microelectrode Recording; First Array.

61868 — Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, with Intraoperative Microelectrode Recording; each additional array.

J3393 — Injection, betibeglogene autotemcel, per treatment.

J3394 — Injection, lovotibeglogene autotemcel, per treatment.

61885 — Subcutaneous Placement Cranial Neurostimulator Pulse Generator/Receiver; With Connection Single Electrode Array.

61886 — Subcutaneous Placement Cranial Neurostimulator Pulse Generator/Receiver; With Connection 2+ Electrode Arrays.

61889 — Insertion of skull-mounted cranial neurostimulator pulse generator or receiver, including craniectomy or craniotomy.

61891 — Revision or replacement of skull-mounted cranial neurostimulator pulse generator or receiver with connection to depth and/or cortical strip electrode arrays.

E0761 — Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electromagnetic Device.

64596 — Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator; initial electrode array.

64597 — Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator; additional entries.

64624 — Destruction by neurolytic agent, genicular nerve branches including imaging guidance.

64640 — Destruction, Neurolytic; Other Peripheral Nerve/Branch.

64716 — Neuroplasty and/or transposition; cranial nerve (specify).

64736 — Transection/Avulsion; Mental Nerve.

64738 — Transection/Avulsion; Inferior Alveolar Nerve, Osteotomy.

64740 — Transection/Avulsion; Lingual Nerve.

64732 — Transection/Avulsion; Supraorbital Nerve.

64734 — Transection/Avulsion; Infraorbital Nerve.

64742 — (entry truncated in source) — additional cranial nerve procedure codes.

J1561 — Injection, immune globulin (Gamunex/Gamunex-C/Gammaked), 500 mg.

J1566 — Injection, immune globulin, intravenous, lyophilized, 500 mg.

J1568 — Injection, immune globulin (Octagam), intravenous, 500 mg.

J1575 — Injection, immune globulin/hyaluronidase (Hyqvia), 100 mg immuneglobulin.

J1576 — Injection, immune globulin (Panzyga), intravenous, 500 mg.

J1595 — Injection, glatiramer acetate, 20 mg.

J1602 — Injection, golimumab, 1 mg, for intravenous use.

J1628 — Injection, guselkumab, 1 mg.

J1743 — Injection, idursulfase, 1 mg.

J1744 — Injection, icatibant, 1 mg.

J7195 — Factor IX (antihemophilic factor, recombinant) per IU.

J7200 — Injection, factor IX, (antihemophilic factor, recombinant), rixubis, per IU.

J7201 — Injection, factor IX, Fc fusion protein (recombinant), Alprolix, 1 IU.

J7202 — Injection, factor IX, albumin fusion protein (recombinant), Idelvion, 1 IU.

J7203 — Injection Factor IX, glycopegylated (Rebinyn), 1 IU.

J7205 — Injection, factor VIII Fc fusion (recombinant), per IU.

J7207 — Injection, factor VIII (antihemophilic factor, recombinant), pegylated, 1 IU.

J7208 — Injection, factor VIII, pegylated-aucl (Jivi), 1 IU.

J7209 — Injection, factor VIII (nuwiq), 1 IU.

J7210 — (additional factor products listed in full policy).

Procedure & Billing Codes (Samples)

Selected HCPCS / DME Codes (NY Medicaid)HCPCS

D7996	Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report
D7946	LeFort I (maxilla - total)
D7947	Lefort I (Maxilla - Segmented)
D7949	Lefort II Or Lefort III - With Bone Graft
D7941	Osteotomy - Mandibular Rami

Therapy & Imaging CPT CodesCPT

97110	Therapeutic Proc, 1+ Areas, Each 15 Min; Therapeutic Exercises
97112	Therapeutic Proc, 1+ Areas, Each 15 Min; Neuromuscular Reeducation
70482	CT Scan, Orbit/Sella/Posterior Fossa/ Outer, Middle, Inner Ear; W/O Contrast, Then W/Contrast

Additional Medicaid Procedure Codesmixed

93922	Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair
A7037	Tubing Used With Positive Airway Pressure Device
A7034	Nasal Interface (Mask Or Cannula Type) Used With Positive Airway Press
A7035	Headgear Used With Positive Airway Pressure Device
A7028	Oral cushion for combination oral/nasal mask, replacement only, each

