CPT/HCPCS Prior Authorization Code List — Commercial & Medicare Advantage
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Lists CPT/HCPCS codes, prior authorization requirements, submission processes, and vendor-managed delegations for Commercial and Medicare Advantage plans administered by Medical Mutual - Ohio.
No material clinical or coverage changes in this revision.
Coverage Criteria and Per‑Code Authorization Stance
Medicare Advantage Coverage Alignment
Medicare Advantage determinations adhere to CMS NCDs and, where applicable, LCDs implemented by MACs.
Home Health Coverage Note
Exception to prior authorization requirement for home health:
Per-code authorization/coverage stance
This excerpt records per-CPT-code coverage-management stance (primarily prior authorization requirements) and notes exceptions.
Examples
- CPT 11971: Commercial — prior authorization required (medical policy); prior authorization not required for personal history of breast cancer; Medicare Advantage — prior authorization required - follow Medicare coverage criteria.
- CPT 19357: Prior authorization required - medical policy; prior authorization not required for personal history of breast cancer.
- CPT 15771: Prior authorization required for commercial plans (CMP/InterQual) and Medicare Advantage per listing; details appear in code entry notes.
Breast reconstruction and related procedures coverage stance
Listed CPT codes related to breast reconstruction and peri-implant procedures require prior authorization under medical policy; exemption noted for patients with personal history of breast cancer.
Sample affected codes
- CPT 19342 — insertion or replacement of breast implant (separate day from mastectomy): prior authorization required; prior authorization not required for personal history of breast cancer.
- CPT 19357 — tissue expander placement in breast reconstruction: prior authorization required; prior authorization not required for personal history of breast cancer.
- CPT 19499 — unlisted breast procedure: prior authorization required; notes include CMP references and an exception for personal history of breast cancer.
Craniofacial, spine, and grafting procedures coverage stance
Multiple craniofacial, spine, and grafting CPT codes are subject to prior authorization and mapped to InterQual or Medicare coverage criteria as specified.
Examples
- CPT 20931 — allograft/osteopromotive material for spine: prior authorization required - medical policy (CMP200403/InterQual).
- CPT 21182–21184 — craniofacial reconstruction stratified by grafting area (eg, <40 sq cm, 40–80 sq cm, >80 sq cm): prior authorization required - InterQual; some entries also state follow Medicare coverage criteria.
Prior authorization and coverage guidance (fragment)
Coverage stance for listed surgical CPT codes in this fragment
Additional guidance
- Some codes explicitly instruct to 'follow Medicare coverage criteria' when evaluating Medicare Advantage prior authorization requests.
- Certain reconstruction and grafting codes include specific thresholds (e.g., grafting area) that are referenced in the code descriptions and may affect authorization pathways.
Prior Authorization and Criteria Mapping (excerpt)
Prior authorization stance and applicable criteria source for listed CPTs in this excerpt.
Criteria sources
- InterQual is the referenced clinical criteria source for many surgical and endoscopic CPTs (e.g., ankle arthroscopy, nasal/sinus endoscopy, ethmoidectomy lines).
- Some CPTs cite a Corporate Medical Policy (CMP) identifier as the basis for medical-policy-driven prior authorization decisions.
Per-code coverage nodes (excerpted)
Per-code coverage/authorization stance and special notes:
ANY of the following
- CPT 44705: Entry lists both 'PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY' and 'PRIOR AUTHORIZATION NOT REQUIRED' in different flags; consult notes for the specific condition and payor applicability.
- CPT 51715: Listed as prior authorization not required in some contexts but prior authorization required for Medicare Advantage; see line-item notes for applicability.
Prior authorization and gender-affirming exceptions
Authorization and coverage stance for listed procedures
ANY of the following
- Exception: Some procedures specify authorization is required only when performed for gender-affirming diagnoses (ICD F64.x; Z87.890) — in these cases prior approval is required only when the gender-affirming diagnosis is present.
- Some entries indicate prior authorization is required for Medicare Advantage only or instruct to follow Medicare coverage criteria for Medicare Advantage members.
Authorization and criteria mapping
Stated coverage/authorization stance for listed gynecologic procedures in this fragment
ANY of the following
- Authorization may be conditional: some gynecologic entries require authorization only when performed for gender-affirming diagnoses (ICD F64.0, F64.2, F64.8, F64.9, Z87.890).
