List of items and services requiring prior authorization
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A payer-managed list of Medicare procedure and supply codes that require prior authorization for coverage decisions; applies to claims/services billed under this policy.
No material clinical or coverage changes in this revision.
Coverage & Prior Authorization Criteria
Prior authorization coverage stance
Codes listed require prior authorization per this document; coverage determinations are subject to prior authorization.
Listed procedures requiring prior authorization (partial list)
Procedures and services listed here require prior authorization.
ALL of the following
Examples include
- Spine surgeries and related procedures (e.g., arthrodesis, osteotomy, laminectomy)
- Non-invasive and implantable neurostimulation devices and related procedures (e.g., vagus nerve stimulator, phrenic nerve stimulator, neurostimulator interrogation)
- Dermal and skin substitute products (e.g., SurgiMend, dermal substitutes)
- Image-guided injection and vertebral augmentation procedures (e.g., percutaneous vertebroplasty, kyphoplasty)
Prior authorization required items (partial list)
Codes listed below require prior authorization per the payer's policy excerpt.
Major categories
- Imaging procedures (MRA, CTA, CT, MRI of head/neck/spine/pelvis)
- Spine surgical procedures (laminotomy, laminectomy, discectomy, decompression)
- Wound products and amniotic/dermal biologic matrices (HCPCS Q-/A-codes)
- Durable medical equipment and implantable devices (power wheelchairs, cochlear implants, neurostimulators)
Listed services requiring prior authorization (excerpt)
Procedures and services listed below require prior authorization:
ANY of the following
- Selected surgical and interventional procedures (arthroscopy, coronary catheterization/angiography, epidural injections)
- MRI/CT imaging of multiple body regions (breast, abdomen, pelvis, spine, extremities)
- Implantable neurostimulator devices and generators
Prior authorization listing (partial)
Procedures listed require prior authorization
Prior authorization requirement (code list only)
Codes listed in this part require prior authorization; clinical criteria and submission instructions are not included in these chunks.
Full list contains many additional CPT/HCPCS/J-codes across surgical procedures, imaging, implants, biologics, wound matrix products; see source document for complete enumerated list.
Prior authorization requirement
Codes listed below require prior authorization before services will be approved for coverage.
ANY of the following
- Select G/Q codes and composite radiation procedure codes requiring prior authorization
Prior authorization requirement (enumeration-only)
Procedure codes enumerated in this segment require prior authorization per the payer's policy list.
ANY of the following
Prior authorization list (partial)
Procedure codes listed below require prior authorization prior to claim/payment.
ANY of the following
- Advanced implantable cardiac systems and related insertion/removal codes
Prior authorization required — code list (partial)
Codes listed below require prior authorization per the payer's policy.
ANY of the following
Prior Authorization Required — Code Listings (examples)
Procedure codes requiring prior authorization (selected entries from document part 11):
ALL of the following
- Environmental and specialized testing codes (e.g., 0394U PFAS panel)
These are examples from part 11; the full part contains many additional entries.
Prior authorization-required services (partial list)
Procedure codes and descriptions requiring prior authorization (partial list — part 12 of 15).
ANY of the following
Prior authorization code list
Codes listed require prior authorization as indicated by the policy list.
ANY of the following
- Selected injectable drug codes (e.g., J0178)
Refer to specific chunks for full code and description entries; entries shown are representative.
Prior Authorization Required - Code Listings (partial)
Codes listed below require prior authorization according to the payer's administrative policy.
ANY of the following
Codes requiring prior authorization (excerpt)
Codes listed below require prior authorization; specific medical necessity criteria and submission requirements are provided elsewhere in the overall policy.
ANY of the following
Providers must consult the full prior authorization document for required documentation, clinical indications, and submission instructions for these codes.
Representative CPT / HCPCS / Procedure Code Examples
| 22632 | Arthrodesis, Post Interbody W/Laminect &/Or Diskect, Prep Interspace, Sngl Intrspc |
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar |
| E0735 | Non-invasive vagus nerve stimulator |
| C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend) |
| 15277 | Application of skin substitute graft to face... first 100 sq cm |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended |
| E0470 | Respiratory assist device, bi-level pressure capability, without backup rate |
| C9600 | Percutaneous transcatheter placement of drug eluting intracoronary stent(s) |
| 72159 | MRA, Spine W/Wo Contrast |
| 70496 | Computed tomographic angiography, head, with contrast |
| 97153 | Adaptive behavior treatment by protocol, technician, per 15 minutes |
| 0894T | Cannulation of liver allograft for normothermic perfusion (prep) and decannulation |
| 0895T | Connection of liver allograft to normothermic perfusion device; initial 4 hours monitoring |
| 0926T | Programming device evaluation (in person) with iterative adjustment |
| J7208 | Injection, factor VIII recombinant, pegylated (jivi), 1 IU |
| L5845 | Knee-Shin System Stance Flexion |
| J7324-J7327 | Hyaluronan or derivative intra-articular injection products |
| J7xxx (multiple) | Injectable biologics and specialty medications listed |
| E2500-E2633 (selected) | Speech generating devices, wheelchair cushions, and accessories |
Provider Requirements & Operational Notes
Prior authorization requirement — general
This document lists Medicare procedure and supply codes that require prior authorization before services will be approved for coverage.
