Prior Authorization List — Medicare HCPCS/E-codes

This document lists Medicare procedure codes (HCPCS/E-codes) and descriptions for items and services that require prior authorization.

Prior Authorization Requirement — listed HCPCS codes

Prior authorization is required for the procedure (HCPCS/Medicare) codes and descriptions listed in this section; providers must obtain authorization prior to service for coverage to be considered.

Power wheelchair prior authorization

Power wheelchairs and power mobility device codes listed (K0-series) require prior authorization.

• Examples include K0820, K0814, K0807, K0808 (power wheelchair/POV group codes).

Durable medical equipment and wheelchair accessories - prior authorization

Durable medical equipment and wheelchair accessories (E- and L-codes shown) require prior authorization when billed for members.

• Examples include E1036, E1220, E2294, L1970 (DME and wheelchair accessory entries).

Power wheelchair prior authorization

Power wheelchairs across multiple groups and weight capacities require prior authorization; include documentation of patient weight capacity and component needs.

• Includes Group 1–3 and extra/very heavy duty entries (e.g., K0813, K0849, K0858, K0828).
• Provider documentation should support weight capacity and selected component features.

Therapy services prior authorization

Various therapy procedure codes and functional assessments (CPT therapy/modality codes) require prior authorization according to this list.

• Examples include 97110, 97116, 97530, 97129, 97035, 97542 (therapeutic exercises, gait training, therapeutic activities, wheelchair management).
• Modalities such as ultrasound (97035) and biofeedback (90913/90912) are included.

Genetic/molecular testing prior authorization

Selected molecular/genetic tests reported with U-codes require prior authorization.

• Examples include 0162U (Hereditary colon cancer mRNA panel), 0071U/0072U/0074U/0075U (CYP2D6 analyses).

Miscellaneous devices and therapeutic services

Whirlpool and speech-generating device therapeutic services and accessories are included in the list of items requiring prior authorization.

• Examples: 92609 (therapeutic services for speech-generating device), speech-generating device E2508/E2506 entries.

Modalities and genomic/onco testing

Numerous modalities (biofeedback, sensory integration) and a large set of genomic and oncology-related U-codes require prior authorization as listed.

• Modalities include 97533 (sensory integrative techniques), 90912 (biofeedback); genomic examples include 0242U, 0239U, 0307U and others in the U-code series.

Hereditary and cytogenomic testing

Established hereditary and cytogenomic testing codes are listed as requiring prior authorization.

• Examples include BRCA and CFTR entries (81162, 81223), cytogenomic microarray (81229, 81228), FMR1 (81244), HEXA (81255).

Genetic test codes requiring prior authorization (sample)

Specific Medicare procedure codes for gene analyses (sample list) require prior authorization.

• Sample codes: 81221, 81222, 81220, 81200, 81195, 81229, 81228, 81244, 81255.

Noninvasive prenatal and advanced genomic sequencing codes

Noninvasive prenatal testing (NIPT), fetal aneuploidy panels, and advanced rapid/ultra-rapid genome sequencing codes require prior authorization.

• Examples include 81420 (fetal aneuploidy NIPT), 0426U/0425U (ultra-rapid/rapid genome sequence analysis).

Tumor and pharmacogenomic panel codes

Tumor and pharmacogenomic panel codes, cell-free genomic panels, and molecular pathology procedure levels listed require prior authorization.

• Examples include 81455/81458/81459 (solid organ neoplasm panels), 81418 (pharmacogenomics panel), and high‑content NGS oncology panels (0391U, 0333U).

Genomic/exome and diagnostic panels

Prior authorization is required for specified genomic/exome panels and related sequencing procedures as listed.

• Examples include 81419 (epilepsy genomic panel), 81415/81416/81417 (exome analyses and comparators).

Genome and targeted panels

Prior authorization is required for genome-level analyses, targeted panels, and specialized rare-disease testing entries shown.

• Examples include 81426/81427 (genome analyses and re-evaluation), 0215U/0214U (whole exome/mitochondrial analyses).

mRNA/gene-expression and algorithmic assays

mRNA gene‑expression profiling and related algorithmic/oncology/transplant/reproductive assay codes require prior authorization.

• Examples include 81595 (cardiology transplant mRNA score), 81519 and 81523 (breast oncology expression profiling), 81546 (thyroid mRNA analysis).

Specialty genomic and mapping tests

Various specialty genomic, optical mapping, mRNA/DNA NGS, and noninvasive prenatal tests are listed as requiring prior authorization.

• Examples include 0158U, 0264U, 0299U (optical genome mapping), 0444U, 0532U (rapid whole genome), and multiple specialty U-code assays.

Oncology/transplant/carrier/device entries

Additional oncology, transplant, carrier screening, and device/accessory codes requiring prior authorization are enumerated in the list.