- Some myomectomy/hysterectomy entries reference uterus weight thresholds (eg, >250 gm) or InterQual as the criteria source and note exceptions for members with a personal history of cancer.
Per-code authorization and exception summary (partial)
Coverage stance varies by CPT code; common patterns are prior authorization required (often with an InterQual or CMP reference), some codes follow Medicare/CMS criteria, and some codes have explicit exceptions where prior authorization is not required.
ANY of the following
- Exceptions noted include prior authorization not required for personal history of cancer on select gynecologic and reconstructive codes.
- Some codes require prior authorization only for members meeting age thresholds (eg, certain strabismus/eye procedure codes are prior authorization required only for members ≥18 years old).
Prior authorization stance by code
Codes listed in this segment require prior authorization and are tied to specific clinical review criteria or programs.
Notable details
- CPT 69706 (balloon dilation of eustachian tube) shows a Medicare Advantage exception in the line item notes — prior authorization not required for Medicare Advantage in some flags; verify the applicable payor guidance.
Coverage routing by CPT code
Authorization and coverage routing for listed CPT gene tests
ANY of the following
- A subset of molecular/genetic CPTs explicitly reference Medical Policy CMP201303 as the authorization basis (examples include certain FLT3, F9, and other single-gene tests).
- Many genetic test entries instruct to 'follow Medicare coverage criteria' for Medicare Advantage members; verify Medicare applicability per code line.
Coverage stance for listed genetic CPT codes
Each CPT code entry indicates prior authorization is required and specifies which review criteria to apply.
Examples
- CPT 81289–81293 (KIT, MLH1, etc.) — prior authorization required with InterQual indicated as the review tool and 'follow Medicare coverage criteria' flags present on many entries.
Coverage stance and authorization criteria (partial)
Stated coverage stance for listed CPT codes in this excerpt
Prior authorization and referencing rules
Authorization and coverage guidance for listed CPT codes
ANY of the following
- CPT 81354 (OGM) is annotated with InterQual = CMP201303 and shows a mixed flag in the excerpt (PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY and also PRIOR AUTHORIZATION NOT REQUIRED under certain Medicare flags); consult the line-item notes to reconcile the mixed status.
- CPT 81410 genomic sequence panel (aortic dysfunction/dilation) requires sequencing of at least 9 specified genes as part of the panel requirement; panel composition must be provided when seeking authorization.
Coverage criteria summary for excerpted CPT codes
Coverage stance and requirements for listed molecular/genomic CPT codes in this excerpt
ANY of the following
- Many disease-specific genomic panels include minimum gene-count requirements (examples: CPT 81410 requires sequencing of at least 9 genes for aortic dysfunction/dilation panels; CPT 81432 requires at least 10 genes for hereditary breast/ovarian/endometrial cancer panels; CPT 81430 requires at least 60 genes for certain hearing-loss panels).
Code Lists and Code‑Level Details
| 00170 | Anesthesia for intraoral procedures; prior authorization required - medical policy (CMP202010) |
| 11920 | Tattooing/micropigmentation ≤6.0 sq cm; prior authorization required - medical policy (CMP94002); prior auth not required for personal history of breast cancer |
| 11921 | Tattooing 6.1–20.0 sq cm; prior authorization required - medical policy (CMP94002); prior auth not required for personal history of breast cancer |
| 11950 | Subcutaneous injection of filling material ≤1 cc; prior authorization required |
| 11951 | Subcutaneous injection of filling material 1.1–5.0 cc; prior authorization required |
| 11952 | Subcutaneous injection of filling material 5.1–10.0 cc; prior authorization required |
| 11954 | Subcutaneous injection of filling material >10.0 cc; prior authorization required |
| 11960 | Insertion of tissue expander(s) for other than breast; prior authorization required |
| 11970 | Replacement of tissue expander with permanent implant; prior authorization required (CMP94002); prior auth not required for personal history of breast cancer |
| 11971 | Removal of tissue expander without insertion of implant; prior authorization required (CMP94002); prior auth not required for personal history of breast cancer |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy; prior authorization required (CMP202103/CMP201929/CMP94002); prior auth not required for personal history of breast cancer |
| 19350 | Nipple/areola reconstruction; prior authorization required (CMP202103/CMP201929/CMP94002); prior auth not required for personal history of breast cancer |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansions; prior authorization required (CMP202103/CMP201929/CMP94002); prior auth not required for personal history of breast cancer |
