Prior authorization required codes (sample)

Selected procedure and HCPCS codes in Part 1 require prior authorization before services are provided or billed. Examples include: 93930 (Duplex scan, upper extremity arteries; complete bilateral study), 0330T (Tear film imaging), 0308T (Insertion of ocular telescope prosthesis), 0513T (Extracorporeal shock wave for wound healing), 0672T (Endovaginal cryogen-cooled RF remodeling), A2023/A2022/A2024 (InnovaMatrix/Resolve Matrix products), 0417T (Programming device evaluation for implantable cardiac contractility modulation), 0379T (Visual field assessment with remote surveillance), and 0350T.

• Provider must obtain prior authorization for the listed procedure/HCPCS codes prior to performing or billing the service.
• This list is an extract (Part 1); refer to the full policy for the complete code set and any clinical prerequisites.

Prior authorization required codes (additional)

Additional procedure codes listed in this section require prior authorization. Examples include polysomnography and sleep studies (95808, 95807, 95806, 95801, 95805, 95810), mechanomyography (0778T), and implantable device procedures (33289, 33287, 33285, 33281, 33276, 33279, 33277, 33278).

• Obtain prior authorization before scheduling or billing sleep studies and the device implantation/replacement procedures shown.
• This extract is partial—consult the full prior authorization list for related codes and details.

Prior authorization required — procedure and supply codes (partial list)

The payer requires prior authorization for the listed procedure and supply CPT codes. Examples in this partial list include facet and epidural injection codes (64493, 64490, 64484, 64479), CT breast (0636T), adenoidectomy/tonsillectomy in children (42835, 42830, 42820), and brain MRI with contrast (70552).

• Prior authorization must be obtained for the specific injection, imaging, and pediatric ENT procedures shown before service delivery or billing.
• Refer to the full policy for additional levels, modifiers, and documentation requirements.

Imaging — prior authorization required

Imaging procedures listed require prior authorization. Notable examples include brain functional MRI (70554), CT thorax (71260), CT/lumbar/cervical spine CTs (72129, 72131, 72126), MRI chest/pelvis/spine entries (71551, 72195, 72156), and PET imaging (78812, 78814, 78815).

• Obtain prior authorization for the specified MRI, CT, and PET procedures prior to performing or billing them.
• Bilateral breast MRI codes (77049) and related breast imaging entries also appear on the list and require authorization.

Devices, implants, genetic tests — prior authorization required

Device implants, neurostimulators, certain genetic tests and related injections require prior authorization. Examples include CFTR gene analysis (81220), intrathecal/epidural drug infusion pump implantation/replacement (62362), neurostimulator electrode implantation (63650, 63655), cochlear device (L8614), and radiofrequency transmitter for sacral neurostimulator (L8684).

• Obtain prior authorization before implantation, replacement, or billing of implantable devices and before ordering listed genetic tests.
• Authorization is required for associated procedures (e.g., imaging guidance) when listed.

Prior authorization required — procedural/devices listing

This document section enumerates procedures and implantable devices that require prior authorization, including surgical procedures, neurostimulator implantation/revision, and other device-related codes; obtain authorization before service provision and billing.

• Providers must reference the listed Medicare procedure codes and descriptions and secure prior authorization prior to scheduling or billing.
• See the full prior authorization list for the complete device and surgical code set.

Prior authorization required — DME/HCPCS items

Durable medical equipment and HCPCS items listed require prior authorization. The policy includes enteral/parenteral pumps and supplies (B9002, B4034–B4036), ambulance ALS nonemergency transport (A0426), virtual reality CBT device (E1905), and other DME items.

• Obtain prior authorization before supplying or billing the DME/HCPCS items shown.
• This extract includes both pumps and supply kits that are subject to prior authorization.

Prior authorization required — sleep and PAP related items

Prior authorization is required for sleep-related devices and PAP components as well as sleep testing. Examples include replacement cushions and interfaces (A7031–A7038), humidifiers (E0562), and home sleep test entries and polysomnography codes included elsewhere on the list.

• Obtain prior authorization for PAP mask/interface components, tubing, filters, humidifiers, and for sleep study procedures prior to service or billing.
• Home sleep test codes (G0398/G0400/G0399) and polysomnography entries are included in the prior authorization list.

