Prior authorization requirement list (intro)

This document is a list of items and services that require prior authorization.

Therapies and speech devices

Includes specific Medicare procedure/HCPCS codes for therapy services and speech-generating devices that require prior authorization (examples: CPT 92507, 92508, 97164, 97168; HCPCS E2508 speech generating device).

• CPT 92507, 92508 — speech therapy (individual and group) require prior authorization.
• CPT 97164, 97168 — therapy re-evaluation codes require prior authorization.
• HCPCS E2508 — speech generating device requires prior authorization.

Power mobility / power wheelchair

Multiple power wheelchair and power mobility device codes (K-series) require prior authorization; providers must request authorization before supplying these devices (examples include K0813, K0849, K0868, K0886, K0880).

• K0813 — POWER WHEELCHAIR, GROUP 1 STANDARD, portable
• K0868 / K0886 / K0880 — various GROUP 3/4 power wheelchair codes listed for prior authorization

Wheelchair accessories and cushions

Wheelchair accessories, cushions, batteries, caster and drive wheel components are listed as requiring prior authorization (examples: E2624 seat cushion, E2397 lithium battery, E2394 drive wheel).

• E2624 — skin protection and positioning wheelchair seat cushion (adjustable, <22 in)
• E2397 — power wheelchair accessory, lithium-based battery
• E2394 — power wheelchair accessory, drive wheel (replacement)

Prosthetics and orthotics

Prosthetic and orthotic L-codes (including myoelectric upper-limb prostheses and socket replacements) require prior authorization prior to provision (examples: L6880, L6881, L6715, L5700).

• L6880 — electric hand, myoelectric, independently articulating digits
• L6881 — automatic grasp feature, addition to upper limb electric prosthetic terminal
• L5700 — replace socket below knee

Prior authorization requirement list (excerpt)

This excerpt reiterates that the listed items and services shown in these sections require prior authorization for coverage; providers must obtain approval before furnishing listed items.

Wheelchair accessory prior authorization entries

Numerous Medicare HCPCS E-codes for power wheelchair accessories, controllers, batteries, tires and related replacement components are included in the prior authorization list (examples: E2376 expandable controller, E2367 battery charger, E2381 pneumatic drive wheel tire).

• E2376 — expandable controller, including all related components
• E2367 — battery charger, dual mode
• E2381 — power wheelchair accessory, pneumatic drive wheel tire (replacement)

Prior Authorization - DME and accessories

The DME and related accessory codes listed (including static progressive stretch devices, manual and power wheelchair components) require prior authorization before supply or billing.

• E1831 — static progressive stretch toe device
• E1806 — static progressive stretch wrist device
• K0849 / K0813 — power wheelchair group codes included

Prior Authorization - Radiation oncology

Radiation treatment delivery, planning, and related physics consultation codes are listed as requiring prior authorization (examples: 77295 3-dimensional radiotherapy plan; 77412 radiation treatment delivery for 3+ areas).

• 77295 — 3-dimensional radiotherapy plan requires prior authorization
• 77412 — radiation treatment delivery, 3+ separate treatment areas requires prior authorization
• 77370 — special medical radiation physics consultation listed (chunk 53)

Prior Authorization - Drugs and genetic testing

Selected injections, biologics, high‑cost drugs, specialty therapies, and genetic/molecular testing codes require prior authorization (examples include J0175 donanemab, J2468 palonosetron, and molecular panels 81430/81456).

• J0175 — donanemab injection listed as requiring prior authorization
• 81430 / 81456 — genomic sequence analysis panels require prior authorization
• J2468 — palonosetron listed among injectable drugs requiring prior authorization

Listed CPT/HCPCS/J-codes requiring prior authorization

This section lists specific CPT/HCPCS/J-codes identified as requiring prior authorization (examples in this segment include 81317, 81322, 75573, J0175, and several spine surgery codes).

• 81317 — listed among genetic tests requiring prior authorization
• 81322 — listed among genetic tests requiring prior authorization
• 75573 — CT heart with contrast included in list

Injectable biologics and specialty drugs

Additional injectable biologic and specialty drug J‑codes shown in the list require prior authorization (examples include J0225 vutrisiran, J0202 alemtuzumab, J0567 cerliponase alfa).

• J0225 — vutrisiran, 1 mg requires prior authorization
• J0202 — alemtuzumab, 1 mg listed as requiring prior authorization
• J0567 — cerliponase alfa, 1 mg listed

Prior Authorization Requirement - list segment

This segment reiterates that providers must request prior authorization for the items and procedure codes listed in the payer's master list prior to service delivery.

Prior Authorization required — sample entries (continued list)

Sample entries in the continued list identify codes across categories that require prior authorization, including J9028 and IMRT equipment code 77338, therapy codes 97535 and 97129, and genomic panel 81413.

