Medicaid Procedure Code List — New York (prior-authorization code excerpts)
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This document section lists Medicaid procedure codes and brief descriptions (New York state) used for mapping or reference in reimbursement/payment policies; it affects claims coding and billing for NY Medicaid.
No material clinical or coverage changes in this revision.
Coverage & Prior Authorization Criteria
Prior Authorization Required — Code List (partial)
Prior Authorization Required — Code List (partial). The following procedure and supply codes require prior authorization for Medicaid members in New York (state = NY). This is a consolidated excerpt; all listed codes require prior authorization.
Procedure & Billing Codes (Samples)
| 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 |
| 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 |
| 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) |
| 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 |
| 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 |
| 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 |
Provider Actions & Billing Impact
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
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
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.
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).
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.
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.
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.
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
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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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 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.
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.
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.
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)
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.
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.
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.
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.
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.
Definitions & Notes
Revision History & Update Notes
Prior authorization code list for NY Medicaid was updated (sections marked 'Updated : 2/11/2026' indicate refreshed additions to the PA list).
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