Prior authorization required — listed procedures

Prior authorization is required for the listed Medicare procedure codes in this section (partial extract). Examples include percutaneous injections of allogeneic cellular/tissue products (0629T, 0627T, 0628T), various oral prosthesis and sleep apnea devices (0965T/0966T), and multiple paravertebral injection codes (0214T–0218T).

• Providers must secure prior authorization for the specific T-codes and listed procedural entries before providing or billing these services.
• Refer to the full list for additional procedural codes and any case-specific criteria.

Prior authorization required — J-codes

Specified injectable drug J-codes require prior authorization. Examples listed include J9177 (enfortumab vedotin-ejfv), J9227 (isatuximab-irfc), J9316, J9281, and J9358.

• Obtain prior authorization for the injectable drugs listed prior to infusion or billing.
• Check the full code list for additional J-codes and any drug-specific prerequisites.

Prior authorization required — Q-codes (skin substitutes/amnion products)

Numerous HCPCS Q-codes for skin substitutes, dermal matrices, and amniotic products require prior authorization. Examples include Q4306, Q4305, Q4310, Q4309, Q4308, Q4102, Q4105, and Q4136.

• Secure prior authorization before dispensing or billing the listed Q-code products.
• This includes wound matrices, amniotic membrane products, and other biologic dressings shown in the extract.

Prior authorization required — biologic/amnio/skinin products

HCPCS Q-codes for amniotic and skin biologic products require prior authorization. Examples include Q4242 (AmnioCyte Plus), Q4241 (PolyCyte), Q4240 (CoreCyte), Q4239 (Amnio-Maxx), Q4237, and many others shown in the extract.

• Obtain prior authorization for the specific amniotic/skin biologic products prior to use or billing.
• Refer to the full list to confirm product-specific code and allowance.

Prior authorization required — wheelchair accessories

Wheelchair accessories and mounting hardware HCPCS E-codes listed require prior authorization. Examples include E1034, E1033, and E1032 (manual swingaway/retractable mounting hardware for trunk, headrest, and joystick interfaces).

• Prior authorization must be obtained before supplying or billing the wheelchair accessory items shown.
• See the broader DME/wheelchair accessory sections for additional E-code entries that require authorization.

Prior authorization required — prosthetics/orthotics, wound products, drugs

Prosthetic and orthotic additions, wound-related Q-codes, certain drugs and compression garments require prior authorization. Examples include L6700 (upper extremity myoelectronic control module), L5827, L1952, L1933, Q4264, J9153, A6518, A6611, and Q2049.

• Obtain prior authorization for listed prosthetic/orthotic components, wound products, and specified drug entries before provision or billing.
• This extract is partial; consult the full prior authorization list for all affected L/Q/J/A codes.

Prior authorization required — surgeries, imaging, sleep studies, device interrogation

Selected surgeries, diagnostic imaging, sleep study procedures, and device interrogation services require prior authorization. Examples include removal/replacement of phrenic nerve stimulator (33288), percutaneous vertebroplasty (22511), polysomnography entries (95811), phrenic nerve stimulator interrogation (93153), arthroscopy entries (29879, 29874), and breast MRI (77047).

• Obtain prior authorization prior to performing or billing the surgical, imaging, sleep, and device interrogation procedures listed.
• Confirm code-specific authorization requirements and related documentation in the full policy.

Prior authorization required services (excerpt)

This excerpt reiterates that specific procedure, HCPCS, and Q-codes require prior authorization; providers must secure authorization before providing or billing the services shown in the list.

• Use the listed code examples in this excerpt to identify items requiring prior authorization and obtain approval prior to service.
• The list is part of a multi-part prior authorization master list updated 2/11/2026.

Prior Authorization Required Codes (partial list)

This section of the document lists procedure and HCPCS codes requiring prior authorization (partial list); providers must obtain authorization before service delivery and billing.

• Refer to the enumerated procedure and HCPCS codes in this segment and obtain prior authorization for those items.
• Updated: 2/11/2026 — consult the complete policy for full code coverage.

DME Prior Authorization (partial)

Durable medical equipment (E-codes, L-codes) and wheelchair accessories in these sections require prior authorization. The policy includes various E- and L-series entries for accessories, power seating, and componentry.

• Prior authorization is required before supplying or billing the DME and wheelchair accessory items listed.
• Providers should confirm specific E/L codes against the complete prior authorization list.