Representative Surgical CPT/HCPCS (PA required)CPTCovered

27332	Arthrotomy, W/Excision, Semilunar Cartilage (Meniscectomy) Knee; Medial/Lateral
27130	Arthroplasty, Acetabular/Proximal Femoral Prosthetic Replacement
27333	Arthrotomy, W/Excision, Semilunar Cartilage (Meniscectomy) Knee; Medial & Lateral

Additional Procedural Codes Requiring Prior AuthorizationCPTCovered

29867	Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty)
29863	Arthroscopy, Hip, Surgical; W/Synovectomy
29877	Arthroscopy, Knee, Surgical; Debridement/Shaving, Articular Cartilage (Chondroplasty)

Radiation & Brachytherapy CodesCPTCovered

77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking
77373	Stereotactic body radiation therapy, treatment delivery, per fraction
77432	Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

Pharmaceutical J/Q Codes (Selected)HCPCSCovered

J7353	Anacaulase-bcdb, 8.8% gel, 1 gm
J9298	Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg
Q5103	Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg

Durable Medical Equipment & ProstheticsHCPCSCovered

L7190	Elbow Adolescent Myoelectron
L5301	Below knee, molded socket, shin, SACH foot, endoskeletal system
L2628	Metal Frame Recipro Hip & Ca

Selected Power Wheelchair Accessories (NY Medicaid)HCPCS

E2301	Wheelchair accessory, power standing system, any type
E2330	Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional
E2359	Power wheelchair accessory, group 34 sealed lead acid battery, each
E2361	Power wheelchair accessory, 22nf sealed lead acid battery, each

Selected CPT Procedures (Neutral)CPT

61630	Balloon angioplasty, intracranial, percutaneous
61715	MRI guided focused ultrasound high intensity stereotactic intracranial ablation
61864	Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; ea addl Array

Selected DME K-codes (Covered)HCPCSCovered

K0836	POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300
K0855	POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE
K0856	POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK

Representative Prior Authorization Codes (samples)mixedCovered

77525	Proton Treatment Delivery; Complex
J7173	Injection, concizumab-mtci, 0.5 mg
J7174	Injection, fitusiran, 0.04 mg
Q5155	Injection, aflibercept-jbvf (Yesafili), biosimilar, 1 mg
Q5154	Injection, omalizumab-igec (Omlyclo), biosimilar, 5 mg
Q5156	Injection, tocilizumab-anoh (Avtozma), biosimilar, 1 mg
Q5157	Injection, denosumab-bmwo (Stoboclo/Osenvelt), biosimilar, 1 mg

NY Medicaid Prior Auth Power Wheelchair Accessories (selected)HCPCSCovered

E2310	Power wheelchair accessory, electronic connection between wheelchair controller
E2311	Power wheelchair accessory, electronic connection between wheelchair controller
E2312	Power wheelchair accessory, hand or chin control interface, mini-proportional
E2321	Power wheelchair accessory, hand control interface, remote joystick
E2322	Power wheelchair accessory, hand control interface, multiple mechanical switches
E2323	Power wheelchair accessory, specialty joystick handle for hand control
E2324	Power wheelchair accessory, chin cup for chin control interface
E2313	Power wheelchair accessory, harness for upgrade to expandable controller
E2326	Power wheelchair accessory, breath tube kit for sip and puff interface
E2327	Power wheelchair accessory, head control interface, mechanical, proportional

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Additional Power Wheelchair Batteries & ComponentsHCPCSCovered

E2358	Power wheelchair accessory, group 34 nonsealed lead acid battery, each
E2362	Power wheelchair accessory, group 24 non-sealed lead acid battery, each
E2360	Power wheelchair accessory, 22 nf non-sealed lead acid battery, each

Orthoses & Prosthetic Component CodesHCPCSCovered

L0632	LSO, sagittal control, with rigid anterior and posterior panels
L0999	Add To Spinal Orthosis Nos
L2034	KAFO, full plastic, single upright, with or without free motion knee

Upper Extremity Prosthetics & Add-onsHCPCSCovered

L6026	Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended
L6677	Upper extremity addition, harness, triple control
L6715	Terminal device, multiple articulating digit, includes motor(s)

Representative Surgical CPT Codes Requiring PACPTCovered

61885	Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Single Electrode Array
61886	Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection 2+ Electrode Arrays
61889	Insertion of skull-mounted cranial neurostimulator pulse generator or receiver

