Listed below are codes for items and services that require prior authorization. This list is a partial excerpt of the full policy and includes CPT, HCPCS, and other Medicare procedure codes with brief descriptions. Codes are grouped into related clusters (therapy modalities; DME, orthotics/prosthetics, wheelchairs and accessories; home health/hospice G-codes; medications and biologics; complex procedures and devices; advanced diagnostics and molecular testing; surgical and implant procedures).
Medicare Procedure Code = 97012: Application of a modality to 1 or more areas; traction, mechanical.
Medicare Procedure Code = 90912: Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, initial 15 minutes one-on-one.
Medicare Procedure Code = 92507: Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
Medicare Procedure Code = 97110: Therapeutic procedures, 1+ areas, each 15 min; therapeutic exercises.
Medicare Procedure Code = 97113: Aquatic therapy with exercises, each 15 min.
Medicare Procedure Code = 97124: Massage, each 15 min.
Medicare Procedure Code = 97035: Application of ultrasound, each 15 min.
Medicare Procedure Code = 97032: Electrical stimulation (manual), each 15 min.
Medicare Procedure Code = 97542: Wheelchair management (assessment, fitting, training), each 15 min.
Medicare Procedure Code = 97537: Community/work reintegration training, direct one-on-one, each 15 min.
Medicare Procedure Code = 97535: Self-care/home management training, direct one-on-one, each 15 min.
Medicare Procedure Code = 97530: Therapeutic activities, direct one-on-one, each 15 min.
Medicare Procedure Code = 97150: Therapeutic procedures, group (2+ individuals).
Medicare Procedure Code = E0483: High frequency chest wall oscillation system, includes accessories and supplies, each.
Medicare Procedure Code = E0447: Portable oxygen contents, liquid, 1 month's supply (prescribed amount at rest/night exceeds 4 LPM).
Medicare Procedure Code = E0604: Breast pump, hospital grade, electric.
Medicare Procedure Code = E0639: Patient lift, moveable from room to room with disassembly/reassembly.
Medicare Procedure Code = E0782: Non-programmable infusion pump.
Medicare Procedure Code = E0770: Functional electrical stimulator, transcutaneous; complete system.
Medicare Procedure Code = E0764: Functional neuromuscular stimulation, transcutaneous sequential muscle groups with computer.
Medicare Procedure Code = E0747: Electrical osteogen stimulator (not spine).
Medicare Procedure Code = E0760: Osteogen ultrasound stimulator.
Medicare Procedure Code = E0955: Wheelchair accessory, headrest, cushioned, prefabricated, each.
Medicare Procedure Code = E0953: Wheelchair accessory, lateral thigh or knee support, including fixed mounting hardware, each.
Medicare Procedure Code = E0951: Loop heel.
Medicare Procedure Code = E0856: Cervical traction device, cervical collar with inflatable air bladder.
Medicare Procedure Code = E0840: Traction device (trimmed/customized to specific patient).
Medicare Procedure Code = E2322: Power wheelchair accessory, hand control interface, multiple mechanical switches.
Medicare Procedure Code = E2321: Power wheelchair accessory, hand control interface, remote joystick.
Medicare Procedure Code = E2311: Power wheelchair accessory, electronic connection between wheelchair controller.
Medicare Procedure Code = E2301: Wheelchair accessory, power standing system, any type.
Medicare Procedure Code = E2294: Contour seat for pediatric size wheelchair.
Medicare Procedure Code = E2295: Manual wheelchair accessory for pediatric size, dynamic seating frame.
Medicare Procedure Code = E2231: Manual wheelchair accessory, solid seat support base (replaces sling seat).
Medicare Procedure Code = E2293: Contour back for pediatric size wheelchair.
Medicare Procedure Code = E2292: Planar seat for pediatric size wheelchair.
Medicare Procedure Code = E2291: Planar back for pediatric size wheelchair.
Medicare Procedure Code = E2228: Manual wheelchair accessory, wheel braking system and lock, complete, each.
Medicare Procedure Code = E2359: Power wheelchair accessory, group 34 sealed lead acid battery, each.
Medicare Procedure Code = E2361: Power wheelchair accessory, group 27 sealed lead acid battery, each.
Medicare Procedure Code = E2369: Power wheelchair component, drive wheel gear box, replacement only.
Medicare Procedure Code = E2368: Power wheelchair component, drive wheel motor, replacement only.
Medicare Procedure Code = E2364: Power wheelchair accessory, U-1 non-sealed lead acid battery, each.
Medicare Procedure Code = E2363: Power wheelchair accessory, group 24 sealed lead acid battery, each.
Medicare Procedure Code = E2371: Power wheelchair accessory, group 27 sealed lead acid battery.
Medicare Procedure Code = E2398: Wheelchair accessory, dynamic positioning hardware for back.
Medicare Procedure Code = E2397: Power wheelchair accessory, lithium-based battery, each.
Medicare Procedure Code = E2396: Power wheelchair accessory, caster fork, replacement only, each.