Prior authorization required — wheelchair accessories

Prior authorization is required for the wheelchair accessory E-codes listed (examples shown: E0980, E0974, E0971, E0969, E0968, E0967, E0957, E0961, E0960, E0959, E0958, E0956, E1084, E1060, E1036, E1028, E1018).

• Obtain prior authorization before ordering, supplying, or billing the wheelchair accessory items enumerated.
• Check the full DME/wheelchair accessory section for additional E-code requirements.

Prior authorization required — power seating and bases

Power seating components and wheelchair base E-codes require prior authorization. Examples include E1016, E1010, E1014, E1012, E1009, E1007, E1005, E1003, E1002, E1195, E1172, E1171, E1222, E1150, and E1100.

• Secure prior authorization before providing or billing power seating and wheelchair base components listed.
• Refer to the comprehensive list for group/base-specific K-code cross-references.

Prior authorization required — seating, misc DME, K-codes

Custom seating, miscellaneous DME, and multiple power wheelchair K-codes require prior authorization. Examples include E2624, K0606, E1399, K0010, K0041, K0040, K0037, and K0047.

• Obtain prior authorization for custom seating cushions, AED garment-type devices, and the K-code wheelchair frame/part items listed.
• Confirm device-specific criteria and documentation requirements in the full prior authorization list.

Prior authorization required — power wheelchairs and related equipment

Power wheelchair and power mobility K-codes require prior authorization. Examples listed include K0806, K0814, K0815, K0821, K0822, K0824, K0825, K0826, and K0827 (various group/weight-capacity bases).

• Prior authorization must be obtained before ordering, fitting, or billing the specified power wheelchair/power-operated vehicle codes.
• See the policy for the complete K-code listing and any assessment or documentation prerequisites.

Prior authorization required — orthotics/prosthetics

Orthotics and prosthetics L-codes and custom-fabricated devices listed require prior authorization. Examples include L0468, L0492, L0488, L0974, L1630, L1970, L2038, and L2037.

• Obtain prior authorization prior to ordering or billing the listed L-code orthotic and prosthetic items, including custom-fabricated devices.
• Confirm device-specific coverage rules and required supporting documentation in the full policy.

Prior authorization required — wheelchair accessories and therapies

Prior authorization is required for wheelchair accessories, seating systems, and pediatric equipment entries shown (E2311, E2325, E1008, E0990, E0966, E1238, E1270).

• Secure prior authorization before supplying or billing these wheelchair accessory and pediatric seating items.
• Consult the complete list for additional E-code and device requirements.

Prior authorization required — code listing (partial)

This section enumerates specific procedure and HCPCS/CPT/J-codes and descriptions that require prior authorization (examples noted include K0860, E2605, and E0194). Providers must obtain authorization before service or billing.

• Use the code examples to identify items requiring prior authorization and obtain approval prior to service delivery.
• Refer to the full policy for the comprehensive code list and any coding/clinical criteria.

Prior authorization required — high-cost procedures and therapies

High-cost procedures and specialty therapies (e.g., organ perfusion, autologous cell therapies, complex reconstructions, and advanced cellular therapies) require prior authorization. Examples include 0495T (donor lung perfusion), 0263T (intramuscular autologous bone marrow cell therapy), 21155/21160 reconstruction codes, and various CAR-T and advanced therapy Q-codes.

• Obtain prior authorization prior to providing or billing high-cost/advanced therapy procedures and services listed.
• These entries typically require detailed clinical documentation and case review—see the full policy for requirements.

Prior authorization required — selected codes (partial list)

Selected procedure and HCPCS codes in this partial list require prior authorization. Examples include TMS codes (90867, 90868) and multiple injectable and specialty drug J-codes (J2507, J2778, J2786, J3285, J3358, J3380, J3399) shown at the start of this window.

• Providers must secure prior authorization for the listed behavioral neuromodulation and specialty injectable codes before treatment or billing.
• Confirm any clinical criteria or quantity limits in the full prior authorization policy.

Prior authorization required — biologics and specialty drugs (partial)

Additional biologic and specialty injectable drug codes require prior authorization. The list includes many J-codes (examples shown in the extract) that must be authorized before administration and billing.

• Obtain prior authorization for the injectable biologic and specialty drug codes listed in the policy.
• Review drug-specific prior authorization criteria and documentation requirements in the full list.

