Obtain prior authorization for listed Medicare procedure codes

This document enumerates Medicare procedure codes and descriptions for items and services that require prior authorization; providers must obtain prior authorization before performing or billing for listed codes.

Secure authorization for power wheelchair accessories and speech devices

Examples of HCPCS/Medicare codes requiring prior authorization include power wheelchair accessories (E2340, E2330, E2331) and speech generating devices (E2511, E2508, E2506); verify authorization before supply or service delivery.

• E2340, E2330, E2331 — power wheelchair accessories
• E2511, E2508, E2506 — speech generating devices

Prior authorization required for wheelchair cushions and seating components

Continued HCPCS entries (E2624 series and related wheelchair cushions, arm/back supports, replacement covers) are subject to prior authorization; obtain approval prior to ordering or fitting.

• E2624, E2625, E2623, E2622 — wheelchair seat cushions
• E2619 — replacement cushion cover
• E2615–E2621 — back/positioning cushions

Obtain prior authorization for wheelchair parts and power wheelchair classifications

Additional wheelchair components and power wheelchair classifications (replacement footrests, arm pads, group K power wheelchair codes) updated 2/11/2026 require prior authorization; confirm authorization for replacements and class-based power chairs.

• K0043, K0042, K0041, K0040 — footplate/footrest items
• K0006–K0012, K0070–K0071 — wheelchair group and wheel assemblies
• K0017, K0019, K0037 — arm pads and related components

Submit prior authorization for listed therapy and modality CPT/HCPCS codes

The payer lists specific therapy and modality CPT codes (biofeedback, therapeutic exercises, orthotics management, TENS) that require prior authorization; submit prior auth for these services before treatment.

• L3918 — hand orthosis (biofeedback context)
• E0455, 97024, 97035 — TENS/diathermy/ultrasound modalities
• 90912, 90913, 92507–92508 — biofeedback and speech therapy services

Get prior authorization for listed physical therapy and procedure codes

Selected physical therapy and related procedure codes (e.g., 97035, 97016, 97110, 97164) are on the prior authorization list; obtain authorization before providing or billing these therapy modalities.

• 97035 — Ultrasound application, each 15 min
• 97016 — Vasopneumatic devices
• 97110 — Therapeutic exercises, each 15 min
• 97164 — PT re-evaluation requiring components

Prior authorization required for select PT modalities and specified U‑codes

Providers must obtain prior authorization for various listed physical therapy, motion analysis, orthotic management codes and select genomic U‑codes (examples include 97035, 96001, 0536U, 0032U).

• 96001 — Comprehensive computer-based motion analysis
• 0536U — Fetal RhD PCR analysis
• 0032U — COMT gene analysis (drug metabolism)

Obtain prior authorization for genomic and pharmacogenomic U‑codes

A broad set of genomic and pharmacogenomic U‑codes (e.g., 0071U, 0073U, 0075U, 0242U, 0239U, 0333U) require prior authorization; submit authorization requests before ordering these molecular tests.

• 0071U–0076U — CYP2D6 and related gene analyses
• 0242U, 0239U — targeted cfDNA/genomic panels
• 0333U — HCC surveillance methylation cfDNA assay

Secure prior authorization for additional genomic, oncology, and infectious tests

Additional oncology, infectious and pharmacogenomic testing U‑codes (e.g., 0348U, 0347U, 0410U, 0409U, 0392U) are listed as requiring prior authorization; ensure authorization is obtained prior to specimen submission or testing.

• 0348U, 0347U — multi‑gene drug metabolism panels (25/16 gene reports)
• 0410U — Whole genome sequencing with enrichment for oncology detection
• 0409U — Plasma NGS DNA (80 genes) plus RNA

Prior authorization required for comprehensive oncology/molecular assays

Comprehensive ctDNA/cfDNA, methylation and MRD assays (examples: 0487U, 0539U, 0561U, 0565U) require prior authorization; obtain approval before ordering these comprehensive molecular oncology assays.

• 0487U — ctDNA targeted panel (84 genes)
• 0539U — ctDNA 152‑gene NGS panel
• 0561U — MRD genomic sequence analysis (subsequent assessment)
• 0565U — large methylation pattern assay for HCC

Obtain prior authorization for hereditary and cytogenomic genetic tests

Hereditary and cytogenomic testing codes (e.g., 81161, 81164, 81223, 81220, 81165) are on the prior authorization list; obtain authorization for whole‑gene, duplication/deletion, and cytogenomic analyses prior to testing.

