This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00100
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
00102
00103
00104
00120
No
No
No
No
Description
ANES- SALIVARY GLANDS INCL BX
ANES-PROC INVOLVING PLASTIC REPAIR
CLEFT LIP
ANES-RECON PROCS EYELID
ANES- ELEC-CONVULS THERAP
ANES- EXT/MID/INNER EAR W/BX; NOS
00124
No
ANES- EXT/MID/INNER EAR W/BX; OTOSC
No
00126
00140
00142
00144
00145
00147
00148
00160
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
00162
No
ANES- EXT/MID/INNER EAR W/BX; TYMP
ANES- EYE; NOS
ANES- EYE; LENS SURG
ANES- EYE; CORNEAL TRANSPL
ANES- EYE; VITRECTOMY
ANES- EYE; IRIDECTOMY
ANES- EYE; OPHTH
ANES- NOSE & ACCES SINUSES; NOS
ANES- NOSE/ACCES SINUSES; RAD
SURG
00164
No
ANES- NOSE/ACCES SINUSES; BX TISS
No
00170
00172
00174
00176
00190
00192
00210
No
No
No
No
No
No
No
ANES- INTRAORAL PROC, INCL BX; NOS
ANES- INTRAORAL W/BX; REPR CLEFT
ANES- INTRAORAL W/BX; EXC TUMOR
ANES- INTRAORAL W/BX; RAD SURG
ANES- FACIAL BONES; NOS
ANES- FACIAL BONES; RADICAL SURG
ANES- INTRACRAN PROC; NOS
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
00212
No
00214
00215
No
No
00216
No
Description
ANES- INTRACRAN PROC; SUBDURAL
TAPS
ANES-CRAN; BURR HOLESVENTRICOGRPHY
ANES- INTRACRAN; ELEVAT SKULL FX
ANES- INTRACRAN PROC; VASCULAR
PROC
00218
No
ANES- INTRACRAN; PROC SITTING POSIT
No
00220
No
No
00222
No
00300
No
00320
No
ANES- INTRACRAN; SPINAL FLUID SHUNT
ANES- INTRACRAN; ELECTROCOAG
NERV
ANES-INTEG-MUSC/NRV-HEAD/TRUNKNOS
ANES- PROC ESOPHA/THYROID/TRAC;
NOS
00322
No
No
00326
00350
No
No
00352
No
00400
00402
No
No
ANES- PROC ESOPHA/THYRO/TRACH; BX
ANES-ON THE LARYNX&TRACHEA
CHILDREN < 1 YEAR AGE
ANES- MAJOR VESSELS NECK; NOS
ANES- MAJOR VESSELS NECK; SIMPL
LIG
ANES-INTEG-EXTREM/TRNK/PERINEM;
NOS
ANES-INTEG-TRUNK; BREAST RECON
No
No
00404
No
ANES-INTEG-TRUNK; RAD BREAST PROC
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00406
No
00410
00450
No
No
00452
00454
00470
No
No
No
00472
No
00474
00500
Description
ANES-INTEG; RAD BRST W/NODE DISSEC
ANES-INTEG SYS-TRNK; CONVERT
ARRYTH
ANES- CLAV & SCAPULA; NOS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
ANES- CLAV & SCAPULA; RADICAL SURG
ANES- CLAV & SCAPULA; BX CLAV
ANES- PART RIB RESECT; NOS
ANES- PART RIB RESECT;
THORACOPLSTY
ANES- PART RIB RESECT; RADICAL
PROC
ANES- ALL PROC ESOPHAGUS
00520
No
ANES-CLO CHEST; (INCL BRONCH) NOS
No
00522
No
ANES-CLO CHEST; NEEDLE BX PLEURA
No
00524
No
No
00528
No
00529
No
00530
No
00532
No
ANES-CLO CHEST; PNEUMOCENTESIS
ANES-CLO
CHST;MEDIASTIN&THORACSCP NO 1
LUNG VENT
ANES-CLOS CHST;MEDIASTN&DX
THORACSCP 1 LUNG VENT
ANES- TRANSVENOUS PACEMAKER
INSRT
ANES- ACCES TO CENT VENOUS
CIRCULAT
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00534
No
00537
No
00539
00540
No
No
00541
No
00542
No
00546
No
00548
00550
Description
ANES- TRANSVENOUS INSRT
CARDIOVERT
ANES-CARDIAC ELECTROPHYSIOLOGIC
PROC
ANESTHESIA FOR TRACHEOBRONCHIAL
RECONSTRUCTION
ANES- THORACOT W/LUNGS; NOS
ANES-THORACOT PROC; UTILIZING 1
LUNG VENTILATION
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
ANES- THORACOT W/LUNGS; DECORTIC
ANES- THORACOT W/LUNGS;
THORACOPLST
ANES- THORCOT W/LUNGS; INTHOR
TRACH
ANES-STERNAL DEBRID
No
No
No
00560
No
ANES- HEART; WO PUMP OXYGENATOR
No
00562
No
No
00563
No
No
00566
No
ANES- HEART; W/ PUMP OXYGENATOR
ANES-W PUMP OXYGENATOR W
HYPOTHERM CIRCU ARREST
ANES-DIRECT CORONARY ARTERY
BYPASS GRAFT
00580
00600
No
No
ANES- HEART TRANSPL OR HEART/LUNG
ANES- CERV SPINE & CORD; NOS
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00604
00620
No
No
00622
00625
00626
00630
No
No
No
No
00632
No
00634
No
00635
No
00640
00670
00700
No
No
No
00702
00730
No
No
00740
No
ANES- CERV SPINE; POST LAMIN SITTNG