Medicare Procedure Code = E2391: Power wheelchair accessory, solid caster tire (removable), any size.
Medicare Procedure Code = E2392: Power wheelchair accessory, solid caster tire with integrated ...
Medicare Procedure Code = E2388: Power wheelchair accessory, foam drive wheel tire, any size, replacement only.
Medicare Procedure Code = E2390: Power wheelchair accessory, solid drive wheel tire.
Medicare Procedure Code = E2383: Power wheelchair accessory, insert for pneumatic drive wheel tire (removable).
Medicare Procedure Code = E2633: Wheelchair accessory, addition to mobile arm support, supinator.
Medicare Procedure Code = E1150: Wheelchair standard with leg rests.
Medicare Procedure Code = E1230: Power operated vehicle (scooter).
Medicare Procedure Code = E2203: Manual wheelchair accessory, nonstandard seat frame depth, replacement only.
Medicare Procedure Code = E2326: Power wheelchair accessory, breath tube kit for sip and puff interface.
Medicare Procedure Code = E2312: Power wheelchair accessory, hand or chin control interface, mini-proportional.
Medicare Procedure Code = E0957: Wheelchair accessory, medial thigh support, prefabricated, each.
Medicare Procedure Code = G0151: Services by a qualified physical therapist in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0159: Qualified physical therapist services in home health for maintenance program, each 15 minutes.
Medicare Procedure Code = G0161: Qualified speech-language pathologist services in home health maintenance program, each 15 minutes.
Medicare Procedure Code = G0160: Qualified occupational therapist services in home health maintenance program, each 15 minutes.
Medicare Procedure Code = G0300: Direct skilled nursing services of a licensed practical nurse (LPN) in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0496: Skilled services of an LPN in training/education of patient or family in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0155: Services of clinical social worker in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0495: Skilled services of an RN in training/education of patient or family in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0494: Skilled services of an LPN for observation and assessment of patient's condition, each 15 minutes.
Medicare Procedure Code = G0493: Skilled services of an RN for observation and assessment of patient's condition, each 15 minutes.
Medicare Procedure Code = G0299: Direct skilled nursing services of an RN in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0158: Services by a qualified occupational therapist assistant in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0157: Services by a qualified physical therapist assistant in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0156: Services of home health/hospice aide in home health/hospice, each 15 minutes.
Medicare Procedure Code = E0601: Continuous positive airway pressure (CPAP) device.
Medicare Procedure Code = 77371: Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course cranial lesion(s).
Medicare Procedure Code = J9022: Injection, atezolizumab, 10 mg.
Medicare Procedure Code = J9023: Injection, avelumab, 10 mg.
Medicare Procedure Code = J9203: Injection, gemtuzumab ozogamicin, 0.1 mg.
Medicare Procedure Code = Q5108: Injection, pegfilgrastim-jmdb (Fulphila), 0.5 mg.
Medicare Procedure Code = J9316: Injection, pertuzumab, 1 mg (also J9312, J9313 variants).
Medicare Procedure Code = J9312: Injection, rituximab, 10 mg.
Medicare Procedure Code = Q5122: Injection, pegfilgrastim-apgf (Nyvepria), 0.5 mg.
Medicare Procedure Code = Q5118: Injection, bevacizumab-bvzr (Zirabev), 10 mg.
Medicare Procedure Code = J9207: Injection, ixabepilone, 1 mg.
Medicare Procedure Code = J9281: Mitomycin pyelocalyceal instillation, 1 mg.
Medicare Procedure Code = J9271: Injection, pembrolizumab, 1 mg.
Medicare Procedure Code = J9015: Injection, aldesleukin, per single use vial.
Medicare Procedure Code = J9032: Injection, belinostat, 10 mg.
Medicare Procedure Code = 57155: Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy.
Medicare Procedure Code = 58346: Insertion, Heyman Capsules, clinical brachytherapy.
Medicare Procedure Code = 63621 / 63620: Stereotactic radiosurgery for spinal lesions (codes for 1 and additional lesions).
Medicare Procedure Code = 77373 / 77372: Stereotactic body radiation therapy (SBRT) delivery and SRS delivery.
Medicare Procedure Code = 77338: Multi-leaf collimator device(s) for IMRT design and construction per IMRT course.
Medicare Procedure Code = 77317-77318: Brachytherapy isodose plan (simple/intermediate/complex) dosimetry codes.
Medicare Procedure Code = 77522 / 77525: Proton treatment delivery codes.
Medicare Procedure Code = 22870: Insertion of interlaminar/interspinous process stabilization/distraction device, lumbar; second level.
Medicare Procedure Code = 0350T: Radiostereometric analysis (RSA) lower extremity(s).
Medicare Procedure Code = 0864T: Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy.
Medicare Procedure Code = 0565T: Autologous cellular implant derived from adipose tissue for treatment of knee osteoarthritis; harvesting and implant creation.
Medicare Procedure Code = 0546T: Radiofrequency spectroscopy, intraoperative margin assessment at partial mastectomy.
Medicare Procedure Code = 63082 / 63091: Vertebral corpectomy add-on segments, thoracic/lumbar.