Prior authorization required — advanced therapies and devices (partial)

Advanced therapies, cell therapies, device/implant codes and other high-cost services are flagged for prior authorization in this section. Examples include Q2053, Q4074, Q5103/Q5104 biosimilars, and CAR-T/auto-cell therapy Q-codes.

• Prior authorization is required for the advanced therapy and device codes listed before service provision or billing.
• These services commonly require extensive clinical documentation and prior review—see full policy guidance.

Prior authorization required — therapy and rehabilitation services (partial)

A range of therapy, rehabilitation, and related modality CPT codes require prior authorization. Examples include 0202T, 97530, 97036, 97150, 92609, 90912, 97035, 97116, 97537, 92507, 92508, 92526, 97168, and 97033.

• Obtain prior authorization for the listed therapy and rehabilitation services prior to delivering or billing them.
• Confirm whether individual therapy sessions, group modalities, or assistive-technology assessments need prior authorization per the full prior authorization list.

Prior authorization requirement list (partial document window)

The prior authorization requirement list is maintained and was updated 2/11/2026; providers must obtain authorization for items and services enumerated in this document prior to service or billing.

• Check the updated list (2/11/2026) for the current codes requiring prior authorization.
• If in doubt, verify authorization requirements with the payer before providing or billing services.

Specialty product prior authorization

Specialty products and non-clinical items such as wound matrices, MatriDerm, and implant receptors are included on the prior authorization list and require authorization before use or billing.

• Obtain prior authorization for listed specialty wound matrix products and implant-related supplies prior to procurement or billing.
• Refer to the specific HCPCS/Q-code entries in the full policy for product-level authorization requirements.

Prior authorization requirement — genomic/molecular tests

Genomic and molecular tests listed require prior authorization. The policy enumerates a range of procedure codes for single-gene tests, targeted panels, exome/genome testing, and multianalyte assays that must be authorized before testing.

• Prior authorization is required for the genomic/molecular procedure codes shown (single-gene, targeted panels, exome/genome, and ctDNA/NGS panels).
• Examples include single-gene codes (81346, 81291, 81381, 81350), exome/genome re-evaluation (81417, 81427, 0214U/0215U), and multianalyte assays (81519, 81595).

Example single-gene and pharmacogenetic tests

Single-gene and pharmacogenetic test procedure codes shown (e.g., 81346 TYMS, 81291 MTHFR, 81381 HLA class I typing, 81350 UGT1A1) require prior authorization before testing and billing.

• Obtain prior authorization for the single-gene and pharmacogenetic tests listed prior to ordering or billing.
• Ensure required test-specific documentation accompanies the prior authorization request when specified.

Exome/genome and multi-gene panel tests

Exome, genome, and multi-gene panel sequencing and re-evaluation codes require prior authorization. Examples include 81417 (exome re-evaluation), 81414 (cardiac ion channel panel with required genes), 81410 and 81427 (large panels/genome), and 0214U/0215U (whole exome/genome rare disease panels).

• Prior authorization must be obtained before performing or billing exome/genome and large panel genetic testing codes.
• Some panel codes specify minimum gene counts or required genes—confirm panel-specific criteria in the full policy.

Multianalyte/algorithmic assays

Proprietary multianalyte/algorithmic assays require prior authorization. Examples shown include 81519, 81546, 81554, and 81595 (oncology, pulmonary, cardiology expression/algorithm tests).

• Obtain prior authorization before ordering or billing multianalyte algorithmic assays listed.
• These assays often require specific clinical indications and supporting documentation—see the full policy for details.

Prior authorization list (section excerpt)

This section excerpt lists specific Medicare procedure codes and descriptions that require prior authorization; providers must secure authorization prior to providing or billing the items shown in this window.

• Use the code listings in this excerpt to determine which services require prior authorization and obtain approval before service.
• When a code is on the list, prior authorization is required regardless of site of service unless otherwise noted.

Additional specified services requiring prior authorization

Additional specified services require prior authorization, including remote device interrogation (0948T), implantable neurostimulator pulse generators (L8685/L8686), donor-derived cfDNA and other specialty services; obtain authorization prior to service or billing.

• Secure prior authorization for the named device interrogation and implantable neurostimulator generator codes before providing or billing service.
• Refer to the full list for related procedure and tariff codes included under this requirement.