ANES- THORACIC SPINE & CORD; NOS
ANES- THORACIC; THORACOLUM
SYMPATHE
ANES SPINE TRANTHOR W/O VENT
ANES, SPINE TRANSTHOR W/VENT
ANES- PROC LUMBAR REGION; NOS
ANES- LUMBAR REGION;
SYMPATHECTOMY
ANES- LUMBAR REGION;
CHEMONUCLEOLYS
ANES- LUMBAR REGION; DIAGN OR
THERAPEUTIC LUMB PUNCT
ANES-MANIP SPN/CLOS PROC CERV
THOR/LUMB SPN
ANES- EXTEN SPINE & SPINAL CORD
ANES- UPPER ANT ABD WALL; NOS
ANES- UP ANT ABD WALL;PERQ LIVER
BX
ANES- UPPER POST ABD WALL
ANES-UGI ENDOSCOP-INTRO PROX
DUOD
00750
No
ANES- HERNIA REPR UPPER ABD; NOS
No
00752
No
No
00754
No
ANES- HERNIA REPR UP ABD; & DEHISCE
ANES- HERNIA REPR UP ABD;
OMPHALOCE
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00756
00770
00790
No
No
No
00792
No
00794
No
00796
No
00797
00800
No
No
00802
No
00810
00820
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
ANES- HERNIA REPR UP ABD; TRANSABD
ANES- ALL MAJOR ABD BLD VESSELS
ANES- INTRAPERITONEAL W/LAP; NOS
ANES- INTRAPERITONL W/LAP;:
HEPATEC
ANES- INTRAPERITON W/LAP;
PANCREATE
ANES- INTRAPERITONEAL; LIVER
TRANSP
ANESTH - UPPER ABD GASTRIC
RESTRICT
ANES- LOWER ANT ABD WALL; NOS
ANES- LO ANT ABD WALL;
PANNICULECTO
ANES-LO INTES ENDOSCOP-DIST TO
DUOD
ANES- LOWER POST ABD WALL
00830
No
ANES- HERNIA REPR LOWER ABD; NOS
No
00832
No
No
00834
No
00836
No
ANES- HERNIA REPR; VENTRAL & INCS
ANES-HERNIA REPR LOWER ABD NOS
UNDER 1 YEAR AGE
ANES-HERN REP NOS INFNTS <37 WK
BRTH&<50 WK SURG
00840
No
ANES- INTRAPERITONEAL LO ABD; NOS
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00842
No
00844
No
00846
No
00848
00851
No
No
00860
00862
No
No
00864
No
00865
No
00866
00868
00870
No
No
No
00872
No
00873
No
00880
00882
00902
Description
ANES- INTRAPERITONEAL LO ABD;
AMNIO
ANES- INTRAPERITONEAL; ABDPERINEAL
ANES- INTRAPERITONL W/LAP; RAD
HYST
ANES- INTRAPERITONEAL; PELVIC
EXENT
ANES- STERILIZATIONS
ANES- EXTRAPERITONEAL URINARY;
NOS
ANES- EXTRAPERIT; UP 1/3 URETER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
ANES- EXTRAPERIT; TOT CYSTECTOMY
ANES- EXTRAPERIT; RAD
PROSTATECTOMY
No
No
No
No
No
ANES- EXTRAPERIT; ADRENALECTOMY
ANES- EXTRAPERIT; RENAL TRANSPL
ANES- EXTRAPERIT; CYSTOLITHTOMY
ANES- LITH EXTRACORPOR; W/H2O
BATH
ANES- LITH EXTRACORPOR; WO H2O
BATH
ANES- MAJOR LOWER ABD VESSELS;
NOS
No
No
ANES- MAJOR VESS; INFER VENA CAVA
ANES- PERINEAL INTEG; ANORECTAL
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
00904
No
ANES- PERINEAL INTEG; RAD PERINEAL
No
00906
No
No
00908
00910
No
No
00912
00914
No
No
00916
No
00918
No
ANES- PERINEAL INTEG; VULVECTOMY
ANES- PERINEAL INTEG;
PROSTATECTOMY
ANES- TRANSURETHRAL PROC; NOS
ANES- TRANSURETH; RESEC BLADDER
TUM
ANES- TRANSURETHRAL; TURP
ANES- TRANSURETHR; POST RESECT
BLED
ANES-TRNSURETH; W/MANIP/REMOV
CALC
00920
No
00921
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
ANES- MALE EXT GENIT; SEMINAL VESIC
ANES-MALE GNT INCL OP URETH;
VASECT UNILAT/BILAT
00922
No
ANES- MALE EXT GENIT; SEMINAL VESIC
No
00924
00926
No
No
ANES- MALE; UNDESCEN TESTIS UNI/BIL
ANES- MALE; RAD ORCHIECTOMY ING
No
No
00928
00930
00932
No
No
No
No
No
No
00934
No
ANES- MALE; RAD ORCHIECTOMY ABD
ANES- MALE; ORCHIOPEXY UNI/BILAT
ANES- MALE; COMPLT AMPUT PENIS
ANES- MALE; RAD AMP PENIS ING
LYMPH
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00936
00938
00940
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
00942
00944
00948
00950
No
No
No
No
00952
No
01112
01120
01130
No
No
No
01140
No
01150
Description
ANES- MALE; AMP PENIS ING & ILIAC
ANES- MALE; INSRT PENILE PROSTH
ANES- VAG PROC; NOS
ANES- VAG; COLPOT, COLPEC,
COLPORRH
ANES- VAG PROC; VAG HYST
ANES- VAG PROC; CERV CERCLAGE
ANES- VAG PROC; CULDOSCOPY
ANES-VAG;
HYSTEROSCOP/SALPINGRPHY
ANES- BONE MARROW ASPIRA &/OR BX,
