Prior Authorization Matrix

Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Developmental/ Behavioral/Neuropsychological/Neuro Cl Testing (outside the pediatrician's office) 96105-96146 X Diabetic shoes and inserts A5500-A5514 X Covered only for the treatment of diabetic foot [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Endobronchial Brachytherapy 0182T, 77321, 77326-77328, 77750- 77799, C1715-C1719, C2616, C2634- C2643, C2698-C2699, C9725-C9726 X Endoscopic Therapies for GERD: Bard EndoCinch, StomaphyX or EsophyX [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Flow Cytometry 88182, 88184, 88185, 88187, 88188, 88189 X Fluoroscopic guided injections such as ESI 62320-62327 X Focused US ablation other than uterine fibroids, (including but not limited to Magnet [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Genetic Testing Include but not limited to the following: 21217, 81105-81167, 81170-81190, 81200-81299, 81300-81364, 81400- 81493, 81504-81512, 81517-81599, 83698, 87901-87912, 88240-88241, 88245-882 [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider High Cost Specialty Medications See Medication Tab X See "Medications" Tab. [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Immunizations 90476-90749, Q2033-Q2039 X Immunizations listed on the schedules of the CDC are covered. [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Inpatient - Unplanned/Acute or Planned/Elective X Heath plan notification required within 24 hours of all admission including maternity deliveries. Inpatient Rehabili [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Measurement of Lipoprotein- Associated Phospholipase A2 in the Assessment of Cardiovascular Risk Lipoprotein-associated phospholipase A2 (Lp-PLA2) 83698 X Microwave Tumor Ablation 32998, 47382, 50592 [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Non-Specific Codes Procedure and HCPCS codes ending in 99 X Unspecific HCPCS codes ending in 99 require PA Occipital Nerve Stimulation 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T X Occup [...] Last updated: 04/04/2024Services/Procedures Example of Codes Prior Authorization Required No Prior Authorization Required Benefit Exclusion/ Limitation Additional Information for Provider Surgical deactivation of headache Trigger Site X Synagis (RSV antibody IM injection) 90378 X Please refer provider to obtain pre-cert from Optum Rx unless the provider explicitly indicate they are abl