List of items and services that require Prior Authorization (Medicare procedure codes)
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A payer-maintained list of specific CPT/HCPCS (Medicare) procedure codes and descriptions that require prior authorization; intended for providers and billing staff submitting authorization requests.
No material clinical or coverage changes in this revision.
Codes and Items Requiring Prior Authorization
Prior Authorization Requirement (enumerated codes - partial)
Codes listed in this document require prior authorization as indicated by the payer.
See individual code lists in chunks 1 and 0 for examples and complete enumeration within this part.
Prior authorization requirement
Codes listed below require prior authorization prior to billing or service delivery.
Providers must submit prior authorization requests for these codes before performing the service.
Prior Authorization Requirement — Listed Codes
Codes listed require prior authorization prior to services being provided to be considered for coverage.
Prior Authorization Code Entries (partial)
Codes listed below require prior authorization (partial extract shown).
Prior authorization required — listed codes
Items and services listed below (by Medicare procedure code and description) require prior authorization per this policy portion.
Prior authorization code list (partial)
Code-level prior authorization requirement list (partial):
Prior authorization code list (partial)
Codes in this list require prior authorization as indicated by the payer.
Prior authorization requirement (codes listed)
The listed CPT/HCPCS/genetic/molecular and other procedure codes require prior authorization.
Codes requiring prior authorization (partial)
The following codes and items in this partial extract require prior authorization:
List-only prior authorization requirements (partial)
Listed codes require prior authorization before services are rendered or billed.
Prior Authorization code list (this segment)
Codes listed below are subject to the payer's prior authorization process.
Prior authorization requirement (code list)
Codes listed below are identified as requiring prior authorization.
Codes requiring prior authorization (partial list)
Listed codes require prior authorization prior to billing or administration.
Prior authorization code list (partial segment)
Codes listed in this segment require prior authorization per the payer's policy.
Prior authorization required services (partial list)
Listed services require prior authorization (codes and brief descriptions provided).
Representative CPT/HCPCS/J/U Code Examples
| G0158 | Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes |
| G0159 | Services performed by a qualified physical therapist in the home health setting, establishment or delivery of maintenance program, each 15 minutes |
| G0496 | Skilled services of a licensed practical nurse (LPN) training/education of a patient or family member, home health or hospice, each 15 minutes |
| G0299 | Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes |
| E2190-E2399 (selected) | Extensive list of wheelchair, power wheelchair accessories, cushions, batteries, and components |
| E0760-E0770 (selected) | Bone growth/neuromuscular stimulation and related devices |
| 90867-90868 | Therapeutic repetitive transcranial magnetic stimulation (initial and subsequent) |
| J0180 | Agalsidase beta injection |
| A9543, C8903, C9727, C9807, C9808 | Selected radiotherapeutic, imaging, implant and device codes |
| 81554 | 10,196 genes, fine needle aspirate, algorithm categorical result |
| 81316 | Pulmonary disease mRNA gene expression analysis of 190 genes |
| 81445 | Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes |
| 75573 | Computed tomography, heart, with contrast material |
| 78431 | Myocardial imaging, PET, perfusion study; multiple studies at rest and stress |
What Providers Must Do
Prior Authorization Required
Prior authorization is required for many procedures, devices, biologicals, drugs, imaging studies, diagnostics and genomic panels listed below. Submit prior authorization requests before scheduling services to avoid denials or delays. This list is a consolidated, partial sample of codes that require prior authorization — it is not exhaustive. Always verify requirements for individual members and products.
- Examples include advanced imaging (MR/CT/MRA/CTA), interventional spine procedures and implants, major spine and reconstructive surgeries, implantable neurostimulators and generators, certain DME/power mobility devices and accessories, complex wound/graft products and amniotic/dermal matrices, many specialty injectable drugs and biologics (including CAR-T and gene therapies), immune and clotting factor products, and selected high-complexity lab, genomic, and multianalyte algorithmic tests.
- Prior authorization applies to diagnostic and genomic panels such as BRCA1/BRCA2 full sequencing (81163), multigene oncology panels (0444U, 0214U, 0373T, 0336U, 0215U), CYP and pharmacogenomic panels (81226, 0070U, 81227, 81231-81232), whole exome/genome testing (0215U, 0336U), and other listed molecular/genomic assays (81599, 81554, 81427, 81430-81435).