ANTERIOR OR POSTERIOR
ANES- BONY PELVIS
ANES- BODY CAST APPLIC OR REVIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
ANES- INTERPELVIABDOMINAL AMPUTA
ANES- RAD PROC TUMOR PELV EX
AMPUT
01160
No
ANES- CLO PROC W/S PUBIS/SACROIL JT
No
01170
No
No
01173
No
01180
No
01190
01200
No
No
ANES- OPEN PROC W/S PUBIS/SACILI JT
ANES-OPEN REP FX DISRUPT
PELV/COLUMN FX ACETAB
ANES- OBTURATOR NEURECT;
EXTRAPELV
ANES- OBTURATOR NEURECT;
INTRAPELV
ANES- ALL CLO PROC INVOLV HIP JT
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
01202
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
01210
No
ANES- OPEN PROC INVOLV HIP JT; NOS
No
01212
No
ANES- OPEN PROC INVOLV HIP; DISART
No
01214
No
No
01215
01220
No
No
ANES- OPEN HIP; TOT HIP REPLC/REVIS
ANES- REVIS OF TOTAL HIP
ANTHROPSCOPY
ANES- ALL CLO INVOLV UP 2/3 FEMUR
No
No
01230
No
ANES- OPEN INVOLV UP 2/3 FEMUR; NOS
No
01232
No
No
01234
No
ANES- OPEN UPPER 2/3 FEMUR; AMPUTA
ANES- OPEN UP 2/3 FEMUR; RAD
RESECT
01250
No
ANES- ALL NERV/MUSCL/FASCIA UP LEG
No
01260
No
ANES- ALL INVOLV VEIN UP LEG W/EXPL
No
01270
No
ANES- INVOLV ART UP LEG W/GFT; NOS
No
01272
No
No
01274
No
ANES- INVOLV ART LEG W/GFT; FEM LIG
ANES- INVOLV ART LEG W/GFT; FEM
EMB
No
01320
No
ANES- NERV/MUSCL/BURSAE KNEE/POP
No
Description
ANES- ARTHROSCOPIC PROC HIP JT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
01340
No
01360
01380
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
ANES- ALL CLO PROC LOWER 1/3 FEMUR
ANES- ALL OPEN PROC LOWER 1/3
FEMUR
ANES- ALL CLO PROC KNEE JT
01382
No
ANES- ARTHROSCOPIC PROC KNEE JT
No
01390
No
ANES- ALL CLO UP ENDS TIB/FIB/PATEL
No
01392
01400
No
No
No
No
01402
No
ANES- ALL OPEN UP END TIB/FIB/PATEL
ANES- OPEN PROC KNEE JT; NOS
ANES- OPEN KNEE JT; TOT KNEE
REPLAC
No
01404
No
ANES- OPEN KNEE JT; DISART AT KNEE
No
01420
01430
No
No
ANES- ALL CAST APPLIC/REPR W/KNEE
ANES- VEINS KNEE & POP AREA; NOS
No
No
01432
01440
No
No
No
No
01442
No
01444
01462
01464
01470
No
No
No
No
ANES- VEINS KNEE/POP AREA; AV FISTU
ANES- ART KNEE & POP AREA; NOS
ANES- ART KNEE; POP
THROMBOENDART
ANES- ART KNEE; POP EXC
OCC/U/ANEUR
ANES- ALL CLO LOWER LEG/ANK/FT
ANES- ARTHROSCOPIC PROC ANK JT
ANES- NERV/FASCIA LO LEG/FT; NOS
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
01472
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
01474
No
01480
No
01482
No
01484
No
01486
No
01490
No
01500
01502
01520
No
No
No
01522
No
01610
No
01620
No
01622
No
01630
01632
Description
ANES- NERV LO LEG; REPR ACHILLES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
ANES- NERV LO LEG; GASTROC RECESS
ANES- OPEN BONES LO LEG/ANK/FT;
NOS
ANES- OPEN BONES LO LEG; RAD
RESECT
ANES- OPEN BONES LO LEG;
OSTEOTOMY
ANES- OPEN BON LO LEG; TOT ANK
REPL
ANES- LO LEG CAST
APPLIC/REMOV/REPR
No
ANES- ART LO LEG W/BYPASS GFT; NOS
ANES- ART LO LEG W/GFT; EMBOLEC
ANES- VEINS LOWER LEG; NOS
ANES- VEINS LO LEG; THROMBEC
DIRECT
ANES- ALL PROC NERV, MUSCL,
TENDONS
No
No
No
No
No
ANES- ALL CLO HUMERAL/AC/SHLDR JT
ANES- ARTHROSCOPIC PROC
SHOULDER JT
ANES- OPEN HUMERAL/AC/SHLDR JT;
NOS
No
ANES- OPEN HUMER/AC JT; RAD RESECT
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
01634
No
01636
No
01638
01650
No
No
01652
No
Description
ANES- OPEN HUMER/AC JT; SHLDR
DISAR
ANES- OPEN HUMER/AC; INTERTHOR
AMPU
ANES- OPEN HUMER/AC; TOT SHLDR
REPL
ANES- ART SHOULDER AXILLA; NOS
ANES- ART SHLDR/AX; AX-BRACH
ANEURY
01654
No
ANES- ART SHLDR & AXIL; BYPASS GFT
No
01656
01670
No
No
ANES- ART SHLDR & AX; AX-FEM BYPASS
ANES- ALL VEINS SHLDR & AXILLA
No
No
01680
No
ANES- SHLDR CAST APPLIC REPR; NOS
No
01682
No
No
01710
No
01712
No
01714
No
01716
No
01730
No
ANES- SHLDR CAST REPR; SHLDR SPICA
ANES- NERV/BURSAE UP ARM/ELBOW;