• 81161 — DMD deletion/duplication analysis
• 81164 — BRCA1/BRCA2 duplication/deletion analysis
• 81223 — CFTR full gene sequence
• 81220 — CFTR common variant analysis
• 81165 — BRCA1 full sequence analysis

Prior authorization required for listed genetic/molecular procedure codes

Procedure codes for genetic and molecular testing listed (e.g., 81223, 81224, 81222, 81221, 81205) require prior authorization per this section; secure authorization before performing or billing these tests.

• 81223–81224, 81222, 81221 — CFTR gene analyses (full sequence, intron 8 poly-T, duplication/deletion, familial variants)
• 81205 — BCKDHB gene analysis (common variants)

Secure prior authorization for molecular/genomic and pharmacogenomic tests

Additional molecular, genomic and pharmacogenomic procedure codes (examples include 81558, 81542, 81525, 81459, 81230) require prior authorization; obtain approval before requesting these specialized assays.

• 81558 — mRNA gene expression profiling (allograft rejection)
• 81525 — 12‑gene oncology expression profiling
• 81459 — Solid organ neoplasm genomic sequence panel
• 81230 — CYP3A4 gene analysis (drug metabolism)

Obtain prior authorization for listed genetic/genomic and specialized services

Listed genetic/genomic and specialized services (e.g., 81321, 81427, 81456, 0500U, 0499U) require prior authorization; providers must obtain prior authorization before ordering these panels, genome analyses, and select proprietary tests.

• 81321 — PTEN full sequence analysis
• 81427 — Genome re‑evaluation/sequence analysis
• 81456 — Targeted genomic sequence panel ≥51 genes
• 0499U/0500U — proprietary oncology NGS entries

Prior authorization required for listed Medicare procedure codes (excerpt)

Medicare procedure codes in this excerpt (e.g., 0506U, 0549U, 88365, 0516U) require prior authorization; follow payer authorization process before using these codes for testing, supplies or injections.

• 0506U — midazolam injection description entry
• 0549U — urine methylated PCR assay (urothelial)
• 88365 — Tissue In Situ Hybridization interpretation & report
• 0516U — receptor sole replacement for L8720

Prior authorization required for additional genomic and oncology codes

Additional genomic and oncology‑related codes (e.g., 81318, 81519, 81426, 0543U, 0567U) are included on the prior authorization list; obtain authorization before providing these genomic panels or whole‑genome analyses.

• 81318 — PMS2 known familial variants
• 81519 — 21‑gene breast recurrence score
• 81426 — genome sequence analysis comparator
• 0543U — 517‑gene NGS panel (FFPE)
• 0567U — whole‑genome sequence (short & long reads)

Obtain prior authorization for cytogenomic and targeted panels

Cytogenomic and targeted panel codes (e.g., 81229, 0209U, 0424U, 81458, 81170) require prior authorization; providers must secure authorization prior to ordering microarray, exosome, or large targeted panels.

• 81229 — Cytogenomic constitutional microarray analysis
• 0209U — genome‑wide cytogenomic analysis
• 0424U — exosome‑based sncRNA urine assay
• 81458 — solid organ genomic sequence panel

Prior authorization required for additional gene analyses and molecular procedures

Additional gene analyses and molecular procedure codes (e.g., 81233, 81295, 81353, 81401, 0460U) require prior authorization; obtain approval before ordering gene‑specific and molecular pathology tests.

• 81233 — BTK gene analysis (common variants)
• 81295/81298 — MSH2/MSH6 full sequence analyses
• 81353 — TP53 known familial variant analysis
• 81401 — Molecular pathology procedure level 2

Obtain prior authorization for reproductive and complex genomic testing

Reproductive and complex genomic testing (e.g., 0554U, 0552U, 81416, 81193, 81293) are listed as requiring prior authorization; secure authorization before ordering preimplantation, exome, or complex genomic instability tests.

• 0554U/0552U — preimplantation genetic assessment analyses
• 81416 — exome sequence analysis (comparator exome)
• 81193 — NTRK3 translocation analysis
• 81293 — MLH1 known familial variants

Prior authorization required for variant analyses and comprehensive tumor profiling

Variant analyses and comprehensive tumor profiling codes (e.g., 81291, 81335, 81207, 81251) are on the prior authorization list; obtain prior authorization before ordering enzyme/gene variant or comprehensive oncology panels.

• 81291 — MTHFR common variant analysis
• 81335 — TPMT gene analysis
• 81207 — BCR/ABL1 minor breakpoint translocation analysis
• 81251 — GBA gene common variant analysis

Secure prior authorization for psychiatric genomic panels and whole‑genome tests

Psychiatric genomic panels, whole‑genome entries, and related codes (e.g., 0345U, 0496U, 0213U, 0334U) require prior authorization; obtain authorization prior to ordering panels for psychiatric or whole‑genome testing.