| 21180 | Reconstruction, forehead/supraorbital rims with autograft; prior authorization required - InterQual |
| 21182 | Reconstruction of orbital walls/rims/forehead with multiple autografts; total area <40 sq cm; prior authorization required - InterQual |
| 21183 | Reconstruction ... total area 40-80 sq cm; prior authorization required - InterQual |
| 21184 | Reconstruction ... total area >80 sq cm; prior authorization required - InterQual |
| 21230 | Graft, rib cartilage, autogenous, to face/chin/nose/ear; prior authorization required (InterQual/CMP20129) |
| 29892 | Arthroscopic aided repair, ankle/talar dome/tibial plafond; prior authorization required - medical policy (CMP202406) |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; prior authorization required - medical policy (CMP200509) |
| 29892 | Arthroscopic aided repair, ankle/talar dome/tibial plafond; prior authorization required - medical policy (CMP202406) |
| 29894 | Arthroscopy, ankle; removal loose/foreign body; prior authorization required - InterQual |
| 29895 | Arthroscopy, ankle; synovectomy, partial; prior authorization required - InterQual |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; prior authorization required - medical policy (CMP200509) |
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid; prior authorization required - medical policy (CMP200509) |
| 31299 | Nasal/sinus endoscopy w/dilation of frontal & sphenoid sinus ostia - unlisted; prior authorization required - InterQual (CMP202405) |
| 33990 | Replacement of VAD pump(s); implantable intracorporeal, single ventricle; prior authorization required - InterQual/CMP references |
| 36465 | Injection of non-compounded foam sclerosant... single incompetent extremity truncal vein; prior authorization required - InterQual (CMP202014); initial 8 treatments not requiring prior authorization |
| 36475-36479, 36482-36483 | Endovenous ablation, injection/sclerotherapy, chemical adhesive and laser codes listed with prior authorization and InterQual references |
| 43644-43775, 43842-43848 | Gastric restrictive/bariatric procedure codes listed with prior authorization required and CMP94030 references |
| 53445 | Insertion of inflatable urethral/bladder neck sphincter; includes pump, reservoir, cuff; prior authorization flags mixed - see notes (prior auth not required in some notes); Medicare Advantage prior auth follow Medicare criteria |
| 53448 | Removal and replacement of inflatable urethral/bladder neck sphincter through infected field at same session; prior authorization flags mixed - see notes |
| 53899 | Unlisted procedure, urinary system; prior authorization required - medical policy in many entries |
| 54400 | Insertion of penile prosthesis; non-inflatable (semi-rigid); prior authorization required - medical policy (CMP201609/CMP95034) |
| 54401 | Insertion of penile prosthesis; inflatable (self-contained); prior authorization required - medical policy (CMP201609/CMP95034); prior approval required for gender-affirming diagnoses |
| 54405 | Insertion of multi-component inflatable penile prosthesis; prior authorization required - medical policy (CMP201609/CMP95034); prior approval required for gender-affirming diagnoses |
| 57107 | Vaginectomy, partial removal of vaginal wall; prior authorization required - medical policy (CMP201609/CMP201303); authorization required only when for gender-affirming diagnosis (F64.x, Z87.890) |
| 56800 | Plastic repair of introitus; referenced in fragment with prior authorization required - medical policy |
| 56805 | Clitoroplasty for intersex state; prior authorization required - medical policy (authorization only required when for gender-affirming diagnosis) |
| 58548 | Laparoscopic myomectomy / related mapping in fragment; prior authorization required - InterQual; prior auth not required for personal history of cancer |
| 58550 | Laparoscopic myomectomy - mappings; prior authorization required - InterQual; prior auth not required for personal history of cancer |
| 58552 | Laparoscopic myomectomy - mappings referenced; prior authorization required - InterQual/CMP201609; prior auth not required for personal history of cancer |
| 58553 | Laparoscopic myomectomy - mappings referenced; prior authorization required - InterQual; prior auth not required for personal history of cancer |
| 58554 | Laparoscopic myomectomy - mappings referenced; prior authorization required - InterQual/CMP201609; prior auth not required for personal history of cancer |
| 58558 | Hysteroscopy with sampling; prior authorization required - InterQual; prior auth not required for personal history of cancer |
| 58573 | Laparoscopic/myomectomy related code referenced to InterQual (CMP201609); prior authorization required with noted exceptions for personal history of cancer |
| 58578 | Unlisted laparoscopy procedure, uterus; prior authorization required - InterQual (CMP202405); prior auth not required for personal history of cancer |
| 58580 | Transcervical ablation of uterine fibroid(s); InterQual (CMP202404); mixed prior auth notes - some lines indicate prior authorization required, others indicate not required; prior auth not required for personal history of cancer |