NOS
ANES- NERV UP ARM/ELBOW;
TENOTOMY
ANES- NERV UP ARM/ELBOW;
TENOPLASTY
ANES- NERV UP ARM/ELBOW;
TENODESIS
ANES- ALL CLO PROC HUMERUS &
ELBOW
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
01732
No
01740
No
01742
No
01744
No
01756
No
01758
No
01760
No
01770
No
01772
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
ANES- ARTHROSCOPIC PROC ELBOW JT
ANES- OPEN PROC HUMERUS & ELBW;
NOS
ANES- OPEN HUMERUS & ELBW;
OSTEOTMY
ANES- OPEN HUMER/ELB; REPR
NONUNION
ANES- OPEN HUMERUS/ELB; RADICL
PROC
ANES- OPEN HUMERUS; EXC CYST
HUMER
ANES- OPEN HUMER; TOT ELBOW
REPLAC
No
No
No
ANES- ART UPPER ARM & ELBOW; NOS
ANES- ART UP ARM/ELBOW;
EMBOLECTOMY
01780
No
ANES- VEINS UPPER ARM & ELBOW; NOS
No
01782
No
No
01810
No
01820
No
01829
No
ANES- VEINS UP ARM; PHLEBORRHAPHY
ANES- ALL NERV/MUSCL
FOREARM/HAND
ANES- ALL CLO RADIUS/ULNA/HAND
BONE
ANESTHESIA DIAGNOSTIC
ARTHROSCOPIC PROC WRIST
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
01830
No
01832
No
01840
No
01842
No
01844
No
01850
No
01852
No
01860
No
01905
No
01916
No
01920
No
01922
No
01924
01925
No
No
01926
No
Description
ANES- OPEN RAD/ULNA/HAND BONES;
NOS
ANES- OPEN RAD/ULN BONES; TOT
WRIST
ANES- ART FOREARM/WRIST/HAND; NOS
ANES- ART FOREARM/WRIST/HAND;
EMBOL
ANES- VASCULAR SHUNT/REVIS ANY
TYPE
ANES- VEINS FOREARM/WRIST/HAND;
NOS
ANES- VEINS FOREARM/HAND;
PHLEBORRH
ANES- FOREARM/HAND CAST
APPLIC/REPR
ANES- INJ MYELOGRAPHY,
DISKOGRAPHY, VERTEBROPLASTY
ANES- ARTERIOGRAMS/NEEDLE;
CAROTID
ANES- CARD CATH W/CORON
ARTERIOGPHY
ANES- NON-INVASIVE IMAG/RAD THERAP
ANES- THERAP INTERVENT
VENOUS/LYMPH
ANES- CAROTID OR CORONARY
ANES- INTRACRANIAL, INTRACARDIAC,
OR AORTIC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
01930
01931
01932
01933
No
No
No
No
01951
No
01952
No
01953
No
01958
01960
01961
01962
01963
01965
01966
01967
No
No
No
No
No
No
No
No
01968
No
01969
No
01990
No
01991
No
Description
ANES- THERA INTERVENT INVOLV
VENOUS/LYMPH
ANES- TRANSCUT PORTO CAV SHUNT
ANES- INTRATHOR OR JUGULR
ANES- INTRACRANIAL
ANES- BURN EXCIS OR DEBRID 2ND &
3RD DEGREE
ANES- BURN EXCIS OR DEBRID 1-9%
TOTAL BODY SURFACE AREA
ANES- BURN EXCIS OR DEBRID EA
ADDNL 9% TOTAL BODY SURFACE
ANESTHESIA EXTERNAL CEPHALIC
VERSION PROCEDURE
ANES- VAG DELIV ONLY
ANES- CES DELIV ONLY
ANES- URGE HYSTER FOLLOW DELIV
ANES- HYSTERECTOMIES
ANES INCOMPL/MISSED AB
ANES INDUCED AB
ANES- NEURAXIAL LABOR ANAGLESIA
ANES- CES DELIV FOLLOW NEURAXIAL
LABOR ANAGLESIA
ANES- CES HYSTER FOLLOW
NEURAXIAL LABOR ANAGLESIA
PHYSIOL SUPPORT - DONOR-BRAIN
DEAD
ANES-DX/TX NRV BLKS&INJ; OTH THAN
PRONE PSTN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
01992
No
01995
01996
01999
10021
10022
10040
10060
10061
10080
10081
10120
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
ANES-DX/TX NRV BLKS&INJ; PRONE
PSTN
REGIONL IV ADMIN LOCAL ANES/OTH
MED
ANES- DA MGMT EPIDUR DRUG ADMIN
UNLISTED ANES PROC
FINE NDLE ASPIR; W/O IMAGING GUID
FINE NEEDLE ASPIR; W/IMAGING GUID
ACNE SURG
I&D ABSCESS; SIMPL/SNGL
I&D ABSCESS; COMPLIC/MX
I&D PILONIDAL CYST; SIMPL
I&D PILONIDAL CYST; COMPLIC
INCS & REMOV FB SUBQ TISS; SIMPL
10121
Yes
INCS & REMOV FB SUBQ TISS; COMPLIC
No
10140
Yes
No
10160
10180
Yes
Yes
I&D HEMATOMA/SEROMA/FLUID COLLEC
PUNCT ASPIR
ABSCES/HEMAT/BULLA/CYST
I&D COMPLX POSTOP WOUND INFEC
11000
No
DEBRID EXTEN INFEC SKIN; TO 10% SUR
No
11001
Yes
No
11004
Yes
11005
Yes
DEBRID EXTEN INFEC SKIN; EA AD 10%
DEBRID SKN SUBQ TISS MUSC&FASC;
EXT GENITL&PERIN
DEBRID SKN SUBQ TISS MUSC&FASC;
ABD WALL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
11006
Yes
11008
11010
Yes
No
11011
No
11012
11040
11041
11042
11043
No
No
No
No
No
11044
11055
11056
11057
No
Yes
Yes
Yes
11100
No
11101
11200
11201
11300
11301