Selected J-codes & Specialty Drugs Requiring PAHCPCSCovered

J3393	Injection, betibeglogene autotemcel, per treatment
J3394	Injection, lovotibeglogene autotemcel, per treatment
J3392	Injection, exagamglogene autotemcel, per treatment

Immune Globulins & Factor Products (Selected)HCPCSCovered

J1569	Injection, immune globulin, (Gammagard liquid), nonlyophilized, 500 mg
J7198	Anti-Inhibitor
J7195	Factor IX (antihemophilic factor, recombinant) per IU

Selected J-codes (Additional)HCPCSCovered

J7311	Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg
J7312	Injection, dexamethasone, intravitreal implant, 0.1 mg
J7313	Injection, fluocinolone acetonide, intravitreal implant (Iluvien), 0.01 mg

Cell & Gene Therapy Q-codes (Selected)HCPCSCovered

Q2042	Tisagenlecleucel, up to 600 million CAR-positive viable T cells, per therapeutic dose
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, per therapeutic dose

Selected Molecular Pathology & Genomic Panel CodesCPTCovered

81449	Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes
81310	NPM1 gene analysis, exon 12 variants
81202	APC gene analysis; known familial variants

Provider Actions & Billing Impact

Documentation Required

Medicaid procedure code listings (NY)

Medicaid procedure codes and short descriptions for New York are listed (examples include dental codes D7996, D7946, D7947 and radiation guidance code 77387).

D7996 — Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report
D7946 — LeFort I (maxilla - total)
D7947 — LeFort I (Maxilla - Segmented)
77387 — Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed

Documentation Required

Medicaid procedure code list (NY)

Additional Medicaid procedure codes and brief descriptions for New York are enumerated (examples include vascular study 93922, CPAP accessories A7029/A7037 and duplex scan 93978).

93922 — Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries
A7029 — Nasal pillows for combination oral/nasal mask, replacement only, pair
A7037 — Tubing Used With Positive Airway Pressure Device
93978 — Duplex Scan, Aorta/IVC/Iliac Vasculature; Complete Study
A7046 — Water chamber for humidifier, replacement, each

Prior Authorization

Items and services requiring prior authorization (Medicaid - NY)

The document enumerates items and services that require prior authorization for New York Medicaid; providers must obtain prior authorization for the listed procedures and services before billing or rendering them.

Spine procedures (e.g., 63040, 63267, 63075, 63048, 63056, 63001, 63051)
Coronary/percutaneous procedures (e.g., 92924, C9607, 75580)
Orthopedic revision and other complex surgical procedures (e.g., 27486, 23412)

Prior Authorization

Prior authorization required — code list (fragment)

This fragment lists specific items and services requiring prior authorization (examples include complex radiation planning and proton delivery codes).

76965 — Modulated Radiotherapy Plan W/Dose Volume Histograms
77318 — US Guided, Interstitial Radioelement Application
77316 — Brachytherapy isodose plan; simple
77520 — Proton Treatment Delivery; Simple W/O Compensation
19297 — Placement of radiotherapy afterloading expandable catheter into the breast

Prior Authorization

Prior authorization required — drugs and injections

Drugs and injectable agents (J-codes/Q-codes) listed require prior authorization for NY Medicaid; providers must secure PA prior to administration/billing.

J7353 — Anacaulase-bcdb, 8.8% gel, 1 gm
J9298 — Injection, nivolumab and relatlimab-rmbw, 3 mg/1 mg
J9325 — Injection, talimogene laherparepvec, per 1 million PFU
J9348 — Injection, naxitamab-gqgk, 1 mg

Prior Authorization

Prior authorization required — procedures and DME

Additional procedures and durable medical equipment entries are included in the PA list; providers must obtain prior authorization for these DME and procedure codes before supplying or billing them.

0418T — Interrogation device evaluation with analysis/report, implantable cardiac contractility modulation system
33477 — Transcatheter pulmonary valve implantation, percutaneous approach
33366 — Transcatheter aortic valve replacement (TAVR/TAVI)
E0942 — Cervical Head Harness/Halter

Prior Authorization

Prior Authorization required codes (excerpt)

This excerpt lists many procedure and supply codes that require prior authorization for NY Medicaid (examples include J1756 and other specialty J-codes); providers must obtain PA for the listed HCPCS/CPT codes.