| 67903-67961, 69300 | Unlisted anterior segment/eyelid repair and related procedures (blepharoptosis repair, ectropion repair, canthoplasty, excision/repair of eyelid); prior authorization required - medical policy (CMP201721/CMP202405/CMP96018) and/or follow Medicare coverage criteria; some codes have age-specific or Medicare Advantage exceptions |
| 69706-69930, 76499, 76999, 69930 | Nasopharyngoscopy with dilation (balloon dilation), ear/middle ear procedures, cochlear and osseointegrated implant procedures and various unlisted diagnostic procedure codes; prior authorization required - medical policy or InterQual (CMP202305/CMP200401); 69706 noted prior auth not required for Medicare Advantage only; 69930 mapped to InterQual/CMS |
| 81105-81183 | Series of human platelet antigen genotyping and multiple single-gene/molecular test CPT codes (including BRCA, IDH1/2, many hereditary/neurologic/oncology genes); prior authorization required - InterQual or medical policy (CMP201303) |
| 81179-81183 | Gene analysis examples for spinocerebellar ataxia genes; prior authorization required - InterQual |
| 81186-81227 | Multiple single-gene CPT codes mapped to various gene targets with prior authorization required - InterQual or medical policy |
| 81228-81250 | Cytogenomic microarray and a range of gene analysis CPT codes with prior authorization required - InterQual or follow Medicare coverage criteria |
| 81242-81293 | Range of CPT codes for gene analyses (single variant, full gene sequencing, allele characterization, methylation, rearrangement, chimerism, STR comparative analysis, CNV/duplication/deletion); prior authorization required - InterQual or Medical Policy (CMP201303) or follow Medicare coverage criteria |
| 81289 | KIT gene analysis; prior authorization required - InterQual |
| 81301 | Microsatellite instability analysis; prior authorization required - InterQual |
| 81305 | MYD88 p.Leu265Pro (L265P) variant analysis; prior authorization required - InterQual/CMP201303 |
| 81306 | NUDT15 common variant analysis; prior authorization required - InterQual |
| 81320 | PLCG2 common variants; prior authorization required - InterQual |
| 81329 | SMN1 dosage/deletion analysis including SMN2 if performed; prior authorization required - InterQual |
| 81336 | SMN1 full gene sequence; prior authorization required - InterQual |
| 81345 | TERT targeted sequence analysis (promoter region); prior authorization required - InterQual/CMP201303 |
| 81400-81408 | Molecular pathology procedures, levels 1–9 (81400–81408); prior authorization required - InterQual; follow Medicare coverage criteria as indicated |
| 81340-81348 | Gene analysis / methylation and rearrangement analyses for specific genes (examples shown); prior authorization required - InterQual or follow Medicare coverage criteria |
| 81350-81383 | Cytogenomic (genome-wide) analysis and HLA typing codes with various resolution options; prior authorization required - InterQual/CMP201303; follow Medicare coverage criteria as indicated |
| 81406 | Molecular pathology procedure, level 6; prior authorization required - InterQual |
| 81407 | Molecular pathology procedure, level 8; prior authorization required - InterQual |
| 81408 | Molecular pathology procedure, level 9; prior authorization required - InterQual |
| 81410 | Genomic sequence analysis panel for aortic dysfunction/dilation; must include sequencing of at least 9 specified genes; prior authorization required - InterQual |
| 81430 | Hearing loss genomic sequence panel; must include sequencing of at least 60 genes; prior authorization required - InterQual |
| 81431 | Hearing loss duplication/deletion analysis panel; must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6; prior authorization required - InterQual |
| 81432 | Hereditary breast/ovarian/endometrial cancer panel; must include sequencing of at least 10 genes including BRCA1/2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, TP53; prior authorization required - InterQual |
| 81441 | Inherited bone marrow failure syndromes panel; must include sequencing of at least 30 genes; prior authorization required - InterQual |
| 81445 | Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes; prior authorization required - Medical Policy/InterQual |
| 81450 | Targeted genomic sequence analysis panel, hematolymphoid neoplasm, 5-50 genes; DNA and RNA analysis when performed; prior authorization required - Medical Policy (CMP201923) or InterQual |
| 81455 | Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, 51+ genes; DNA and RNA analysis when performed; prior authorization required - Medical Policy (CMP201303) |
| 81459 | Solid organ neoplasm panel including TMB, MSI, CNV, rearrangements (DNA and/or RNA); prior authorization required - InterQual |
Submission, Prior Authorization Requirements, and Vendor Routing
Prior authorization required for listed services
Prior authorization for the services listed is required for both Commercial and Medicare Advantage plans unless otherwise specified in the special instruction column.