• J9028 — injectable therapy listed requiring prior authorization
• 77338 — multi-leaf collimator for IMRT listed requiring prior authorization
• 97535 / 97129 — self-care/home management training and cognitive-focused therapy interventions require prior authorization

Prior Authorization required — additional entries

Additional entries for devices, injections, therapies, and procedures are listed as requiring prior authorization (examples include L8684 external radiofrequency transmitter and J1429 golodirsen).

• L8684 — radiofrequency transmitter (external) listed
• J1429 — golodirsen injection listed
• 77435 — stereotactic body radiation therapy management listed

Oncology and biologics — prior authorization

Cancer and biologic therapy injections (multiple J‑codes and Q‑codes) are included on the prior authorization list and must be authorized before administration (examples: J9302 ofatumumab, J9306 pertuzumab, Q2053 CAR-T product).

• J9302 — ofatumumab injection requires prior authorization
• J9306 — pertuzumab injection listed
• Q2053 — brexucabtagene autoleucel listed as requiring prior authorization

Prior authorization required - listed codes

The payer lists numerous procedure and HCPCS/J‑codes in this segment that require prior authorization (examples include J3241 teprotumumab, J2327 risankizumab, and spinal procedure 23465).

• J3241 — teprotumumab injection listed
• J2327 — risankizumab listed
• 23465 — capsulorrhaphy, Glenohumeral joint listed

Device interrogation/implantation prior authorization

Interrogation and device evaluation codes and implantable device procedures (remote and in‑person interrogations and implantations) are included on the prior authorization list and require authorization.

• 0948T / 0949T — interrogation device evaluation codes listed requiring prior authorization
• 0908T–0916T series — neurostimulation system implantation/replacement codes listed

Prior authorization required — sample codes and descriptions

Examples of listed items requiring prior authorization include skin substitute products per square centimeter, specific injections, and other supplies (codes such as Q-codes and J‑codes are listed in this segment).

• Q4413 / Q4396 — skin substitute / graft products per sq cm listed
• J1453 — fosaprepitant injection listed
• E1570 — adjustable chair for ESRD patient listed

Drugs requiring prior authorization

A broad range of injectable chemotherapy, immunotherapy, and implant J‑codes are required to have prior authorization (examples include J9219 leuprolide implant, J9351 topotecan, J9271 pembrolizumab).

• J9219 — leuprolide acetate implant listed
• J9271 — pembrolizumab injection listed
• J9351 — topotecan injection listed

Prior authorization required — sample codes

This segment lists additional Medicare procedure/HCPCS codes requiring prior authorization (examples include Q4355/Q4356 amniotic products and ambulance transport codes A0426/A0428).

• Q4355 / Q4356 — amniotic membrane products per sq cm listed
• A0426 / A0428 — ambulance transport services listed

Spine procedures — prior authorization

Spine arthrodesis and related instrumentation CPT codes are included on the prior authorization list; these spinal fusion and instrumentation procedures require prior authorization (examples: 22532, 22534, 22558, 22610, 22632).

• 22532 / 22534 — arthrodesis, lateral extracavitary technique listed
• 22558 / 22610 — anterior/posterior arthrodesis codes listed

Neurostimulation/device procedures — prior authorization

Neurostimulation and other advanced device procedure codes (the 0908T–0918T series and related CPT codes) are listed as requiring prior authorization before implantation or replacement.

• 0908T–0918T series — neurostimulation insertion/removal/replacement codes listed
• 64590 / 64596 — neurostimulator pulse generator and electrode array implantation/replacement listed

Prior authorization required - selected procedure codes

Selected procedure codes (including percutaneous injections, transcatheter and device procedures, and specified U/track codes) require prior authorization; providers must obtain authorization for the listed CPT/HCPCS procedure codes prior to service.

• 0214T–0217T — paravertebral facet injection codes listed
• 0287U / 0339T — specified oncology and transcatheter procedure codes listed

DME and injectable therapies requiring prior authorization

Durable medical equipment items and related J‑code injections (examples: J3394, J3393; E0601 CPAP) are included in the prior authorization list and must be authorized before provision.

• E0601 — CPAP device listed requiring prior authorization
• J3394 / J3393 — listed injectable therapies requiring prior authorization

Therapy and rehabilitation services

Therapy, rehabilitation, assistive technology assessment and training codes (examples: 97537, 97533, 97750, 97755, 97760–97763) are listed as requiring prior authorization.

• 97537 / 97533 — therapeutic activities/self-care training listed
• 97750 / 97755 — physical performance and assistive technology assessment listed
• 97760–97763 — orthotic and prosthetic training codes included

Genomic and molecular pathology prior authorization

Genomic, exome, and other molecular pathology procedure codes (example series 81415–81427 and 81308) require prior authorization when listed (genomic/exome panels and specific gene analyses are included).

