Prior Authorization Required Codes (partial list)

This document identifies procedure codes and descriptions that require prior authorization; providers must obtain authorization before performing or billing the listed codes.

Prior authorization requirement (list)

The payer maintains a list of items and services that require prior authorization; the list enumerates procedure, HCPCS and supply codes for which providers must request authorization prior to service delivery.

Update timestamp

Updated : 2/11/2026 — the code list and sections shown were last updated on 2/11/2026.

Prior authorization required - code list (partial)

Numerous CPT/HCPCS and L/Q/G codes require prior authorization (examples shown include 63030, 15775, 22633, and L8614); providers must obtain prior authorization for the listed surgical and implantable device procedures.

• Example surgical codes: 63030, 22633, 22585
• Example device/implant code: L8614

Prior authorization required - supplies and devices

HCPCS codes for wound products, enteral/parenteral pumps, and supply kits (for example A2019, B9002, B4034) are included on the prior authorization list and require approval before provision.

• Wound products: A2019
• Enteral nutrition infusion pump: B9002
• Enteral feeding supply kit: B4034

Prior authorization required - respiratory/sleep/DME

Respiratory device interfaces, PAP interfaces and related replacement parts, selected sleep study and DME device codes (examples A7032, G0398, J2797) are listed as requiring prior authorization.

• Nasal mask interfaces and replacement cushions: A7032, A7031
• Injection listed example: J2797

Prior authorization required — enumerated codes

The policy enumerates numerous Medicare procedure and HCPCS codes that require prior authorization; providers must secure authorization for the enumerated codes before billing.

Prior authorization required — selected HCPCS Q codes

Specific HCPCS Q-codes (for skin substitutes and biologic matrices) are listed and require prior authorization (examples include Q4242, Q4241, Q4240, Q4239, Q4237).

• Examples: Q4242 (AmnioCyte Plus), Q4241 (PolyCyte), Q4240 (CoreCyte)

Prior authorization required — wheelchair accessories

Wheelchair accessory HCPCS E-codes (for example E1034, E1033, E1032) are included on the prior authorization list and require approval prior to provision.

• E1034 — Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support
• E1033 — Wheelchair accessory for headrest

Prior authorization required — orthoses, drugs, compression garments

Prosthetic/orthotic L-codes, select drug J-codes, and compression garment HCPCS (examples L6700, L5827, L1952, J9153, A6518, A6611, Q2049) are on the list and require prior authorization.

• L6700 — Upper extremity myoelectronic control module
• J9153 — Liposomal daunorubicin/cytarabine injection

Prior authorization required — surgical and imaging procedures

Selected CPT surgical and imaging procedure codes and implants (examples: 33288 removal/replacement of phrenic nerve stimulator; 22511 percutaneous vertebroplasty; 29879 arthroscopy procedures; 77047 breast MRI) require prior authorization.

• 33288 — Removal and replacement of phrenic nerve stimulator
• 77047 — MRI, breast, without contrast; bilateral

Prior authorization required — sleep and neurostimulation procedures

Polysomnography, neurostimulator implantation/programming, radiofrequency ablation, and other sleep/neurostimulation procedure codes (for example 95783, 93152, 64590, 64625) require prior authorization.

• 95783 — Polysomnography, younger than 6 years, with CPAP/BiPAP initiation
• 93152 — Interrogation and programming of implanted phrenic nerve stimulator

Prior Authorization required for listed codes

This segment contains Medicare procedure codes and descriptions that require prior authorization (examples across chunks 90–109); providers must obtain authorization for the listed services.

Examples of Medicare procedure and drug codes requiring prior authorization

Representative Medicare procedure and injectable drug codes require prior authorization — examples include bronchoscopy with catheter placement (31643) and octreotide depot injection (J2353).

• 31643 — Bronchoscopy with placement of catheter(s)
• J2353 — Octreotide, depot form, 1 mg

Oncology procedures and drugs

Oncology procedures and multiple antineoplastic injectable J-codes are listed as requiring prior authorization (examples include G0458 LDR prostate brachytherapy composite rate; J9055 cetuximab; J9303 panitumumab).

• G0458 — LDR prostate brachytherapy services, composite rate
• J9055 — Cetuximab injection

Radiation therapy and stereotactic radiosurgery

Radiation therapy delivery, planning, stereotactic radiosurgery and brachytherapy codes (for example 77772, 77301, 77373, 77435) require prior authorization.

• 77772 — Remote afterloading HDR brachytherapy, >12 channels
• 77301 — IMRT plan with dose volume histograms

Durable medical equipment (DME)

Durable medical equipment (DME), power wheelchair items, and related HCPCS codes (examples E0710, E1590, K0837, E2394) require prior authorization and may also carry billing rules for accessories and replacements.

• E0710 — Restraints Any Type
• K0837 — Power wheelchair, group 2 very heavy duty

Prior Authorization required codes (sample)

The list includes many additional Medicare procedure codes and HCPCS items (examples E2394, E2212, E1841, 0409U, K0017, K0042) that require prior authorization; providers should reference the full list when submitting authorization requests.

Prior Authorization required codes (additional)

Additional Medicare procedure codes and descriptions (including complex surgical and device-related codes such as 33935, L4055, L5858, L6881 and various J-codes) require prior authorization as listed in the document.

• 33935 — Heart-Lung Transplant with recipient cardiectomy-pneumonectomy
• L6881 — Automatic grasp feature, addition to upper limb electric prosthetic