Submission methods and provider responsibility
Medical Mutual contracted providers must submit prior authorization requests via the web; non‑contracted providers may submit via fax. Specific portals and fax numbers vary by service and delegated vendor.
- Contracted providers: submit via web portals as directed.
- Non‑contracted providers: fax submissions where allowed; fax numbers differ by service.
Submission contacts and vendor portals
Use the vendor-specific submission endpoints for delegated services: Cohere Health portal/fax for Cohere-managed services and eviCore portal/phone/fax for Radiation/Oncology; Care Management web/fax applies for Medical Mutual–managed codes.
- Cohere Health: https://login.coherehealth.com; fax (570) 684-4168; phone (855) 482-3649.
- eviCore Radiation/Oncology: Phone 1-888-693-3211, Fax 1-866-699-8160; portal https://www.evicore.com/pages/providerlogin.aspx.
- Care Management: Cohere portal or fax numbers listed on Medical Mutual provider page for Care Management submissions.
Home health services — prior auth exception
No prior authorization is required for home health care services; providers remain responsible to ensure medical necessity for coverage.
Per-code prior authorization annotations and notes
Many CPTs in this document are annotated with prior authorization requirements for Commercial and Medicare Advantage and reference the applicable review criteria (InterQual, CMP/medical policy, or CMS Medicare coverage).
- Entries indicate whether prior authorization is required and which criteria (InterQual, CMP#, or CMS) apply.
- Some lines include exceptions such as 'prior authorization not required for personal history of breast cancer.'
Breast surgery prior authorization and personal history exception
Breast surgery CPT codes (e.g., 19303, 19316, 19318 and related codes) require prior authorization; several entries explicitly state prior authorization is not required when 'personal history of breast cancer' is noted.
- Examples: 19357 (tissue expander placement) and 19342 (implant insertion/replacement) are listed as PRIOR AUTHORIZATION REQUIRED and include notes about the personal history exception.
- Providers should include relevant diagnosis (personal history of breast cancer) when applicable to avoid prior authorization when specified.
Breast reconstruction/mastectomy-related codes require prior authorization
Breast reconstruction and mastectomy-related CPTs (for example 19342, 19350, 19357 and listed peri-implant/reconstruction codes) are designated PRIOR AUTHORIZATION REQUIRED under Medical Policy or to follow Medicare coverage criteria; some lines note exemptions for personal history of breast cancer.
Additional breast procedure CPTs require prior authorization
Additional breast-related procedure codes (e.g., 19370, 19371, 19380, 19396, 19499) are marked PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY and include CMP references; follow the listed policy IDs and notes.
- 19499 is listed PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY with CMP202405 among referenced policies.
- Follow the CMP references shown on each code line when submitting authorization requests.
Spine / osteopromotive and bone healing codes require prior authorization
Allograft, osteopromotive and bone-healing procedure codes for spine and related applications (e.g., 20931, 20975, 20979, 20982, 20983) indicate prior authorization is required and reference Medical Policy or InterQual as the review criteria.