• 81415 / 81425 / 81426 / 81427 — exome/genome sequence analysis codes listed require prior authorization
• 81308 — PALB2 familial variant analysis listed

Imaging and radiation therapy prior authorization

Advanced imaging and PET, CT, and specialized radiation therapy planning/delivery codes require prior authorization (examples: PET whole body 78813/78814/78815, IMRT/MLC 77338, proton therapy 77520/77525).

• 78813 / 78814 / 78815 — PET imaging codes require prior authorization
• 77338 — multi-leaf collimator for IMRT listed
• 77520 / 77525 — proton treatment delivery codes included

CT/medication prior authorization

Selected CT, CT colonography, elastography, and certain injectable medications and diagnostic agents are included on the prior authorization list and must be authorized before use (examples: 74261/74262 CT colonography, 76391 elastography).

• 74261 / 74262 — CT colonography (with/without contrast) listed requiring prior authorization
• 76391 — magnetic resonance elastography listed
• J0870 / J1307 — selected injectable medications listed

Surgical procedure prior authorization

Various spinal surgical procedures and select implantable device insertions require prior authorization (examples include laminectomy and related codes 63290, 63200, 63051 and multi-component inflatable penile prosthesis 63282).

• 63290 / 63200 / 63250 / 63252 — laminectomy and related spinal procedure codes listed
• 63051 — laminoplasty with reconstruction listed
• 63282 — multi-component inflatable penile prosthesis listed

Prior Authorization required — item list (partial)

This partial item list reiterates that certain multi-component devices (for example inflatable penile prostheses) and other items enumerated in this section require prior authorization prior to provision.

Prior Authorization list — updated 2/11/2026 (partial)

The document header and repeated sections show the list was updated 2/11/2026; providers should rely on the listed Medicare procedure and HCPCS/J‑codes in this updated list when determining prior authorization requirements.

• Updated: 2/11/2026 appears on multiple list segments — use current list when requesting authorization

Orthopedic surgical procedures requiring prior authorization

Knee and hip arthroscopy/arthroplasty and related orthopedic surgical procedure codes are included on the prior authorization list and require authorization before surgery (examples: 29879, 29877, 27134, 27138).

• 29879 / 29877 — arthroscopy knee procedures listed
• 27134 / 27138 — revision total hip arthroplasty codes listed

Neurostimulation and neuroablative procedures

Neuroablative, neurostimulation, and radiofrequency procedure codes (eg 64625, 64633, 64634 and neurostimulator implantation codes) are listed as requiring prior authorization prior to performance.

• 64625 / 64633 / 64634 — radiofrequency ablation and neurolytic agent destruction codes listed
• 63621 / 63650 / 63655 — neurostimulator implantation and related codes listed

Molecular/genomic pathology testing

Molecular and genomic pathology testing codes (including large-panel and molecular pathology levels 3–9 and specific oncology panels) are listed as requiring prior authorization (examples: 81504, 81407, 81408, 81420).

• 81504 / 81525 — large oncology genomic profiling panels listed
• 81407 / 81408 / 81403–81406 — molecular pathology levels listed require prior authorization

PET imaging prior authorization

Positron emission tomography (PET) imaging CPT codes (for example 78813, 78814, 78815) require prior authorization when listed.

• 78813 / 78814 / 78815 — PET imaging codes require prior authorization

Other procedures requiring prior authorization

Miscellaneous procedures such as iris prosthesis implantation, biofeedback training, and arthroscopy for infection are listed as requiring prior authorization before service.

• 66683 — iris prosthesis implantation listed
• 90901 — biofeedback training listed
• 29871 — arthroscopy for infection listed

Prior authorization required — code list (partial)

This section contains individual procedure codes and descriptions that require prior authorization; providers must reference the listed CPT/HCPCS codes when submitting authorization requests.

Prior Authorization - code list (partial)

Additional procedure and device codes in this segment (examples include 29806 arthroscopy shoulder and high‑complexity transplant codes) require prior authorization; providers should obtain authorization prior to performing these services.

• 29806 — arthroscopy, shoulder, capsulorrhaphy listed
• 0018U — oncology microRNA profiling listed
• 47135 / 47141 — liver allotransplantation and donor hepatectomy listed

Prior Authorization - orthopedics/devices (partial)

Orthopedic procedure and device codes (for example 27407 repair of torn knee ligament, 27412 autologous chondrocyte implantation, and E1828 dynamic toe device) are included on the prior authorization list and must be authorized before care.

• 27407 / 27412 / 27415 — knee ligament/arthroplasty and graft procedures listed
• E1828 / E1829 — dynamic adjustable toe devices listed

Prior Authorization - drugs and assays (partial)

Drug, biologic, and laboratory assay codes (examples: J9063 mirvetuximab, C1736 intravascular catheter for renal denervation, 82233 beta-amyloid 1-40) are listed as requiring prior authorization and must be authorized prior to use.

• J9063 — mirvetuximab soravtansine injection listed requiring prior authorization
• C1736 — intravascular catheter for renal denervation listed
• 82233 / 82234 — beta-amyloid assays listed