• 0345U — Psychiatry genomic panel (15 genes)
• 0213U — whole genome and mitochondrial DNA sequence analysis (comparator genomes)
• 0334U — FFPE targeted genomic panel (84+ genes)

Obtain prior authorization for Lynch syndrome and targeted panels

Lynch syndrome and targeted panel entries (e.g., 81360, 81317, 81294, 81300) are listed as requiring prior authorization; obtain authorization before performing Lynch‑related gene testing or targeted panels.

• 81360 — ZRSR2 gene analysis
• 81317 — PMS2 full sequence analysis
• 81294 — MLH1 duplication/deletion variants
• 81300 — MSH6 duplication/deletion variants

Prior authorization required for metabolic and oncology molecular tests

Metabolic and oncology molecular tests (e.g., 81291 MTHFR, TPMT 81335, FLT3 quantitative 0046U, comprehensive genomic profiling 0244U) require prior authorization; providers must secure authorization before ordering these metabolic or comprehensive oncology assays.

• 81291 — MTHFR gene analysis
• 81335 — TPMT gene analysis
• 0046U — FLT3 ITD quantitative testing
• 0244U — 257‑gene comprehensive genomic profiling

Secure prior authorization for inherited disorder and oncology/vascular profiling tests

Inherited disorder and oncology/vascular profiling codes (e.g., 81220, 81165, 81334, 81493, 81464) are listed as requiring prior authorization; obtain approval before ordering CFTR, BRCA, RUNX1, PTEN, or coronary artery expression profiling tests.

• 81220 — CFTR common variant analysis
• 81165 — BRCA1 full sequence analysis
• 81334 — RUNX1 targeted sequence analysis
• 81493 — Coronary artery disease mRNA expression profiling
• 81464 — Solid organ neoplasm cell‑free nucleic acid panel

Obtain prior authorization for listed genetic tests and selected home health/hospice codes

Prior authorization is required for the listed genetic/genomic codes and selected home health/hospice service codes (e.g., 81220, 81165, 0327U and G0157/G0151); obtain authorization prior to providing genetic tests or home health skilled services when these codes apply.

• G0157, G0151 — Home health/hospice PT services (15 min)
• 81220, 81165 — CFTR and BRCA analyses
• 0327U — Fetal aneuploidy DNA sequence analysis via maternal plasma

Prior authorization required for home health, hospice and select procedure codes

Home health, hospice, and select procedural/technical codes (e.g., G0300, G0158, G0156, G0299, L6037, 0253T) require prior authorization; secure authorization before delivering or billing these services.

• G0300, G0299 — Skilled nursing services in home health/hospice
• G0158, G0156 — Home health therapy assistant/aide services
• L6037 — Immediate postsurgical/early fitting application

Obtain prior authorization for interventional, regenerative and monitoring procedures

Interventional, regenerative, and specialized monitoring/intervention procedure codes (e.g., 0379T, 0348T, 0490T, 0566T, 0565T) require prior authorization; obtain authorization before performing these interventional or regenerative procedures.

• 0379T — Remote surveillance visual field assessment with real‑time data
• 0490T — Autologous adipose‑derived regenerative cell therapy (scleroderma)
• 0566T/0565T — Autologous cellular implants derived from adipose tissue (knee)

Secure prior authorization for wound matrices, device services and sleep studies

Wound matrix/biologic products, device programming, and sleep study procedure codes (e.g., Q4342, Q4304, Q4102, 93150, 95810) require prior authorization; obtain prior authorization before ordering wound matrices, programming devices, or conducting listed sleep studies.

• Q4342, Q4304, Q4303 — Wound matrix/biologic products per sq cm
• Q4102, Q4101 — Oasis, Apligraf wound matrices
• 93150–93153 — Phrenic nerve stimulator interrogation/programming
• 95810, 95811 — Polysomnography variations

Obtain prior authorization for implants, spine and orthopedic procedures

Implants, spine, and orthopedic surgical procedure codes (e.g., 29805, 22511, 33276, 22634, 27130) are listed as requiring prior authorization; obtain authorization before scheduling implant, spine or major orthopedic surgeries.

• 29805 — Arthroscopy, shoulder diagnostic
• 22511/22513/22514 — Vertebral augmentation/vertebroplasty/kyphoplasty entries
• 22634 — Arthrodesis with posterior interbody technique
• 27130 — Hip arthroplasty procedures

Prior authorization required for musculoskeletal, imaging, DME and related procedures

A broad set of musculoskeletal, imaging, DME, reconstructive and injectable codes (examples include 22859, Q4286, 23410, 70470, 27447) require prior authorization; confirm authorization before performing or billing these services and related DME.