• Examples include 0465U (urothelial methylation PCR), 0449U (carrier screening), 0471U (NTRK translocation analysis).

Cytogenomic, pharmacogenomic, and oncology molecular tests

Cytogenomic, pharmacogenomic, molecular pathology levels, targeted gene analyses, and various oncology-related tests listed require prior authorization.

• Includes molecular pathology procedure levels (e.g., 81404, 81406, 88365) and gene-specific codes (e.g., 81307 PALB2, 81336 SMN1).

Additional tumor/cardiology/molecular assays

Additional tumor profiling, cardiology genetic risk, methylation panels, and other molecular assays require prior authorization as listed.

• Examples include 0471U (KRAS/NRAS PCR variants), 0440U (cardiology SNP panel), 0391U (437-gene oncology NGS).

Genetic / molecular pathology tests prior authorization

Prior authorization is required for listed genetic / molecular pathology tests (example: 0471U NTRK analysis).

• Example code highlighted: 0471U (NTRK translocation analysis).

Home health / hospice services prior authorization

Home health and hospice skilled service G-codes require prior authorization.

• Examples include G0158, G0159, G0299, G0493, G0300 (home health/hospice skilled services billed per 15 minutes).

Injectable drugs prior authorization

Prior authorization is required for listed injectable drug codes (J- and Q-codes).

• Examples include J9204, J9035, J1566, and multiple biosimilar/antineoplastic J/Q codes shown.

Prior authorization required — home health/hospice G-codes

Prior authorization is required for the Medicare home health/hospice G-code services shown (examples: skilled nursing, therapy maintenance).

• Examples include G0299, G0493, G0300, G0156 (home health skilled services).

Prior authorization required — injectable medications (J/Q codes)

Prior authorization is required for listed injectable medications including numerous antineoplastic and immune globulin products (J-, Q-, biosimilar codes).

• Examples include J9035 (bevacizumab), J1566 (immune globulin), Q5101 (bevacizumab-awwb biosimilar) and many others.

Prior authorization required — radiation/brachytherapy procedures

Prior authorization is required for listed radiation therapy and brachytherapy procedure codes, including SRS, SBRT, proton therapy, and brachytherapy planning/delivery codes.

• Examples include 77373, 77372, 77412, 77522, 77778, 61796 (stereotactic radiosurgery).

Prior authorization required — sleep studies

Prior authorization is required for listed sleep study codes including attended and unattended polysomnography and home sleep testing.

• Examples include 95810, 95806, 95782, 95811, G0399 (home sleep test type III).

Code-level prior authorization requirements (examples)

Specific Medicare procedure/HCPCS codes at the code level are listed as requiring prior authorization (examples provided).

• Sample codes called out include 61796, 55874, 77767, 77402, 77387, 0572T.

Sleep study and cardiac device related codes

Additional polysomnography/home sleep test and cardiac device procedure codes require prior authorization.

• Examples include 95810, 95806, 33244, 33241, 0417T, 0418T (cardiac device extraction/programming).

Imaging, echocardiography and coronary intervention codes

Imaging, echocardiography, CT angiography and coronary intervention codes require prior authorization as listed.

• Examples include 73706, 72191, 71275 (CT angiography), 78429 (PET myocardial imaging), 93303/93351 (echocardiography), 92920/92924 (coronary intervention).

DME, sleep accessories and vascular duplex studies

Durable medical equipment, sleep therapy accessories, and duplex vascular studies listed require prior authorization.

• Examples include A7xxx sleep/DME supplies, E0471, E0561/E0562, and vascular duplex codes 93880/93882.

Advanced cardiac and body imaging codes

Advanced cardiac and body imaging codes (CT/MRI/MRA cardiac and abdominal/pelvis imaging and radiostereometric analysis codes) require prior authorization.

• Examples include 75571/75572/75563 (cardiac CT/MRI), 74185/74175, and 0348T-0350T (radiostereometric analysis).

Head/neck and thorax imaging codes

Head/neck CT and MRI codes and multiple thorax/abdomen CT codes are included on the prior authorization list.

• Examples include 70470/70460/70487/70482 series, 70540-70543, 70551-70555 and thorax CT codes listed.

Spine, extremity, pelvis and joint imaging codes

Spine, extremity, pelvis and joint CT/MRI codes require prior authorization as enumerated by Medicare procedure codes in this section.

• Examples include 72133, 72142, 73200-73223, 73700-73725, 74176-74178 and related series.

Imaging procedures (spine/upper extremity)

Prior authorization is required for listed spine/upper extremity imaging procedures as enumerated by Medicare procedure codes.

• Sample codes: 72133, 72142, 72132, 72130, 72127, 73202, 73201, 73200.