11302
11303
11305
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
DEBRID SKN SUBQ TISS; EXT GENIT
W/WO FASCL CLOS
REMV PROS MATL/MESH ABD WALL
NECROT SFT TISS INF
DEBRID W/REMOV MAT; SKIN & SUBQ
DEBRID W/REMOV MAT; SKIN-SUBQMUSC
DEBRID W/REMOV MAT; SKIN-MUSCBONE
DEBRID; SKIN PART THICK
DEBRID; SKIN FULL THICK
DEBRID; SKIN & SUBQ TISS
DEBRID; SKIN-SUBQ TISS-MUSCL
DEBRID; SKIN-SUBQ TISS-MUSCL-BONE
PARING/CUTTING BEN LES; 1 LES
PARING/CUTTING BEN LES; 2-4 LES
PARING/CUTTING BEN LES; > 4 LES
BX SKIN SUBQ TISSUE &/ MUCOUS
MEMBRANE; 1 LESION
BX SKIN SUBQ TISSUE &/ MUCOUS
MEMBRANE; EA ADD
REMOV SKIN TAGS; TO & INCL 15 LES
REMOV SKIN TAGS; EA ADD 10 LES
SHAVING 1 LES TRUNK; 0.5 CM/LESS
SHAVING 1 LES TRUNK; 0.6 TO 1.0 CM
SHAVING 1 LES TRUNK; 1.1 TO 2.0 CM
SHAVING 1 LES TRUNK; OVER 2.0 CM
SHAVING 1 LES SCALP; 0.5CM/LESS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
11450
Yes
EXC SKIN HIDRADEN AX; SIMPL/INTERM
No
11451
Yes
EXC SKIN HIDRADEN AX; COMPLX REPR
No
Description
SHAVING 1 LES SCALP; 0.6 TO 1.0 CM
SHAVING 1 LES SCALP; 1.1 TO 2.0 CM
SHAVING 1 LES SCALP; OVER 2.0 CM
SHAVING 1 LES FACE; 0.5 CM/LESS
SHAVING 1 LES FACE; 0.6 TO 1.0 CM
SHAVING 1 LES FACE; 1.1 TO 2.0 CM
SHAVING 1 LES FACE; OVER 2.0 CM
EXC BEN LES TRUNK; 0.5 CM/LESS
EXC BEN LES TRUNK; 0.6 TO 1.0 CM
EXC BEN LES TRUNK; 1.1 TO 2.0 CM
EXC BEN LES TRUNK; 2.1 TO 3.0 CM
EXC BEN LES TRUNK; 3.1 TO 4.0 CM
EXC BEN LES TRUNK; OVER 4.0 CM
EXC BEN LES SCALP; 0.5 CM/LESS
EXC BEN LES SCALP; 0.6 TO 1.0 CM
EXC BEN LES SCALP; 1.1 TO 2.0 CM
EXC BEN LES SCALP; 2.1 TO 3.0 CM
EXC BEN LES SCALP; 3.1 TO 4.0 CM
EXC BEN LES SCALP; OVER 4.0 CM
EXC BEN LES FACE; 0.5 CM/LESS
EXC BEN LES FACE; 0.6 TO 1.0 CM
EXC BEN LES FACE; 1.1 TO 2.0 CM
EXC BEN LES FACE; 2.1 TO 3.0 CM
EXC BEN LES FACE; 3.1 TO 4.0 CM
EXC BEN LES FACE; OVER 4.0 CM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
11462
Yes
EXC SKIN HIDRADEN ING; SIMPL/INTERM
No
11463
Yes
EXC SKIN HIDRADEN ING; COMPLX REPR
No
11470
Yes
EXC SKIN HIDRADEN PERIANAL; SIMPL
No
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
11719
11720
Yes
Yes
EXC SKIN HIDRADEN PERIANAL; COMPLX
EXC MALIG LES TRUNK; 0.5 CM/LESS
EXC MALIG LES TRUNK; 0.6 TO 1.0 CM
EXC MALIG LES TRUNK; 1.1 TO 2.0 CM
EXC MALIG LES TRUNK; 2.1 TO 3.0 CM
EXC MALIG LES TRUNK; 3.1 TO 4.0 CM
EXC MALIG LES TRUNK; OVER 4.0 CM
EXC MALIG LES SCLP; 0.5 CM/LESS
EXC MALIG LES SCLP; 0.6 TO 1.0 CM
EXC MALIG LES SCLP; 1.1 TO 2.0 CM
EXC MALIG LES SCLP; 2.1 TO 3.0 CM
EXC MALIG LES SCLP; 3.1 TO 4.0 CM
EXC MALIG LES SCLP; OVER 4.0 CM
EXC MALIG LES FACE; 0.5 CM/LESS
EXC MALIG LES FACE; 0.6 TO 1.0 CM
EXC MALIG LES FACE; 1.1 TO 2.0 CM
EXC MALIG LES FACE; 2.1 TO 3.0 CM
EXC MALIG LES FACE; 3.1 TO 4.0 CM
EXC MALIG LES FACE; OVER 4.0 CM
TRIM NONDYSTROPHIC NAILS-ANY
NUMBER
DEBRID NAIL(S) ANY METHD(S); 1 TO 5
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
11721
Yes
11730
Yes
11732
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
DEBRID NAIL(S) ANY METHD(S); 6/MORE
AVULSION PLATE PART/COMPLT SIMPL;
1
AVULSION PLATE PART/COMPLT SMPL;
EA
11740
Yes
EVACUATION SUBUNGUAL HEMATOMA
No
11750
Yes
EXC NAIL/MATRIX PART/COMPLT PERM
No
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
11920
Not Reimbursable
EXC NAIL/MATRIX PERM; AMPUT DISTAL
BX NAIL UNIT ANY METHD (SEP PRO)
REPR NAIL BED
RECON NAIL BED W/GFT
WEDGE EXC SKIN NAIL FOLD
EXC PILONIDAL CYST/SINUS; SIMPL
EXC PILONIDAL CYST/SINUS; EXTEN
EXC PILONIDAL CYST/SINUS; COMPLIC
INJ INTRALES; UP TO & INCL 7 LES
INJ INTRALES; MORE THAN 7 LES
TATTOOING W/MICROPIGMEN; 6.0 SQ
CM
11921
YES
11922
11950
11951
Not Reimbursable
Not Reimbursable
Not Reimbursable
TATTOOING W/MICROPIGMEN; 6.0-20 CM
TATTOOING W/MICROPIGMEN; EA ADD
20.