• 22859 — Insertion of intervertebral biomechanical devices
• Q4286 — NuDYN SL matrix per sq cm
• 23410–23415 — Shoulder cuff repair/related procedures
• 70470, 70480 — CT head/brain CT entries
• 27447 — Knee arthroplasty procedures

Verify and obtain prior authorization for codes on the list

This list identifies specific procedure and supply codes that require prior authorization; providers must check the full payer list and obtain authorization prior to furnishing or billing any listed item or service.

Obtain prior authorization for listed drug, device and cardiac procedure codes

Medicare procedure codes and descriptions in the partial list (e.g., J0207, L8684, 93458) require prior authorization; confirm authorization for these drug, device, and cardiac procedure entries before service.

• J0207 — Amifostine
• L8684 — External RF transmitter for sacral root neurostimulator
• 93458 — Coronary angiography with left heart catheterization

Use updated (2/11/2026) code list when requesting prior authorization

The code list was updated on 2/11/2026; providers should confirm the most recent code updates (e.g., 0911T, 0717T, 63015, C9781) when submitting prior authorization requests.

• 0911T — Electronic analysis of implanted integrated neurostimulation system
• 0717T — ADRC therapy for partial thickness rotator cuff tear
• 63015 — Multisegment cervical laminectomy

Prior authorization required for enteral/parenteral supplies and implantable device codes

Enteral/parenteral supply kits and implantable device-related HCPCS codes (e.g., B4034–B4036, B9002–B9004, C9356) require prior authorization; obtain authorization before supplying enteral/parenteral kits or implantable device materials.

• B4034–B4036 — Enteral feeding supply kits (syringe/pump/gravity)
• B9002, B9004 — Nutrition/parenteral pumps
• C9356, C9353, C9355 — Tendon/collagen implantable products

Obtain prior authorization for listed spine surgery codes

Surgical spine procedure codes (e.g., 63045, 63044, 63076, 63050, 63048) require prior authorization; obtain authorization prior to scheduling cervical and other spinal surgeries.

• 63045, 63044, 63048 — Cervical laminectomy/laminotomy/related procedures
• 63050, 63076 — Cervical laminoplasty and diskectomy entries

Prior authorization required for advanced imaging and vascular CTA/MRA

Advanced imaging and vascular CTA/MRA codes (e.g., 70546–70549, 72191, 72198, 71275, 74175, 74174) require prior authorization; secure authorization before performing these advanced imaging studies.

• 70546–70549 — Head and neck MRA variants
• 72191, 72198 — Spinal MRA/CTA variants
• 71275, 74174, 74175 — Chest/abdomen CTA/CT angiography codes

Obtain prior authorization for PAP/DME devices and accessories

PAP device interfaces, accessories and related durable medical equipment (HCPCS A70xx series, A7030–A7046, E0470/E0471, E0562) require prior authorization; obtain prior authorization before dispensing PAP interfaces, humidifiers, filters, masks, or PAP devices.

• A7030–A7046 — PAP masks, cushions, tubing, filters, replacements
• E0470/E0471 — Respiratory assist devices (bi‑level)
• E0562 — Heated humidifier used with PAP device

Prior authorization required for implantable cardiac/neuromodulation device procedures

Implantable cardiac and neuromodulation device procedures (e.g., cardiac contractility modulation system codes 0410T–0416T, integrated neurostimulation codes 0908T–0910T) require prior authorization; secure authorization prior to device implantation, replacement, or related programming.

• 0410T–0416T — Cardiac contractility modulation system insertion/replacement
• 0908T–0910T — Integrated neurostimulation system implantation/revision
• 0913T/0910T — Percutaneous therapeutic drug delivery and vagus device entries

Obtain prior authorization for percutaneous spine and interventional procedures

Percutaneous spine/interventional procedures (e.g., intradiscal cellular product codes 0629T–0630T, sacroplasty 0200T–0201T, percutaneous laminotomy 0274T) require prior authorization; obtain authorization before performing these percutaneous interventions.

• 0629T–0630T — Intradiscal cellular product injections
• 0200T–0201T — Percutaneous sacral augmentation (sacroplasty)
• 0274T — Percutaneous laminotomy/laminectomy entries

Obtain prior authorization for codes listed in this section (partial)

This section lists numerous Medicare procedure and HCPCS codes (examples include Q4306, Q4305, 15826, Q4310, 15271, 20932) that require prior authorization; providers must obtain authorization before performing or billing these listed items and services.