Craniofacial/reconstruction codes require prior authorization (InterQual/CMS)
Craniofacial and reconstruction CPTs (examples: 21120–21184 and related codes) are mapped to PRIOR AUTHORIZATION REQUIRED with InterQual or Medicare coverage criteria; follow the referenced InterQual/CMP guidance when requesting authorization.
- Codes such as 21180–21184 are explicitly listed PRIOR AUTHORIZATION REQUIRED - INTERQUAL and may also state FOLLOW MEDICARE COVERAGE CRITERIA.
- Bone graft area thresholds (21182 <40 sq cm; 21183 40–80 sq cm; 21184 >80 sq cm) are noted and affect the criteria source.
Prior authorization requirement summary for reconstruction codes
Many craniofacial and related reconstruction CPTs (e.g., 21180, 21182, 21183, 21184 and similar codes) are designated PRIOR AUTHORIZATION REQUIRED - INTERQUAL or reference a Medical Policy; providers must follow the specified criteria source.
Follow referenced CMP medical policy IDs for authorization
Specific CPT lines reference Corporate Medical Policy identifiers as the basis for prior authorization decisions (for example, 21230 references CMP20129 and other listed codes reference CMP IDs shown on each line).
- When a CMP ID is shown on a code line, providers must adhere to that Medical Policy for the prior authorization review.
Arthroscopy and rhinoplasty CPTs require prior authorization (InterQual / CMP)
Multiple arthroscopy and rhinoplasty CPTs (including ankle arthroscopy codes 29892–29899 and rhinoplasty codes 30400–30462) are marked PRIOR AUTHORIZATION REQUIRED and typically reference InterQual or a Medical Policy as the review tool.
- Ankle arthroscopy examples: 29892 is PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY (CMP202406); 29894–29898 reference INTERQUAL.
- Rhinoplasty codes (30400–30462) cite CMP200509 and may instruct to follow Medicare coverage criteria where indicated.
Ankle arthroscopy codes require prior authorization
Ankle arthroscopy and related procedures (e.g., 29892, 29894–29899) require prior authorization; the entries reference either Medical Policy (CMP202406) or InterQual as the criteria source.
Nasal / rhinoplasty / septoplasty procedures prior authorization
Nasal, rhinoplasty, and septoplasty procedures (e.g., 30115, 30400–30450, 30520, 30999) require prior authorization and reference InterQual, CMP200509, or Medicare coverage criteria as indicated on each line.
- Include the applicable clinical documentation tied to InterQual or CMP200509 when submitting requests for nasal/septal surgeries.
Nasal/sinus endoscopy and ethmoidectomy codes require prior authorization
Endoscopic nasal/sinus procedures and ethmoidectomy codes (e.g., 31237, 31253–31297, 31299) require prior authorization with InterQual listed as the criteria source for many CPTs; some entries also map to CMP202405.
Misc procedures — InterQual/CMP cross-reference and prior auth notes
Various procedural CPTs across specialties include cross-references to InterQual or CMPs and indicate prior authorization is required; some entries include Medicare Advantage–specific notes.
- Examples include 31571, 31599, 31899 and other unlisted procedure codes mapping to CMP202405.
- Verify Medicare Advantage notes where they change authorization applicability.
Cardiac device and related CPTs require prior authorization
Cardiac device and related procedure CPTs (for example 33274–33278, 33477, 33927–33929) are listed as PRIOR AUTHORIZATION REQUIRED and reference InterQual or CMP policy identifiers; follow those criteria for authorization.
High‑complexity cardiac/vascular and venous CPTs require prior authorization
High-complexity cardiac, vascular, and venous therapy CPTs (examples: 33975–33999 series, 35206/35236/35266, 36465–36468) require prior authorization; entries reference InterQual, Medical Policy, and in some cases Medicare coverage criteria.
Sclerotherapy prior authorization with initial-treatment exemption
Sclerotherapy injection CPTs (e.g., 36465, 36466) require prior authorization but the entries state prior authorization is not required for the initial eight treatments; any additional treatments must follow applicable criteria.
Specialty / unlisted procedure codes require prior authorization
Specialty and unlisted procedure codes across multiple specialties (e.g., 37799, 38999, 41899, 76499, 76999) are flagged as PRIOR AUTHORIZATION REQUIRED or investigational per medical policy; submit clinical details and follow the referenced CMP or InterQual guidance.