- Drugs, biologics and cellular therapies requiring prior authorization include (partial list): CAR-T and other cellular therapies (Q2055, Q2056, Q3001), many J-codes for oncology/rare-disease/biologic injections (e.g., J1411, J1412, J1304-J1306, J1322-J1323, J1551-J1568, J7207-J7212, J9264, J9319, J9276, J9381), high-cost enzyme/replacement and gene therapies (J1411, J1429, J1301-J1303), injectables such as immune globulins and specialty biologics (J1599, J1556, J1557, J1561, J1566, J1568, J0180), and unclassified biologics (J3590).
- Devices, implants and advanced DME requiring prior authorization include intervertebral biomechanical devices and disc arthroplasty codes (22867, 22854, 22858, 22861-22869, 22532, 22534, 22511), implantable neurostimulator systems and components (C1820, L8682, C1825, C9361, C9364, C9354), powered mobility devices and group-specific K-codes (K0010-K0015, K0815-K0899, K0820-K0899, K1007), complex wheelchair accessories and seating components (E1xxx series, E2312-E2397, E26xx series), and biologic grafts/dermal matrices/amniotic products (Q41xx–Q43xx, A20xx series, C1734, C1778).
- Advanced imaging, transplant, cardiac device, and procedural codes subject to prior authorization (partial): MRA/MRI/MRA spine/head/neck/abdomen (70544, 70545, 70546, 72159, 72198, 74174, 73718, 74150, 77047), CT/CTA/CT colonography and cardiac CT (74150, 74174, 74185, 75571-75574), nuclear cardiology and cardiac MRI (75557, 75559, 75561, 78451-78454, 78472-78473), and specified intraoperative and brachytherapy planning/delivery codes (76965, 77301, 77425, 77761-77762).
- Procedures and major spine/reconstructive surgeries requiring prior authorization include arthrodesis and complex spinal fusion and fixation (22610, 22612, 22808, 22812, 22532, 22533, 22534, 22511, 22864), vertebrectomy/corpectomy and multilevel decompressions (63075-63091, 63012, 63030, 63050, 63081-63088), vertebroplasty/kyphoplasty (22510, 22511), major orthopedic reconstructions and arthroplasties (23472, 27120, 27125, 27486, 23466, 23462).
- Examples of behavioral, therapy and rehabilitation codes requiring prior authorization in selected circumstances: group and individual therapeutic procedures where medical necessity or coverage limits may apply (97150, 97140, 97110, 97112-97116, 97124, 97129, 97150-97156, 97164, 97168, 97537, 97542, 97750, 97760-97763).
- Diagnostic, specialty lab, and multianalyte algorithmic assays requiring prior authorization (partial): multianalyte assays with algorithmic analysis (81599), tumor and neurologic biomarkers (82233, 82234, 84393-84394), amyloid and tau CSF/plasma assays (0349T, 82233, 82234), neurofilament light chain and related tests (83884, 84393-84394), and other listed high-complexity testing (0459U, 0253T, 0117U).
- Medicare DME/device procedural prior authorization excerpt (partial): home ventilators (E0466), air-fluidized beds and specialty mattresses (E0194, E0198), patient lifts (E0639), hospital-grade pediatric beds (E0328-E0329), complex seating and custom wheelchair components (E1012, E1701-E1702, E2220, E2321-E2330, E2360-E2397), and large power wheelchair group codes (K08xx–K08xx series).
Prior authorization required — sample codes
Below is a consolidated partial list of sample codes that require prior authorization. This list groups codes by type to help providers identify common categories subject to authorization. It is illustrative and not exhaustive — confirm requirements for each service and member prior to provision.
- Selected sample CPT/HCPCS/procedure codes requiring prior authorization (partial): 70544, 70545, 70546, 72146, 72159, 72198, 74150, 74174, 73718, 77047, 75571-75574, 78451-78454, 78472-78473, 76965, 77078, 77301, 77425, 77761-77762.
- Selected spine, fusion and reconstructive procedure codes: 22532, 22533, 22534, 22610, 22612, 22808, 22812, 22854, 22858, 22861-22869, 63012, 63015, 63030, 63050, 63075-63091.
- Selected interventional and implantable device codes: 63650, 63090, 29877, 29873, 29822, 29825, C1820, C1825, C1735, C1736, C9352-C9355, C9361, C9364, L8682.
- Selected durable medical equipment, power mobility and wheelchair accessory codes: K0010-K0015, K0815-K0899, K0820-K0899, E0170-E0239, E0300-E0352, E0955-E1100, E1701-E1702, E2220, E2312-E2397, E2502-E2508, E2603-E2633.
Prior authorization required — drugs, devices, imaging
Drugs, biologics, cellular therapies, and high-cost injectables often require prior authorization. The examples below include J-codes and Q-codes for many specialty products and biosimilars. Prior authorization is required for both originator biologics and many biosimilars, as listed.