SUBQ INJ FILLING MAT; 1 CC/LESS
SUBQ INJ FILLING MAT; 1.1 TO 5.0 CC
No
No
Not Reimbursable
YES
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
11952
11954
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Not Reimbursable
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
11960
Yes
11970
Yes
11971
Yes
11975
Not Reimbursable
11976
No
11977
11980
Not Reimbursable
Yes
11981
Yes
11982
Yes
11983
Yes
Description
SUBQ INJ FILLING MAT; 5.1 TO 10 CC
SUBQ INJ FILLING MAT; OVER 10.0 CC
INSRT EXPANDER NOT BREAST
W/SUBSQT
REPLAC TISS EXPANDER W/PERM
PROSTH
REMOV TISS EXPANDER WO INSRT
PROSTH
INSRT IMPLNT CONTRACEPTIVE
CAPSULES
REMOV IMPLNT CONTRACEPTIVE
CAPSULES
REMOV W/REINSRT CONTRACEPTIVE
CAPSU
SUBQ HORMONE PELLET IMPLNT
INSRT NON-BIODEGRADABLE RX DEL
IMPL
REMV NON-BIODEGRADABLE RX DEL
IMPL
REMV REINS NONBIODEGRAD RX DEL
IMPL
12001
12002
12004
Yes
Yes
Yes
SIMPL REPR SCLP/TRUNK; 2.5 CM/LESS
SIMPL REPR SCLP/TRUNK; 2.6-7.5 CM
SIMPL REPR SCLP/TRUNK; 7.6-12.5 CM
No
No
No
12005
Yes
SIMPL REPR SCLP/TRUNK; 12.6-20.0 CM
No
12006
Yes
SIMPL REPR SCLP/TRUNK; 20.1-30.0 CM
No
No
No
No
Not Reimbursable
No
Not Reimbursable
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
12007
12011
Yes
Yes
SIMPL REPR SCLP/TRUNK; OVER 30.0 CM
SIMPL REPR FACE/MUCOUS; 2.5/LESS
No
No
12013
Yes
SIMPL REPR FACE/MUCOUS; 2.6-5.0 CM
No
12014
Yes
SIMPL REPR FACE/MUCOUS; 5.1-7.5 CM
No
12015
12016
12017
Yes
Yes
Yes
SIMPL REPR FACE/MUCOUS; 7.6-12.5 CM
SIMPL REPR FACE/MUCOUS; 12.6-20.0
SIMPL REPR FACE/MUCOUS; 20.1-30.0
No
No
No
12018
Yes
No
12020
Yes
12021
Yes
SIMPL REPR FACE/MUCOUS; OVER 30.0
TX SUPERF WOUND DEHISCENCE;
SIMPL
TX SUPERF WOUND DEHISCENCE;
W/PACK
12031
Yes
LAYER CLO SCLP/TRUNK; 2.5 CM/LESS
No
12032
12034
12035
12036
Yes
Yes
Yes
Yes
LAYER CLO SCLP/TRUNK; 2.6 TO 7.5 CM
LAYER CLO SCLP/TRUNK; 7.6 TO 12.5
LAYER CLO SCLP/TRUNK; 12.6 TO 20.0
LAYER CLO SCLP/TRUNK; 20.1 TO 30.0
No
No
No
No
12037
Yes
LAYER CLO SCLP/TRUNK; OVER 30.0 CM
No
12041
12042
Yes
Yes
LAYER CLO NECK/FT/GENIT; 2.5CM/LESS
LAYER CLO NECK/FT/GENIT; 2.6 TO 7.5
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
12044
12045
12046
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
12047
12051
12052
12053
12054
12055
12056
12057
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
LAYER CLO NECK/FT/GENIT; OVER 30.0
LAYER CLO FACE/LIPS; 2.5 CM/LESS
LAYER CLO FACE/LIPS; 2.6 TO 5.0 CM
LAYER CLO FACE/LIPS; 5.1 TO 7.5 CM
LAYER CLO FACE/LIPS; 7.6 TO 12.5 CM
LAYER CLO FACE/LIPS; 12.6 TO 20.0
LAYER CLO FACE/LIPS; 20.1 TO 30.0
LAYER CLO FACE/LIPS; OVER 30.0 CM
No
No
No
No
No
No
No
No
13100
Yes
REPR COMPLX TRUNK; 1.1 CM TO 2.5 CM
No
13101
Yes
No
13102
Yes
REPR COMPLX TRUNK; 2.6 CM TO 7.5 CM
REPR COMPLX-TRUNK; EA ADD 5
CM/LESS
13120
Yes
REPR COMPLX SCLP/EXTREM; 1.1-2.5 CM
No
13121
Yes
No
13122
Yes
REPR COMPLX SCLP/EXTREM; 2.6-7.5 CM
REPR CMPLX-SCLP/ARM/LEG; EA AD 5
CM
13131
Yes
REPR COMPLX FOREHEAD/AX/FT; 1.1-2.5
No
13132
Yes
REPR COMPLX FOREHEAD/AX/FT; 2.6-7.5
No
Description
LAYER CLO NECK/FT/GENIT; 7.6-12.5
LAYER CLO NECK/FT/GENIT; 12.6-20.0
LAYER CLO NECK/FT/GENIT; 20.1-30.0
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
13133
13150
13151
13152
Yes
Yes
Yes
Yes
13153
Yes
Description
REPR CMPLX-FAC/HAND/FT; EA ADD 5
CM
REPR COMPLX LIDS/LIPS; 1.0/LESS
REPR COMPLX LIDS/LIPS; 1.1-2.5 CM
REPR COMPLX LIDS/LIPS; 2.6-7.5 CM
REPR CMPLX-EYE/NOSE/EAR; EA AD 5
CM
13160
Yes
SECNDRY CLO DEHISCENCE COMPLIC
No
14000
14001
Yes
Yes
ADJAC TISS TRANSF TRUNK; 10 SQ CM
ADJAC TISS TRANSF TRUNK; 10.1-30.0
No
No
14020
14021
14040
14041
14060
14061
Yes
Yes
Yes
Yes
Yes
Yes
ADJAC TRANSF SCLP/LEGS; 10 SQ CM
ADJAC TRANSF SCLP/LEGS; 10.1-30.0
ADJAC TRANSF CHIN/AX/FT; 10 SQ CM
ADJAC TRANSF CHIN/AX/FT; 10.1- 30.0
ADJAC TRANSF LIDS/LIPS; 10 SQ CM
