Prior Authorization Requirement for Unlisted CPT Codes

01999

UNLISTED ANES PROC

76496

UNLISTED FLUOROSCOPIC PROCEDURE

76499

UNLISTED DX RADIOGRAPHIC PROC

76999

UNLISTED ULTRASOUND PROCEDURE

77299

UNLISTED PROC THERAP RAD CLINICAL TX PLANNING

77399

UNLIST PROC MED RAD PHYSICS/DOSIMETRY & TX DEVIC

77499

UNLISTED PROC THERAP RAD CLINICAL TX MGMT

77799

UNLISTED PROC CLINICAL BRACHYTHERAP

78099

UNLISTED ENDOCRINE PROC DX NUCLEAR MEDS

78199

UNLIST HEMATOPOIETIC & LYMPHATIC PROC-DX NUCLEAR

78299

UNLISTED GI PROC DX NUCLEAR MEDS

78399

UNLISTED MS PROC DX NUCLEAR MEDS

78599

UNLISTED RESPIRATORY PROC DX NUCLEAR MEDS

78699

UNLISTED NERV SYST PROC DX NUCLEAR MEDS

90999

UNLISTED DIALYSIS PROC INPT/OUTPT

19499

UNLISTED PROC BREAST

81099

UNLISTED UA PROC

84999

UNLISTED CHEM PROC

85999

UNLISTED HEMATOLOGY & COAGULATION PROC

86849

UNLISTED IMMUNOLOGY PROC

86999

UNLISTED TRANSFUSION MEDS PROC

87999

UNLISTED MICROBIOLOGY PROC

88099

UNLISTED NECROPSY PROC

88199

UNLISTED CYTOPATHOLOGY PROC

88399

UNLISTED SURG PATH PROC

89240

UNLIST MISCELLANEOUS PATHOLOGY TEST

89398

UNLISTED REPROD MED LAB PROC

20999

UNLISTED PROC MS SYST GEN

21089

UNLISTED MAXILLOFACIAL PROSTH PROC

21499

UNLISTED MS PROC HEAD

21899

UNLISTED PROC NECK/THORAX

22999

UNLISTED PROC ABD MS SYST

23929

UNLISTED PROC SHOULDER

24999

UNLISTED PROC HUMERUS/ELBOW

27599

UNLISTED PROC FEMUR/KNEE

28899

UNLISTED PROC FT/TOES

29799

UNLISTED PROC CASTING/STRAPPING

30999

UNLISTED PROC NOSE

31299

UNLISTED PROC ACCES SINUSES

31599

UNLISTED PROC LARYNX

31899

UNLISTED PROC TRACHEA BRONCHI

32999

UNLISTED PROC LUNGS & PLEURA

36299

UNLISTED PROC VASCULAR INJ

37501

UNLISTED VASCULAR ENDOSCOPY PROC

37799

UNLISTED PROC VASCULAR SURG

38129

UNLISTED LAPAROSCOPY SPLEEN

38589

UNLISTED LAP PROC-LYMPHATIC SYST

38999

UNLISTED PROC HEMIC/LYMPHATIC SYST

39499

UNLISTED PROC MEDIASTINUM

39599

UNLISTED PROC DIAPHRAGM

40799

UNLISTED PROC LIPS

40899

UNLISTED PROC VESTIBULE MOUTH

42299

UNLISTED PROC PALATE UVULA

42699

UNLISTED PROC SALIVARY GLANDS/DUCTS

42999

UNLISTED PROC PHARYNX/ADENOIDS/TONSILS

43289

UNLISTED LAPAROSCOPY ESOPHAGUS

43499

UNLISTED PROC ESOPHAGUS

43659

UNLISTED LAPAROSCOPY STOMACH

44238

UNLISTED LAP PROC INTEST NO RECTUM

44899

UNLISTED PROC MECKEL'S DIVERTIC & MESENTERY

44979

UNLISTED LAPAROSCOPY APPENDIX

45399

UNLISTED PROCEDURE COLON

45499

UNLIS LAPS PX RECTUM

47379

UNL LAP PROC LIVER

47399

UNLISTED PROC LIVER

48999

UNLISTED PROC PANCREAS

49329

UNLISTED LAPAROSCOPY ABDOMENT PERITONEUM OMENTUM

49659

UNLISTED LAPAROSCOPY HERNIOPLASTY HERNIORRHAPHY HERNIOTOMY

49999

UNLISTED PROC ABD PERITONEUM & OMENTUM

50549

UNLISTED LAPAROSCOPY RENAL

50949

UNL LAP PROC-URETER

53899

UNLISTED PROC URIN SYST

54699

UNLISTED LAPAROSCOPY TESTIS

55559

UNLISTED LAPAROSCOPY SPERMATIC CORD

55899

UNLISTED PROC MALE GENIT SYST

58578

UNLISTED LAPAROSCOPY UTERUS

58579

UNLISTED HYSTERSCOPY UTERUS

58679

UNLISTED LAPAROSCOPY OVIDUCT OVARY

58999

UNLISTED PROC FE GENIT SYST

59897

UNLIST FETL INVASV PROC W/US GUID

59898

UNLISTED LAPAROSCOPY MATERNITY CARE AND DELIVERY

59899

UNLISTED PROC MATERN CARE & DELIV

60659

UNLISTED LAPAROSCOPY ENDOCRINE SYSTEM

60699

UNLISTED PROC ENDOCRINE SYST

67299

UNLISTED PROC POST SEGMT

67999

UNLISTED PROC EYELIDS

68399

UNLISTED PROC CONJUNC

68899

UNLISTED PROC LACRIMAL SYST

69399

UNLISTED PROC EXT EAR

69799

UNLISTED PROC MID EAR

69949

UNLISTED PROC INNER EAR

69979

UNLISTED PROC TEMPORAL BONE-MID FOSSA APPROACH

90399

UNLISTED IMMUNE GLOBULIN

90899

UNLISTED PSYCH SERV/PROC

91299

UNLISTED DX GASTROENTEROLOGY PROC

92700

UNLIST OTORHINOLARYNGOLOG SRVC/PROC

92499

UNLISTED OPHTH SERV/PROC