• Q4306, Q4305 — American Amnion products per sq cm
• 15826 — Rhytidectomy; Glabellar frown lines
• 15271 — Skin substitute graft application (first 25 sq cm)
• 20932 — Allograft osteoarticular placement

Prior authorization required for wound matrix and biologic products

Additional wound matrix and biologic product HCPCS codes (e.g., Q4102, Q4101, Q4186, Q4158, Q4154) require prior authorization; obtain authorization prior to using or billing these wound biologic products.

• Q4102 — Oasis wound matrix per sq cm
• Q4101 — Apligraf per sq cm
• Q4186 — Epifix per sq cm
• Q4158 — Kerecis Omega‑3 per sq cm

Obtain prior authorization for listed representative CPT/HCPCS codes

Providers must obtain prior authorization for the specific CPT/HCPCS codes listed (e.g., 21125, 0330T, 78813, 74181, Q5120) before providing corresponding procedures, imaging, or injectable products.

• 21125 — Mandibular augmentation with prosthetic material
• 0330T — SimpliMax per sq cm
• 78813 — PET imaging whole body
• 74181 — MRI abdomen without contrast
• Q5120 — Pegfilgrastim biosimilar injection

Prior authorization required for selected procedures and supplies

Selected procedures and supplies in this extract (e.g., 29868, 62264, 93314, 77049, 73725, L8693, C2624, 15017) require prior authorization; obtain authorization prior to scheduling or supplying these services.

• 29868 — Arthroscopy knee with meniscal transplantation
• 62264 — Lysis of percutaneous epidural adhesions
• 93314 — Transesophageal echocardiography
• 77049 — Breast MRI with and without contrast
• C2624 — Implantable pulmonary artery pressure sensor

Obtain prior authorization for listed injectable drugs, biologics and biosimilars

Various injectable drugs, biologics, and biosimilars (J‑codes and Q‑codes listed, e.g., J9311, J9306, J1950, J9144, J9299) require prior authorization; providers must obtain authorization before administering or billing these medications.

• J9311 — Rituximab + hyaluronidase injection
• J9306 — Pertuzumab injection
• J9144 — Daratumumab with hyaluronidase injection
• J9299 — Nivolumab injection (1 mg)
• Q5122/Q5125 — Pegfilgrastim biosimilars

Secure prior authorization for radiation therapy planning and brachytherapy planning

Radiation therapy planning and prostate brachytherapy planning codes (e.g., 32701, 76873) require prior authorization; obtain authorization prior to planning or brachytherapy procedures.

• 32701 — Thoracic target delineation for SBRT (entire course)
• 76873 — Echography, transrectal; prostate volume study for brachytherapy planning

Obtain prior authorization for brachytherapy, IMRT, proton and related radiation services

Brachytherapy, IMRT, proton delivery, robotic radiosurgery and related radiation delivery services (e.g., 77318, 77412, 77525, G0339/G0340) require prior authorization; obtain authorization before planning or delivering these radiation treatments.

• 77318 — Complex brachytherapy isodose plan
• 77412 — Radiation treatment delivery (3+ separate areas)
• 77525 — Proton treatment delivery; complex
• G0339/G0340 — Robotic linear accelerator radiosurgery entries

Prior authorization required for SRS/SBRT, CPAP and related procedures

SRS/SBRT, CPAP devices, stereotactic radiosurgery and related radiation/neurosurgical procedure codes (e.g., 61796–61799, 77407, E0601) require prior authorization; secure authorization prior to treatment delivery or DME provision.

• 61796–61799 — Stereotactic radiosurgery cranial lesion codes
• 77407 — Radiation treatment delivery, 2 separate areas
• E0601 — CPAP device

Obtain prior authorization for high‑cost drugs, biologics and cell/gene therapies

Selected high‑cost drugs, biologics, and cell/gene therapies (e.g., J3398, Q2055, Q2042) are listed as requiring prior authorization; obtain authorization before administration or billing of CAR‑T and gene therapy products.

• J3398 — Voretigene neparvovec (gene therapy)
• Q2055 — Idecabtagene vicleucel (CAR‑T)
• Q2042 — Tisagenlecleucel (CAR‑T)

Secure prior authorization for advanced imaging and interventional cardiology procedures

Advanced imaging and interventional cardiology codes (e.g., 70551, 71250, 74176, 76390, 93351, 92928) require prior authorization; obtain authorization before performing advanced imaging or coronary interventions.

• 70551 — MRI brain without contrast
• 71250 — CT thorax without contrast
• 74176 — CT abdomen and pelvis without contrast
• 93351 — Select echocardiography/cardiac procedure codes
• 92928 — Coronary stent placement with angioplasty