- Selected biologic, injectable and specialty drug codes (partial): J0180, J0275-J0280 (selected enzyme/protein therapies), J1301-J1306, J1322-J1325, J1411-J1429 (gene and cell therapies), J1551-J1568 (immune globulins), J2277, J2323-J2327, J3590 (unclassified biologics), J7191-J7192 (porcine factor VIII), J9024, J9026, J9028, J9042, J9055, J9216-J9292, J9302-J9355, J9381, J9276, J9319.
- Selected biosimilar and specialty injection HCPCS/Q codes: Q5101-Q5133, Q4270-Q4331 series for biosimilars and amniotic/dermal graft products.
- Cellular and gene therapy codes requiring prior authorization: Q2055, Q2056, Q3001, Q4413 (select implant/add-on device descriptors).
Prior authorization required — diagnostic and genomic panels
Diagnostic, genomic and molecular tests frequently require prior authorization, especially high-complexity panels, whole exome/genome tests, and algorithmic multianalyte assays. Coverage may depend on indication, family history, and prior testing. Submit clinical documentation with requests.
- Selected genomic and molecular procedure codes (partial): 0070U, 0117U, 0214U, 0215U, 0336U, 0349T, 0373T, 0400U-0401U, 0444U, 0459U, 0490U, 0568U, 0948T, 0910T.
- Pharmacogenomic and gene variant tests: 81226 (CYP2D6), 81227 (CYP2C9), 81230 (CYP3A4), 81231 (F5 Leiden), 81232 (CYP3A5), 81241 (F5), 81291, 81316, 81319-81322, 81324-81326, 81350, 81353.
- Multianalyte and algorithmic assays: 81517, 81519, 81546, 81554, 81599 (unlisted multianalyte assay with algorithmic analysis).
Prior Authorization Required Codes (partial list)
This section lists many of the procedure, device, drug and test codes that typically require prior authorization. Use the list to identify candidate services and verify member coverage prior to delivery.
- Selected procedure and code list highlights (partial): 19298, 20974, 21120, 21159-21160, 21242, 21255, 21154, 21412, 23410, 23430, 23440, 23472, 23466, 23462, 27120, 27125, 27599, 27702, 29822, 29825, 29873, 29877, 29884-29885, 29873-29877 series.
- Selected high-cost device/graft and biologic codes (partial): C1734, C1778, C8903, C9352-C9355, C9361, C9364, L5827, L5991, L6715, L6881, L6925, L3999, L5615, L5783, L5841, L5926.
Prior Authorization — biologics and cellular therapies
Selected codes related to biologics, biosimilars, and cellular therapies — prior authorization required. This includes many Q- and J-coded biologics, biosimilars, and cellular therapy product codes.
- Cellular and CAR-T therapies: Q2055 (idecabtagene vicleucel), Q2056 (ciltacabtagene autoleucel), Q2054/Q2055 series for CAR products and leukapheresis/dose prep.
- Selected biologic and biosimilar injection codes: Q5101-Q5133 series (filgrastim, pegfilgrastim biosimilars, rituximab, trastuzumab biosimilars), Q5110-Q5127, Q5130-Q5133.
- Selected J-code biologics and specialty injectables (partial): J1304-J1306, J1322-J1325, J1411-J1429, J1551-J1568, J7198-J7209, J7210-J7212, J9024, J9217, J9264-J9319, J9381.
Prior Authorization — major spine and reconstructive procedures
Major spine, implant and reconstructive procedures require prior authorization due to complexity and high cost. Provide operative plans, imaging, and prior conservative care documentation when requesting authorization.
Prior authorization required — examples
Selected examples and common scenarios where prior authorization is required. These examples illustrate typical authorization triggers — complex implants, non-routine DME, high-cost pharmaceuticals, specialized imaging, and advanced molecular testing.
- Example: Implantation of an intervertebral biomechanical device or artificial disc (22854, 22858, 22861-22869) — require prior authorization with imaging and operative indication.
- Example: CAR-T or gene therapy (Q2055, Q2056, J1411 series) — require prior authorization with clinical documentation and treatment plan.
- Example: Power mobility device group codes (K08xx, K0820-K0899, K0850-K0899) and major wheelchair seating systems (E1xxx, E2xxx) — require prior authorization and supplier documentation.
- Example: Complex genomic testing or whole exome/genome analysis (0215U, 0336U, 0444U, 81599) — require prior authorization with indication and prior testing history.