Imaging procedures (abdomen/pelvis/lower extremity/breast)

Prior authorization is required for abdominal/pelvic, lower extremity and breast MRI/CT procedures and MR spectroscopy listed here.

• Examples include 73720-73723, 74176-74178, 77049/77047 (breast MRI) and 74150/74160 series.

Cardiac imaging and interventional procedures

Cardiac MR/CT, PET/CT, selected cardiac catheterization and device-related codes require prior authorization.

• Examples include 75565 (cardiac MR flow mapping), 78815/78816 (PET/CT), 92928, 93458 (catheterization/device codes).

Devices and advanced imaging postprocessing

Various implant/device procedures, 3D rendering services, and specialized imaging postprocessing codes require prior authorization.

• Examples include E0491/E0490 (oral neuromuscular devices), 76376/76377 (3D rendering), and multiple T/041xT device procedure codes.

Misc imaging, sleep, and respiratory device codes

Additional imaging modalities, sleep studies, respiratory devices and certain cardiovascular imaging services are included in the prior authorization list.

• Examples include 76380, 77046, 70480, E0470 (respiratory assist device), 95801/95808 (sleep test variants).

Further imaging, cardiac and PAP-related codes

Additional MRI/MRA, PET, echocardiography, PAP interfaces and CT breast/neck/angiography codes require prior authorization as listed.

• Examples include 73225, 70545, 78466, E0485, 0637T (CT breast with 3D rendering), and 93455.

Advanced device implantation and complex cardiac procedures

Various advanced device implantation and complex cardiac procedure codes require prior authorization.

• Examples include 0571T (substernal ICD electrode insertion), 0412T, 0408T, and C9607/C9608 (complex coronary interventions).

Vascular, sleep, cardiac CT/MRI and miscellaneous device codes

Prior authorization is required for vascular, sleep testing variants, cardiac CT/MRI and miscellaneous device codes listed.

• Examples include 95805/95807 (sleep tests), 93922 (vascular duplex), 75573/70486/70553 (cardiac/fetal imaging).

Prior authorization required — code list (partial)

This document segment lists procedure, drug, device, and service codes that require prior authorization (partial list).

Device- and therapy-specific prior authorization notes

Includes non-opioid medical devices and certain complex therapies that require authorization (examples provided).

• Examples include C9763 (cardiac MRI quantification), C9804 (elastomeric infusion pump), G0465 (autologous PRP for diabetic chronic wounds).

Prior authorization requirement (code list)

Prior authorization is required for the items and services identified by Medicare procedure codes and descriptions in this list.

Scope of items (drugs, devices, services)

Multiple drug and device injections, implants, durable medical equipment, and clinical services are included and require prior authorization as listed.

• Examples include J0565 (GLASSIA), J2326 (nusinersen), enteral feeding supply kits (B4034-B4036), and prosthetic implant codes (L8699).

Prior authorization required — Medicare codes (partial)

Lists Medicare procedure codes and associated descriptions that require prior authorization (partial list shown).

• Examples include Q4402 (Amniodefend), J9245 (melphalan), J9326 (telisotuzumab vedotin), Q4400 (Polygon3 membrane).

Prior authorization required — updated codes

Additional Medicare procedure codes and descriptions added/updated on 2/11/2026 require prior authorization.

• Examples include Q4383, Q4385, Q4409, Q4413, C1889 and other updated Q-code entries.

Prior authorization required — high-cost therapies and devices

CAR-T therapies, implantable devices, prosthetic components, and specific injections are listed as requiring prior authorization.

• Examples include Q2053/Q2055 (CAR‑T products), L8680/L8687 (implantable neurostimulator components), J9210 (emapalumab).

Prior authorization required — selected codes

Medicare procedure codes and descriptions listed here are designated as requiring prior authorization (selected examples).

• Sample codes shown: Q2053, Q2055, Q2056, Q2057, Q2058, Q4123, Q4126, L8680, L8687, L8692.

Prior authorization required — biologics and gene therapies

Gene and biologic therapy injections and high-cost specialty medications listed require prior authorization.

• Examples include J3392, J3393, J3394, J3397, J3399 (gene therapy and high-cost injectables).

Prior authorization required — radiopharmaceuticals, supplies

Radiopharmaceuticals, enteral/parenteral supply kits, and device supplies listed require prior authorization.

• Examples include A9590 (iobenguane), A9607 (lutetium therapeutic), B4034-B4036 (enteral feeding supply kits), A4542-A4544 (device supplies).

Procedure codes requiring prior authorization (partial list)

Lists specific Medicare procedure codes and descriptions that require prior authorization (partial procedure code list).

• Includes procedure examples such as 96137, 93701, 93150 (phrenic nerve stimulator activation), and immunoglobulin administration codes.