Obtain prior authorization for listed procedures
Providers must obtain prior authorization for the Medicare procedure codes and descriptions listed in this document window prior to performing the service.
Examples of procedures requiring PA
Examples of procedures requiring prior authorization include MRA pelvis, MRA chest, and CT angiography of the chest as listed in the document.
Wound products & biologics require PA
Extensive lists of amniotic/biologic and wound matrix Q- and A-codes require prior authorization; each product is listed with its per-sq-cm or per-cc descriptor.
DME and implantable devices require PA
Durable medical equipment (DME) and implantable device codes (cochlear devices, neurostimulators, enteral/pump supplies) listed in this document require prior authorization.
Neurostimulator procedures require PA
Neurostimulator implantation, removal, revision, interrogation and related procedures (multiple CPT and device codes) require prior authorization.
PET / PET-CT imaging requires PA
PET and PET/CT imaging procedure codes (e.g., 78811–78816 series) require prior authorization; the document includes coding distinctions for limited-area, regional and whole-body PET/CT.
Orthopedics & surgical implants require PA
Orthopedic and surgical implant procedure codes (arthroscopy, capsulorrhaphy, knee arthroplasty/revision and graft matrices) listed require prior authorization.
Devices, spine procedures & injections require PA
Devices (dynamic adjustable devices), spine and shoulder procedures, and injection codes (including neurolytic substances) listed require prior authorization.
Interventional procedures & implantable devices require PA
Interventional procedures (vertebral augmentation, endoscopic procedures), device insertions and monitoring system codes listed require prior authorization.
Cardiac/neuromodulation, biologics & sleep studies require PA
Cardiac/neuromodulation interventions, biologic matrices and sleep study codes (including phrenic nerve stimulator codes and multiple Q-codes) listed require prior authorization.
Sleep medicine & maxillofacial/orthopedic items require PA
Additional sleep medicine CPTs, maxillofacial and orthopedic reconstructive procedure codes (TMJ/mandibular reconstruction, graft matrices, knee prosthesis removal) listed require prior authorization.
Wound matrices, hip & regenerative therapies require PA
Wound matrices, hip revision procedures, autologous and regenerative therapies (including autologous cellular implants) listed require prior authorization.
Remote monitoring, regenerative, ophthalmic & wound healing require PA
Remote monitoring systems, autologous therapies, ophthalmic drainage devices, and select wound healing and bone-substitute injection codes listed require prior authorization.
Prior Authorization — code list (partial)
The document includes a multi-part prior authorization code list; providers must prior authorize services for codes appearing in this list (partial code list shown in the policy).
PA required for listed procedure & drug codes
Prior authorization is required for the listed procedure and drug injection codes in the document; see code entries for each code and description.
Prior authorization required — listed Medicare codes (partial)
This section lists Medicare procedure codes and HCPCS/CPT codes that require prior authorization (partial list shown in the document part).
Advanced procedures & devices require PA
Advanced procedures and device codes (including cardiac contractility modulation systems, transcatheter interventions and other advanced implantable devices) require prior authorization as listed.
Prior Authorization Code List (part 10)
The prior authorization code list (part 10) enumerates items and services that require prior authorization, including Medicare procedure and injection codes.
Prior Authorization — Procedure Code Listings (part 11)
Procedure codes listed in part 11 (multiple CPT/HCPCS entries) require prior authorization; refer to the listed entries for each code and description.
PA required — see listed codes
Prior authorization is required for the procedure codes and descriptions listed throughout this multi-part document; providers must refer to the specific code entries when requesting PA.
Prior Authorization Required — Code List (partial)
This document part lists Medicare/HCPCS procedure codes and descriptions that require prior authorization; providers must obtain authorization for items appearing here.
Power wheelchair / mobility devices require PA
Power wheelchair and mobility device codes (K08xx, K09xx and related entries) are included on the prior authorization list and require authorization prior to provision.
Injectable & intra‑articular products require PA
Various injectable and intra‑articular hyaluronan/derivative products (J7324–J7327 and related J‑codes) require prior authorization as listed.
- J7324–J7327 Hyaluronan intra-articular injection products (listed)
- J7340 Carbidopa/levodopa enteral suspension (listed)
Home health services & communication devices require PA
Home health skilled services and speech generating devices (G0157–G0161, E2500–E2511) listed require prior authorization.
Wheelchair cushions & accessories require PA
Wheelchair cushions, backs and wheelchair accessories (E2602–E2633 and related codes) require prior authorization as listed.
Power wheelchair accessories & components require PA
Power wheelchair accessories and components (E2310–E2386 series) including controllers, batteries, drive motors and tires are listed and require prior authorization.
Key Terms & Definitions
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