ADJAC TRANSF LIDS/LIPS; 10.1-30.0
No
No
No
No
No
No
14300
Yes
ADJAC TRANSF > 30.0 SQ CM COMPLIC
No
14350
15000
Yes
Yes
FILLETED FINGER/TOE FLP W/PREP SITE
SURG PREP RECIP SITE; 1ST 100/1%
No
No
15001
15002
15003
15004
Yes
Yes
Yes
Yes
SURG PREP RECIP SITE; EA ADD 100 CM
WND PREP, CH/INF, TRK/ARM/LG
WND PREP, CH/INF ADDL 100 CM
WND PREP CH/INF, F/N/HF/G
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15005
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
15040
15050
15100
15101
No
Yes
Yes
Yes
15110
No
15111
No
15115
No
15116
15120
No
Yes
Description
WND PREP, F/N/HF/G, ADDL CM
HARVEST SKN TISS CLTR SKN AGRFT
100 CM/<
PINCH GFT 1/MX-SM AREA UP TO 2 CM
SPLIT GFT TRUNK; 1ST 100 SQ CM/1%
SPLIT GFT TRUNK; EA ADD 100 SQ/1%
EPIDRM AGRFT T/A/L 1ST 100 CM/</1%
BDY INFT/CHLD
EPIDRM AGRFT T/A/L EA 100 CM/EA 1%
BDY INFT/CHLD
EPIDRM AGRFT F/S/N/H/F/G/M/D GT 1ST
100 CM
EPIDRM AGRFT F/S/N/H/F/G/M/D GT EA
100 CM/EA
SPLIT GFT FACE; 1ST 100 SQ/1%
15121
15130
15131
Yes
No
No
SPLT GFT FACE; EA ADD 100/EA ADD 1%
DRM AGRFT T/A/L 1ST 100 CM
DRM AGRFT T/A/L EA 100 CM/EA
No
No
No
15135
No
No
15136
No
DRM AGRFT F/S/N/H/F/G/M/D GT 1ST 100
DRM AGRFT F/S/N/H/F/G/M/D GT EA 100
CM/EA
15150
No
15151
No
15152
No
CLTR EPIDRM AGRFT T/A/L 1ST 25 CM/<
CLTR EPIDRM AGRFT T/A/L ADDL 1 CM75 CM
CLTR EPIDRM AGRFT T/A/L EA 100 CM/EA
1 % BDY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
15155
No
15156
No
15157
No
15170
No
15171
No
15175
No
15176
No
Description
CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT
1ST 25CM/<
CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT
ADDL 1-75CM
CLTR EPIDRM AGRFT F/S/N/H/F/G/M/D GT
EA 100 EA
ACLR DRM RPLCMT T/A/L 1ST 100 CM/</1
% BDY
ACLR DRM RPLCMT T/A/L EA 100 CM/EA 1
% BDY
ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT
1ST 100 CM
ACLR DRM RPLCMT F/S/N/H/F/G/M/D GT
EA 100 CM/EA
15200
15201
Yes
Yes
FULL THICK GFT TRUNK; 20 SQ CM/LESS
FULL THICK GFT TRUNK; EA AD 20 SQ
No
No
15220
Yes
FULL THICK GFT SCLP; 20 SQ CM/LESS
No
15221
Yes
FULL THICK GFT SCLP; EA AD 20 SQ CM
No
15240
15241
15260
15261
Yes
Yes
Yes
Yes
No
No
No
No
15300
No
FULL THICK GFT CHIN/AX/FT; 20 SQ CM
FULL THICK GFT CHIN/AX/FT; EA AD 20
FULL THICK GFT NOSE/LIPS; 20 SQ CM
FULL THICK GFT NOSE/LIPS; EA AD 20
ALGRFT SKN F/TEMP CLSR T/A/L 1ST 100
CM/</1
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
15301
No
15320
No
15321
15330
No
No
15331
No
15335
No
15336
15340
15341
No
No
No
15360
15361
No
No
15365
No
15366
No
15400
15401
Yes
Yes
15420
No
15421
No
Description
ALGRFT SKN F/TEMP CLSR T/A/L EA 100
CM/EA
ALGRFT SKN F/TEMP CLSR
F/S/N/H/F/G/M/D 1ST 100CM
ALGRFT SKN F/TEMP CLSR
F/S/N/H/F/G/M/D EA 100CM
ACLR DRM ALGRFT T/A/L 1ST 100 CM
ACLR DRM ALGRFT T/A/L EA 100 CM/EA
ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT
1ST 100 CM
ACLR DRM ALGRFT F/S/N/H/F/G/M/D GT
EA 100 CM/EA
TISS CLTR ALGC SKN 1ST 25 CM/<
TISS CLTR ALGC SKN EA 25 CM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
TISS CLTR ALGC DRM T/A/L 1ST 100 CM
TISS CLTR ALGC DRM EA 100 CM/EA
TISS CLTR ALGC DRM F/S/N/H/F/G/M/D
1ST 100 CM
TISS CLTR ALGC DRM F/S/N/H/F/G/M/D
EA 100 CM
No
No
APPLIC XENOGFT SKIN; 100 SQ CM/LESS
APPLIC XENOGFT; EA ADD 100 SQ CM
XENOGRF SKN TEMP CLSR
F/S/N/H/F/G/M/D 1ST 100CM
XENOGRF SKN TEMP CLSR
F/S/N/H/F/G/M/D EA 100CM
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15430
15431
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Yes
15570
Yes
15572
Yes
15574
15576
15600
Yes
Yes
Yes
15610
15620
Description
ACLR XENOGRF IMPLT 1ST 100 CM
ACLR XENOGRF IMPLT EA 100 CM
FORM DIR PEDICLE W/WO TRANSF;
TRUNK
FORM DIR PEDICLE W/WO TRANSF;
SCLP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
Yes
Yes
FORM DIR PEDICLE; CHEEKS/CHIN/AX/FT
FORM DIR PEDICLE; LIDS/NOSE/EARS