J1756 — Antihemophilic factor, recombinant (example listed)
J1830 — Injection, interferon beta-1b
J1932 — Injection, lanreotide, 1 mg
J2356 — Injection, tezepelumab-ekko, 1 mg

Prior Authorization

Prior Authorization required codes (procedures)

Selected surgical and radiologic procedure codes require prior authorization; providers should secure PA before performing or billing these complex procedures.

36903 — Introduction of needle(s)/catheter(s), dialysis circuit, with diagnostic angiography; with transcatheter stent placement
76120 — Cineradiography/Videoradiology
33975 — Insertion, Ventricular Assist Device; Extracorporeal, Single Ventricle
37788 — Penile Revascularization, Artery, W/Wo Vein Graft
53453 — Periurethral transperineal adjustable balloon continence device; removal

Prior Authorization

DME/power wheelchair prior authorization

Durable medical equipment including power wheelchairs and related K-codes require prior authorization for NY Medicaid; providers must obtain PA before dispensing these items.

K0836 — POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION
K0855 — POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY
K0856 — POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION
K0864 — POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION
K0869 — POWER WHEELCHAIR, GROUP 4 STANDARD

Prior Authorization

Drug/injectable prior authorization

Pharmaceutical and specialty injectable codes (J/Q codes and biosimilars) listed require prior authorization for NY Medicaid; providers must secure PA before administration or claim submission.

J7173 — Injection, concizumab-mtci, 0.5 mg
J7174 — Injection, fitusiran, 0.04 mg
J7356 — Injection, foscarbidopa/foslevodopa
Q5155 — Injection, aflibercept-jbvf (biosimilar), 1 mg
Q5154/Q5156/Q5157 — Biosimilar injections (examples listed)

Prior Authorization

Prior Authorization Required Codes (excerpt)

This excerpt reiterates that a comprehensive list of procedure and HCPCS codes require prior authorization for NY Medicaid; providers must follow PA requirements for the codes shown.

77525 — Proton Treatment Delivery; Complex
J7173 — concizumab-mtci injection
J7174 — fitusiran injection
Q5155 — aflibercept-jbvf (biosimilar)

Note

Updated codes (list revision date)

Sections marked 'Updated : 2/11/2026' indicate the prior authorization list was refreshed on that date; providers should use the updated list when determining PA requirements.

Updated : 2/11/2026 — denotes refreshed additions to the NY Medicaid PA list

Prior Authorization

Prior authorization required codes (NY Medicaid)

This NY Medicaid PA list segment enumerates procedure and HCPCS codes that require prior authorization; providers must obtain PA for these items prior to service.

36471 — Injection of sclerosant; multiple incompetent veins
36901/36902 — Introduction of needle(s)/catheter(s), dialysis circuit with diagnostic angiography (with/without transluminal balloon angioplasty)
99600 — Unlisted Home Visit Service/Procedure
A0430/A0431 — Fixed/Rotary Wing Air Transport

Prior Authorization

Prior authorization required — selected wheelchair/accessory codes

Selected wheelchair accessories and pediatric seating components (HCPCS E-codes) require prior authorization; providers must obtain PA before supplying these accessories.

E2228 — Manual wheelchair accessory, wheel braking system and lock, complete, each
E2291 — Planar back for pediatric size wheelchair
E2292/E2293/E2294 — Planar/contour seats and backs for pediatric wheelchairs
E2310/E2311/E2312 — Power wheelchair accessories and hand/chin control interfaces

Prior Authorization

Prior authorization required — infusion/transplant codes

Infusion and transplant procedure codes are listed as requiring prior authorization; providers should secure PA for home infusion visits, bone marrow harvest and HPC transplantation services before rendering them.

G0090 — Initial visit for administration of IV chemotherapy or highly complex infusion in home, per 15 min
G0088 — Initial visit for administration of other IV infusion in home, per 15 min
38230/38232/38240/38241 — Bone marrow and hematopoietic progenitor cell harvesting/transplantation codes

Prior Authorization

Prior authorization required — high-cost drugs, DME, implants, endovascular

High-cost drugs, custom DME, implantable devices and complex endovascular procedures are flagged for prior authorization; providers must obtain PA prior to providing these high-cost items or procedures.

J3399 — Injection, onasemnogene abeparvovec-xioi, per treatment
K0008 — Custom manual wheelchair/base
64582 — Open implantation of hypoglossal nerve neurostimulator array
C9766/C9772 — Revascularization with intravascular lithotripsy (lower extremity)

Prior Authorization

Prior authorization required codes (excerpt)

This excerpt lists numerous items and services requiring prior authorization for NY Medicaid; providers must reference the list when determining PA obligations for specific codes.