Medicare Procedure Code = 77261-77799 (selected): Special and complex radiation therapy related procedure codes requiring prior authorization.
Medicare Procedure Code = 19297-19298: Placement of radiotherapy afterloading brachytherapy catheters into the breast for interstitial radioelement application.
Medicare Procedure Code = 32701: Thoracic target delineation for SBRT, entire course.
Medicare Procedure Code = 67218: Destruction of localized lesion of retina by implantation radiation.
Medicare Procedure Code = 76965 / 77338 / 77316-77318: Ultrasound guidance and brachytherapy planning codes.
Medicare Procedure Code = 77338 / 77317 / 77316: IMRT/ brachytherapy planning and MLC device codes.
Medicare Procedure Code = 19297 / 19298 / 32701 / others: Selected radiation and complex oncology procedure codes.
Medicare Procedure Code = J1459: Injection, triptorelin pamoate, 3.75 mg.
Medicare Procedure Code = J9295: IV immune globulin (Privigen), 500 mg.
Medicare Procedure Code = J9306 / J9349 / J9316 / others: Multiple oncology and biologic drug codes listed.
Medicare Procedure Code = J9204 / J1627 / J9153 / J0185 / J9311: Additional injectable oncology/antiemetic agents.
Medicare Procedure Code = J2506 / J9119 / J9229 / J9264 / J1559: Further oncology/immunologic injectables.
Medicare Procedure Code = J0888 / J1442 / J1552 / J9345 / J9266 / J9308: Biosimilars and specialty injectables included.
Medicare Procedure Code = J9039 / J9057 / J9351 / J2354 / J2506: Additional specified injectables requiring prior authorization.
Medicare Procedure Code = Q5114 / Q5113 / Q5112 / Q5110 / Q5117 / Q5111: Various biosimilar pegfilgrastim and trastuzumab products.
Medicare Procedure Code = J9039 / J9057 / J9351 / J2354: Blinatumomab, copanlisib, topotecan, octreotide (non-depot) included.
Medicare Procedure Code = J9266 / J9308 / Q5135 / others: Multiple oncology therapeutics and newer agents.
Medicare Procedure Code = 22843 / 22630 / 22854 / 22110 / others: Complex spinal and fusion procedures, implants and instrumentation.
Medicare Procedure Code = 29770-29999 (selected): Complex arthroscopy and orthopedic surgical procedures requiring authorization.
Medicare Procedure Code = Q4111 / Q4185 / Q4167 / Q4177 / Q4159: Cellular and amniotic membrane products per square centimeter (advanced wound products).
Medicare Procedure Code = 64493 / 64491 / 64492 / 64494 / 64495: Paravertebral facet joint injections with image guidance (levels and add-on codes) requiring authorization.
Medicare Procedure Code = 0910T / A2013 / 0913T / 93456 / 15775: Various advanced procedures and grafts requiring authorization.
Medicare Procedure Code = 93458 / 0718T / 63685 / 22595 / 23473 / 72158 / 72196: Cardiac, neurostimulator, spinal implant, MRI and complex device/procedure codes.
Medicare Procedure Code = 29821 / 29874 / 27137 / 64575 / 29874 / 27403 / 29876: Arthroscopy, revision arthroplasty and other major orthopedic procedures.
Medicare Procedure Code = K1027: Oral device/appliance used to reduce upper airway collapsibility, custom fabricated, includes fitting and adjustment (sleep apnea oral appliance).
Medicare Procedure Code = 33278 / 33279 / 33289: Phrenic nerve stimulator removal and related device codes.
Medicare Procedure Code = 72133 / 72128 / 70555 / 70543 / 70553 / 70543: Complex neuroimaging MRI/CT codes requiring authorization for specific studies.
Medicare Procedure Code = 29805 / 29806 / 29807 / 29820 / 29822 / 29823 / 29874 / 29876 / 29879 / 29881-29885: Shoulder and knee arthroscopy and related surgical procedure codes requiring prior authorization.
Medicare Procedure Code = 31242 / 31243: Nasal/sinus endoscopy with posterior nasal nerve destruction (radiofrequency or cryoablation).
Medicare Procedure Code = 72500-79999 (selected): High-complexity imaging, interventional, and procedural codes included across the list.
Medicare Procedure Code = 93150 / 93151 / 93152: Therapy activation and interrogation/programming of implanted phrenic nerve stimulator system.
Medicare Procedure Code = 0778T / 0770T: Surface mechanomyography (sMMG) and virtual reality technology to assist therapy.
Medicare Procedure Code = 93312 / 93313 / 93314 / 93317: Transesophageal echocardiography and congenital cardiac echocardiography requiring authorization.
Medicare Procedure Code = 42100-79999: Additional advanced surgical, implant, and device codes listed throughout the source excerpt.
note: This section is a partial excerpt from the payer's comprehensive prior authorization code list (effective 2026-02-11). Providers should reference the full policy/code list for complete details, code modifiers, and any member- or service-specific conditions that apply.