Exceptions and special prior authorization notes — review code notes
Some entries include exceptions or nuanced requirements (for example, 44705 shows both 'PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY' and 'PRIOR AUTHORIZATION NOT REQUIRED'; 51715 notes prior authorization required for Medicare Advantage only). Providers should follow the notes on each code line.
- Verify the 'special instruction' or notes column for code-specific exceptions before submitting.
Follow the listed prior authorization designation and criteria source per CPT
Numerous CPTs are listed as PRIOR AUTHORIZATION REQUIRED in various forms (e.g., PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY, - INTERQUAL, or - FOLLOW MEDICARE COVERAGE CRITERIA); follow the designation and the referenced criteria for each listed procedure.
Authorization requirements for prosthesis and reconstruction CPTs
Prosthesis and reconstruction CPTs (examples: 53445, 53448, 53899, 54125, 54400–54411) indicate PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY and may reference CMP IDs; some entries note authorization is tied to gender-affirming diagnoses or Medicare Advantage specifics.
- When CMP IDs are present (e.g., CMP201609, CMP95034), follow the referenced policy for documentation and criteria.
- Some prosthesis/reconstruction codes require prior approval only for gender-affirming diagnoses.
Gender‑affirming procedure authorization exceptions and requirements
Vaginectomy, vaginoplasty and related reconstructive vulvovaginal CPTs are marked PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY but include statements that authorization is only required when performed for gender-affirming diagnoses (F64.x, Z87.890); include the relevant ICD code when applicable.
- Examples: 57107 and related codes — authorization only required when for gender-affirming diagnoses (F64.0, F64.2, F64.8, F64.9, Z87.890).
- Providers should place the gender-affirming diagnosis code on the procedure line to indicate applicability.
Gynecologic procedure prior authorization requirements and exceptions
Many gynecologic procedures (e.g., revisions of prosthetic vaginal grafts, myomectomy, hysterectomy approaches) are designated PRIOR AUTHORIZATION REQUIRED; some entries reference InterQual or CMP policies and include exceptions such as prior authorization not required for personal history of cancer.
Authorization required only for gender-affirming diagnosis on select codes
Authorization is only required for certain procedures when performed for specific gender-affirming diagnoses (ICD codes F64.0, F64.2, F64.8, F64.9, Z87.890); several entries explicitly reference these diagnoses as the condition that triggers prior authorization requirements.
Per-code prior authorization and criteria source — consult line-item notes
The document lists many CPTs with prior authorization required; specific codes reference InterQual, CMP/medical policy identifiers, or CMS/Medicare coverage criteria as the criteria source — providers must reference the code line to determine which review tool applies.
Ophthalmic/anterior segment procedure codes require prior authorization
Anterior segment and eyelid ophthalmic procedure codes (e.g., 67903–67961, 69300) are designated PRIOR AUTHORIZATION REQUIRED and reference Medical Policy, CMP identifiers, InterQual, or CMS guidance; follow the listed criteria.
Nasopharyngoscopy/ear surgery and implant CPTs require prior authorization
Nasopharyngoscopy, ear surgery, cochlear and implant-related CPTs (e.g., 69706, 69710–69719, 69930) are designated PRIOR AUTHORIZATION REQUIRED; note that 69706 includes a specific note that prior authorization is not required for Medicare Advantage plans only.
- 69706: prior authorization generally required but 'Prior authorization not required for Medicare Advantage plans only' is noted on the line.
- Cochlear/osseointegrated implant codes reference CMP202305/InterQual — include supporting documentation.
Unlisted diagnostic/procedure CPTs require prior authorization
Unlisted diagnostic and procedure codes (e.g., 76499, 76999, 80299, 29999-series unlisted codes) are listed as PRIOR AUTHORIZATION REQUIRED and map to CMP/CMS/InterQual references; submit full clinical details for review.
Genetic/molecular test CPTs require prior authorization (sample codes)
Selected genetic and molecular testing CPTs (examples: human platelet antigen genotyping and IDH1/IDH2 tests such as 81105, 81120, 81121) are designated PRIOR AUTHORIZATION REQUIRED and reference InterQual, CMP201303, or CMS criteria.