L5999 — Lower Extremity Prosthesis NOS
L6026 — Transcarpal/metacarpal or partial hand prosthesis, external power
L6677/L6880 — Upper extremity prosthetic additions and electric hand devices
21086 — Impression & Custom Preparation; Auricular Prosthesis

Prior Authorization

Prior Authorization list (NY Medicaid) — excerpt

The PA list includes procedure and drug codes applicable to NY Medicaid; providers must obtain prior authorization for the listed items before provision or billing.

54410/54411/54440 — Procedures for penile prosthesis removal/replacement
55881 — Transurethral ablation of prostate tissue using thermal ultrasound
61630/61715/61864 — Intracranial balloon angioplasty, MRI-guided focused ultrasound, burr hole craniotomy with implantation of electrode array

Note

Prior Authorization list update note

The prior authorization list was updated on 2/11/2026; providers should rely on the version dated 'Updated : 2/11/2026' for current PA requirements.

Updated : 2/11/2026 — continued list of procedure and injection codes requiring prior authorization

Prior Authorization

Prior Authorization Required Codes (excerpt)

Multiple factor and clotting factor J-codes require prior authorization for NY Medicaid; providers must obtain PA prior to administering or billing these products.

J7195 — Factor IX (antihemophilic factor, recombinant) per IU
J7200 — Injection, factor IX, rixubis, per IU
J7201 — Injection, factor IX, Fc fusion protein (Alprolix), 1 IU
J7202/J7203/J7205/J7207 — Additional factor VIII/IX related J-codes listed

Prior Authorization

Prior Authorization Required — NY Medicaid (partial list)

This partial excerpt lists items and services that require prior authorization for NY Medicaid; providers must secure PA for the specific codes shown before service.

30999 — Unlisted Procedure, Nose
E0986 — Manual wheelchair accessory, push-rim activated power assist, each
55865 — Exposure, Prostate, Any Approach, Radiation Insertion; W/Bilat Pelvic Lymphadenectomy
0408T–0416T — Cardiac contractility modulation system insertion/removal/replacement related codes

Prior Authorization

Prior Authorization Required — Selected Procedures and Genetic Tests

Selected procedures and molecular/genetic test codes are identified as requiring prior authorization for NY Medicaid; providers must obtain PA for molecular pathology and genetic testing codes listed.

Selected procedural codes (e.g., implantation of neurostimulator electrodes, 55862)
81330, 81164, 81405, 81296, 81521 — Molecular/genetic testing codes requiring PA (examples shown)
81244, 81352, 81336, 81307 — Additional gene analysis codes listed

Prior Authorization

Molecular/genetic tests require prior authorization

Molecular and genetic testing codes (examples include 81255, 81254, 81253, 81407, 81240, 81241) require prior authorization under NY Medicaid; providers must secure PA before ordering or billing these tests.

81255 — Alpha thalassemia gene analysis; common deletions or variants
81254 — HEXA gene analysis (Tay-Sachs) common variants
81253 — GJB6 gene analysis common variants
81407 — Molecular Pathology Procedure Level 8
81240 — F2 gene analysis (Prothrombin 20210G>A)
81241 — F5 gene analysis (Coagulation Factor V)

Prior Authorization

Advanced imaging and PET/CT require prior authorization

Advanced imaging including PET/CT, CT and MRI procedure codes require prior authorization for NY Medicaid; providers must obtain PA and note PET/CT fusion reporting guidance where applicable.

78816/78814/78815 — PET/CT and concurrently acquired PET/CT imaging codes (fusion guidance provided)
70488/70491/71270 — CT maxillofacial/soft tissue neck/thorax with and without contrast
73722/75561 — MRI joint and cardiac MRI codes requiring PA

Prior Authorization

Cardiac and head/neck imaging require prior authorization

Echocardiography, CT and MRI head/neck/maxillofacial imaging procedure codes require prior authorization for NY Medicaid; providers must secure PA before performing or billing these imaging services.