Device and imaging codes
Device and imaging codes requiring prior authorization include many advanced imaging, implantable device, graft and matrix products, and complex DME. Provide device model/serial details and medical justification when applicable.
- Selected device, graft and imaging codes (partial): C1735, C1734, C1778, C8903, C9727, C9807-C9808, C9352-C9355, C9361, C9364, L8682.
- Advanced imaging and image-guided procedure codes (partial): 70544-70546, 70545-70546, 72146, 72159, 72198, 73718, 74150, 74174, 77047, 76965, 77078, 75571-75574, 75557-75559.
Prior Authorization requirement (partial list)
This is a partial requirement list — many additional codes and categories require prior authorization. Providers must check member-specific benefits and payer rules; missing an authorization can result in claim denial or member responsibility.
- Prior authorization requirement (partial list) includes: selected surgery/procedure CPT codes, DME/group K-codes for power mobility, E-series wheelchair accessories and seating components, implantable neurostimulator systems and components, most CAR-T and gene therapies, high-cost enzyme and replacement therapies, immune globulins, many inpatient and outpatient advanced imaging studies, and high-complexity molecular/genomic tests.
Prior authorization required — listed procedure codes
The plan requires prior authorization for a broad set of listed procedure codes. When in doubt, submit a prior authorization request with supporting clinical documentation and imaging.
Prior authorization required — selected biologic and seating components
Selected biologic and seating components, amniotic/dermal matrices and grafts, and complex prosthetic/orthotic pieces require prior authorization. Provide measurements, product names, and justification.
- Selected biologic/graft/amniotic matrix codes (partial): Q41xx–Q43xx series (Q4117, Q4118, Q4137-Q4157, Q4184-Q4195, Q4201-Q4331), A20xx–A2027 series, C1734, C1735, C1778, C4323.
- Selected seating and complex wheelchair components (partial): E1012, E1701-E1702, E2220, E2312-E2330, E2360-E2397, E2502-E2508, E2603-E2633, E0955-E1036.
Medicare DME/Device and procedure prior authorization (excerpt)
Medicare-derived DME, device and procedure codes in this excerpt also reflect prior authorization requirements under this plan. When furnishing Medicare-style DME/PDAC-coded items for covered members, obtain prior authorization per payer rules.
Advanced imaging, transplant, lab, and procedural prior authorization codes
Advanced imaging, transplant-related services, complex lab and procedural codes often require prior authorization. Submit imaging reports, transplant evaluation notes, and lab rationale with the request.
- Advanced imaging, MRA/MRI/CTA/CTA of cardiac/abdomen/pelvis and related codes (70544-70546, 70545-70546, 72159, 72198, 74150, 74174, 75557-75574, 73725, 74261, 74262).
- Transplant and donor procedure related codes: 44132-44136 (intestinal allotransplantation/donor enterectomy), 44133, 44136, 44132-44136 series; include transplant center documentation.
- Selected procedural and interventional codes: 76965, 77078, 77301, 77425, 77761-77762, 78451-78454, 78472-78473.
Biologic grafts, biosimilars, specialty devices and additional codes requiring prior authorization
Biologic grafts, biosimilars, specialty devices and many additional HCPCS/Q codes require prior authorization. Include product identifiers, number of square centimeters/units, and clinical indication.
- Selected biologic grafts and matrix product codes (partial): Q4117-Q4331, Q41xx series (CaregrAFT, alloPLY, AmnioTX, ACApatch, XWRAP, Axolotl Graft, many named products).
- Biosimilar injection and biologic HCPCS codes (partial): Q5101-Q5133, Q5110-Q5127, Q5130-Q5133, Q4268-Q4289, Q4290-Q4330 series.
- Specialty device and implant HCPCS/C codes: C1734, C1735, C1778, C8903, C9352-C9364, C9807-C9808.
Prior authorization required: selected injectable drugs/biologics
Selected injectable drugs and biologics (J-codes) require prior authorization. This includes many novel therapies, replacement products, and specialty agents.
Prior authorization required list (partial segment)
This list is a partial segment of codes requiring prior authorization. Providers should use it as a guide and confirm authorization requirements via the payer portal or prior authorization service. When submitting requests, include pertinent clinical documentation to support medical necessity.
- Additional selected codes requiring prior authorization (partial): 81427, 81430-81435 (genomic panels), 81517, 81519, 81546, 81554, 81599, 96130-96133, 97150-97156, 97760-97763, 92282-92285 series, many L- and K-series prosthetic/orthotic codes, and numerous Q-series graft/amniotic product codes (Q41xx–Q43xx).
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