- 81105: PRIOR AUTHORIZATION REQUIRED - INTERQUAL (InterQual = CMP202305 / CMS noted).
- 81120/81121: IDH1/IDH2 common variants — PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY (CMP201303) with Medicare criteria noted.
Hereditary cancer and oncology gene analyses require prior authorization
BRCA and other hereditary cancer/oncology gene analysis CPTs (e.g., 81162–81167 and related codes) are listed as PRIOR AUTHORIZATION REQUIRED — many reference InterQual and instruct following Medicare coverage criteria for Medicare Advantage.
- 81162–81167: BRCA full sequence and duplication/deletion analyses — PRIOR AUTHORIZATION REQUIRED - INTERQUAL; Medicare criteria (CMS) listed where applicable.
Prior authorization required for listed gene analyses (InterQual/CMS)
Multiple gene-analysis CPT entries (for example 81179–81183) and many single-gene CPTs are marked PRIOR AUTHORIZATION REQUIRED - INTERQUAL or PRIOR AUTHORIZATION REQUIRED - FOLLOW MEDICARE COVERAGE CRITERIA; follow the indicated review tool for each code.
Follow CMP medical policy references for certain genetic CPTs
Certain genetics/molecular CPTs are assigned PRIOR AUTHORIZATION REQUIRED - MEDICAL POLICY and reference Medical Policy IDs (e.g., 81187, 81233, 81234, 81238, 81245, 81246 reference CMP201303); providers must follow the named medical policy when requesting authorization.
Prior authorization required for listed CPT genetic tests (examples)
CPTs 81242–81246 and other listed genetic test CPTs require prior authorization and specify to follow Medicare coverage criteria or the named review tool (InterQual or CMP201303) as indicated on each line.
- 81242–81246: PRIOR AUTHORIZATION REQUIRED — InterQual or follow Medicare coverage criteria as shown.
Prior authorization and review tool assignment for gene tests
Some gene-test CPTs are routed to InterQual while others reference CMP201303 (Medical Policy) or Medicare coverage criteria; verify the review tool assigned on the CPT line (e.g., GJB2, immunoglobulin/hematologic related codes reference InterQual or CMP201303).
- 81254–81256 and related GJB2 hearing-loss codes: PRIOR AUTHORIZATION REQUIRED - INTERQUAL.
- 81262–81264: interqual/CMP201303 references for hematologic gene rearrangement analyses.
Prior authorization for oncologic and neurologic gene tests
Oncologic and neurologic gene analyses (examples: KIT, KRAS, HTT, FXN series such as 81270–81288) are identified as PRIOR AUTHORIZATION REQUIRED and reference InterQual, CMP201303, or Medicare coverage criteria; follow the specific code line guidance.
Prior authorization required for listed genetic/molecular CPT codes (summary)
Many genetic and molecular CPT codes (ranges noted throughout the document) require prior authorization and reference InterQual or Medical Policy; check each CPT line for the review tool and any Medicare-specific instructions.
Prior authorization and UM tool references for additional genetic CPTs
Additional CPT genetic entries indicate PRIOR AUTHORIZATION REQUIRED - INTERQUAL or - MEDICAL POLICY depending on the code; InterQual and CMP201303 are commonly used review tools — use the code-line mapping to determine routing.
Molecular pathology and genomic panel CPTs require prior authorization; follow panel and policy rules
Prior authorization requirements for molecular pathology and genomic panel CPTs (81400–81408, 81410, 81430, 81445, 81449–81459, etc.) are indicated as PRIOR AUTHORIZATION REQUIRED — many map to InterQual or to specific Medical Policy IDs (e.g., CMP201303) and some panels specify minimum gene counts.
- 81410: genomic sequence analysis panel for aortic dysfunction/dilation must include sequencing of at least 9 specified genes.
- 81430/81431/81432 etc.: disease‑specific panels list minimum gene counts (examples: 60 genes for some hearing-loss panels, 10 genes for hereditary breast/ovarian/endometrial panels).
- Oncology panels (81445/81449/81455) may be designated MEDICAL POLICY (CMP201303) or INTERQUAL as shown.
Key Terms and Review Tools
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.