93308 — Echocardiography, transthoracic, real-time with image documentation (2D)
70544/70547/70555 — MRA/MRI head/neck and functional MRI brain codes
70496/70498/72148 — CT angiography of head/neck and MRI lumbar spine-related codes

Prior Authorization

Nuclear cardiology and echocardiography require prior authorization

Nuclear cardiology procedures (SPECT/PET), cardiac blood pool imaging and transthoracic/transesophageal echocardiography codes are listed as requiring prior authorization; providers must obtain PA before these cardiac imaging services.

78453/78494/78492/78491 — Myocardial perfusion and cardiac blood pool imaging (SPECT/PET)
78459/78454/78452 — Myocardial perfusion imaging (SPECT) codes
93306/93314/93313 — Echocardiography transthoracic and transesophageal procedure codes requiring PA

Prior Authorization

Prior Authorization - select imaging/nuclear medicine codes

Selected imaging and nuclear medicine procedure codes (including CT, MRI, PET/CT and SPECT codes) require prior authorization for NY Medicaid; providers must obtain PA for these listed imaging services.

73723 — CT abdomen with contrast
78453/78494/78492/78491 — Cardiac/nuclear imaging codes
73722 — MRI any joint, lower extremity; with contrast

Prior Authorization

Prior Authorization - echocardiography and cardiac imaging

Echocardiography and other cardiac imaging procedure codes listed (e.g., 78468, 78466, 93306, 93314, 93313) require prior authorization for NY Medicaid; obtain PA prior to service.

78468/78466 — Myocardial imaging infarct-avid planar techniques
78459 — Myocardial PET metabolic evaluation
93306/93314/93313 — Echocardiography transthoracic and transesophageal codes

Prior Authorization

Prior Authorization - transesophageal and transthoracic echocardiography

Transesophageal and transthoracic echocardiography procedure codes (93312, 93307, 93316, 93304, 93303, 93351, 93315, 93317) require prior authorization; this section is marked 'Updated : 2/11/2026'.

93312 — Echocardiography, transesophageal, real-time with image documentation (2D), including
93307 — Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode
93316/93315/93317 — Transesophageal echocardiography congenital anomaly related codes

Prior Authorization

Prior Authorization - PET/CT and nuclear medicine

PET/CT and related nuclear medicine procedure codes and descriptions require prior authorization for NY Medicaid; the document provides PET/CT vs CT/PET descriptive guidance and reporting code references.

76390 — MR Spectroscopy
78811/78812/78813/78814/78815/78816 — PET imaging and concurrently acquired PET/CT imaging codes with guidance on fusion reporting
78609/78608 — Brain PET perfusion/metabolic evaluation

Definitions & Notes

Medicaid Procedure Code Description (examples)

JurisdictionMedicaid, State = NY

Example codeD7996 — Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report

Other examplesD7946 (LeFort I - maxilla total), D7947 (LeFort I - segmented)

Procedure code description (sample)

JurisdictionMedicaid, State = NY

Example code93922 — Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries

Additional examplesA7029 (Nasal pillows), A7037 (CPAP tubing), 93978 (Duplex Scan, Aorta/Iliac)

Prior Authorization — short label

LabelPrior Authorization (PA) list

DefinitionAn enumerated list of items and services that require prior authorization before provision or payment.

Document markerAppears under heading 'List of items and service that require Prior Authorization'.

Prior Authorization (PA) requirement

RequirementCertain listed items and services must receive prior authorization before they are provided or billed for Medicaid (NY).

ScopeApplies to procedure, CPT/HCPCS, molecular/genetic and DME codes enumerated in the list for State = NY.

EvidenceMultiple list entries and code blocks marked 'List of items and service that require Prior Authorization' and 'Updated : 2/11/2026'.

PA listing label

Listing labelList of items and service that require Prior Authorization

ContentEnumerates procedure codes, HCPCS/J-codes, DME and molecular/genetic tests that require PA for NY Medicaid.

Usage noteProviders must consult the list for state-specific PA applicability before rendering services.

List update date

List update dateUpdated : 2/11/2026

MeaningIndicates the PA list was revised or refreshed on this date.

AppearanceThe 'Updated : 2/11/2026' marker appears adjacent to multiple list sections and code entries.

Jurisdiction

JurisdictionMedicaid — State = NY

ApplicabilityAll codes and services in the extracted list are specific to New York Medicaid.

Provider actionProviders billing NY Medicaid should follow the NY-specific PA requirements listed.

Prior Authorization — descriptive note

Requirement summaryCertain listed services or items must obtain prior authorization before provision; the list enumerates the affected codes.

IncludesProcedure codes, HCPCS/J-codes, molecular/genetic tests, DME, imaging and others as listed for NY Medicaid.

ReferenceSee the 'List of items and service that require Prior Authorization' sections for code details and examples.

Prior Authorization — payer approval requirement

DefinitionPrior Authorization: certain listed procedure and HCPCS codes must obtain approval from the payer before services are rendered or billed.

ExamplesIncludes dialysis circuit angiography codes (36901–36908), wheelchair accessory codes (E22xx), and imaging codes (73723, 78814–78816).

Provider implicationClaims submitted without required PA may be denied or delayed under NY Medicaid rules.

Prior Authorization list — definition entry

DefinitionPrior Authorization list: an enumerated compilation of items and services that require prior authorization for NY Medicaid.

FormPresented as repeated 'List of items and service that require Prior Authorization' sections with code descriptions.

ActionUse this list to determine which codes require PA prior to service delivery.

Updated date (list revision)

Updated dateUpdated : 2/11/2026

InterpretationMarks the revision date for the adjacent PA list entries and code sections.

LocationAppears at the top of multiple list fragments throughout the document excerpt.

Medicaid, State (applicability)

Medicaid, StateNY (New York)

ScopeAll enumerated PA requirements and procedure code descriptions in this extract apply specifically to New York Medicaid.

EvidenceEach code entry is prefaced with 'Medicaid, State = NY' in the source text.

Prior Authorization — procedure and genetic test codes

RequirementPrior Authorization: listed procedure and molecular/genetic test codes must obtain PA before services are rendered for NY Medicaid.

Includes molecular/genetic testsExamples such as 81330, 81164, 81405 are listed and require PA.

Provider noteProviders ordering genetic or molecular pathology tests for NY Medicaid should verify PA requirements prior to testing.

Adaptive behavior services (CPT 97153–97158)

Code groupAdaptive behavior services (CPT 97153–97158)

DescriptionAdaptive behavior treatment by protocol and related assessment/therapy codes are included in the PA list for NY Medicaid.

Examples97153 (adaptive behavior treatment by protocol), 97155 (adaptive behavior treatment with protocol modification).

Molecular/genetic testing codes (examples)

Examples81164, 81330, 81405 are cited as molecular/genetic testing codes requiring PA in the NY Medicaid list.

ContextThese entries appear in the molecular/genetic test sections of the PA list and are state-applicable (NY).

ImplicationGenetic testing orders for Medicaid members in NY should be checked for PA prior to testing.

Prior Authorization (PA) — definition covering procedure and genetic test codes

DefinitionPrior Authorization (PA): a requirement that certain listed procedure and test codes obtain approval from the payer before services are rendered or billed.

ScopeApplies to procedure codes, HCPCS/J-codes, DME, imaging and molecular tests listed for NY Medicaid.

ConsequenceFailure to obtain PA may result in claim denial or delayed payment under NY Medicaid rules.

PET/CT — short definition

Short definitionPET/CT — fused imaging combining positron emission tomography and computed tomography for metabolic and anatomical correlation.

PurposePET provides metabolic imaging; CT provides anatomical imaging; fused PET/CT improves localization and interpretation.

Reporting codesConcurrent acquisition/reporting codes referenced in list include 78814, 78815, 78816 (concurrently acquired PET/CT).

Drug metabolism genomic sequence analysis panel (81418)

Code81418 — Drug metabolism genomic sequence analysis panel

Panel requirementMust include testing of at least 6 genes including CYP2C19 and CYP2D6 and CYP2D6 duplication/deletion.

ContextListed under molecular/genetic procedures requiring prior authorization for NY Medicaid.

PET/CT description

DescriptionPET/CT fusion: PET detects positron-emitting radionuclides (metabolic imaging) and CT provides detailed anatomical cross-sectional images; fused PET/CT combines metabolic and anatomical data for precise localization.

UtilityFusing PET with CT corrects PET spatial resolution limitations by providing anatomical correlation.

Coding guidanceConcurrent acquisition/reporting codes referenced include 78814 (limited area), 78815 (skull base to mid-thigh), 78816 (whole body).

OpenPayer

Medicaid Procedure Code List — New York (prior-authorization code excerpts)

Coverage & Prior Authorization Criteria

Procedure & Billing Codes (Samples)

Provider Actions & Billing Impact

Definitions & Notes

Revision History & Update Notes