DELAY FLAP/SECT FLAP; AT TRUNK
DELAY FLAP/SECT FLAP;
SCLP/ARMS/LEG
DELAY FLAP/SECT; CHIN/AX/GENIT/FT
15630
Yes
DELAY FLAP/SECT; LIDS/NOSE/EARS/LIP
No
15650
15731
Yes
Yes
No
No
15732
Yes
15734
Yes
15736
Yes
15738
15740
15750
Yes
Yes
Yes
TRANSF INTERMED ANY PEDICLE FLAP
FOREHEAD FLAP W/VASC PEDICLE
MUSCL MYOCUT/FASCIOCUT FLAP;
HEAD
MUSCL MYOCUT/FASCIOCUT FLAP;
TRUNK
MUSCL MYOCUT/FASCIOCUT; UP
EXTREM
MUSCL MYOCUT/FASCIOCUT; LOW
EXTREM
FLAP; ISLAND PEDICLE
FLAP; NEUROVASCULAR PEDICLE
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
15756
Yes
15757
Yes
15758
Yes
15760
15770
15775
15776
15780
15781
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
15782
15783
15786
15787
15788
15789
15792
15793
15819
15820
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
15821
15822
Not Reimbursable
Yes
15823
Yes
Description
FREE MUSC FLAP W/MICROVASC
ANASTOM
FREE SKIN FLAP W/MICROVASC
ANASTOM
FREE FASCIAL FLAP W/MICROVASC
ANAST
GFT; COMPOSITE INCL PRIM CLO
DONOR
GFT; DERM-FAT-FASCIA
PUNCH GFT HAIR TRANSPL; 1-15 GFTS
PUNCH GFT HAIR TRANSPL; > 15 GFTS
DERMABRASION; TOT FACE
DERMABRASION; SEGMT FACE
DERMABRASION; REGIONAL NOT FACE
DERMABRASION; SUPERF ANY SITE
ABRASION; SNGL LES
ABRASION; EA ADD 4 LES/LESS
CHEM PEEL FACIAL; EPIDERMAL
CHEM PEEL FACIAL; DERMAL
CHEM PEEL; NONFACIAL; EPIDERMAL
CHEM PEEL; NONFACIAL; DERMAL
CERVICOPLASTY
BLEPHAROPLASTY LOWER EYELID
BLEPHAROPLASTY LOW; HERNIAT FAT
PAD
BLEPHAROPLASTY UPPER EYELID
BLEPHAROPLASTY UPPER; W/EXCESS
SKIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15824
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
15825
Not Reimbursable
15826
15828
15829
15830
15831
15832
15833
15834
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
RHYTIDECTOMY; FOREHEAD
RHYTIDECTOMY; NECK W/PLATYSM
TIGHT
RHYTIDECTOMY; GLABELLAR FROWN
LINES
RHYTIDECTOMY; CHEEK/CHIN/NECK
RHYTIDECTOMY; SMAS FLAP
EXC SKIN ABD
EXC EXCESS SKIN/SUBQ TISS; ABD
EXC EXCESS SKIN/SUBQ TISS; THIGH
EXC EXCESS SKIN/SUBQ TISS; LEG
EXC EXCESS SKIN/SUBQ TISS; HIP
15835
15836
Not Reimbursable
Not Reimbursable
EXC EXCESS SKIN/SUBQ TISS; BUTTOCK
EXC EXCESS SKIN/SUBQ TISS; ARM
Not Reimbursable
Not Reimbursable
15837
Not Reimbursable
Not Reimbursable
15838
15839
Not Reimbursable
Not Reimbursable
15840
Yes
15841
Yes
15842
Yes
15845
15847
Yes
Not Reimbursable
EXC EXCESS SKIN/SUBQ TISS; FOREARM
EXC EXCESS SKIN/SUBQ TISS;
SUBMENTL
EXC EXCESS SKIN/SUBQ TISS; OTHER
GFT FACE NERV PARALYSIS; FASCIA
GFT
GFT FACE NERV PARALYSIS; MUSCL
GFT
GFT FACE NERV PARALYS; MUSCLMICRO
GFT FACE NERV PARALYS; MUSCL
TRANSF
EXC SKIN ABD ADD-ON
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
15850
Bundled
15851
15852
Yes
Yes
15860
Yes
15876
Not Reimbursable
15877
Not Reimbursable
15878
Not Reimbursable
15879
Not Reimbursable
15920
15922
Yes
Yes
15931
Yes
15933
Description
REMOV SUTURES UNDER ANES SAME
SURG
REMOV SUTURES UNDER ANES OTHER
SURG
DSG CHANGE UNDER ANES
IV INJ AGENT-TEST BLD FLOW FLAP/GFT
SUCTION ASSIST LIPECTOMY;
HEAD/NECK
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Bundled
No
No
No
Not Reimbursable
SUCTION ASSISTED LIPECTOMY; TRUNK
SUCTION ASSIST LIPECTOMY; UP
EXTREM
SUCTION ASSIST LIPECTOMY; LO
EXTREM
Not Reimbursable
No
No
Yes
EXC COCCYGEAL ULCER; PRIM SUTURE
EXC COCCYGEAL ULCER; FLAP CLO
EXC SACRAL PRESS ULCER W/PRIM
SUTUR
EXC SACRAL ULCER W/SUTUR;
W/OSTECT
15934
Yes
EXC SACRAL ULCER W/SKIN FLAP CLO
No
15935
Yes
No
15936
Yes
EXC SACRAL ULCER W/FLAP; W/OSTECT
EXC SACRAL ULCR PREP-FLAP/SKIN
GFT;
Not Reimbursable
Not Reimbursable
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
15937
15940
Yes
Yes
15941
Yes
Description
EXC SACRL ULCR PREP-FLP/GFT;
OSTECT
EXC ISCHIAL ULCER W/PRIM SUTURE
EXC ISCHIAL ULCER W/SUTUR;
W/OSTECT
15944
Yes
EXC ISCHIAL ULCER W/SKIN FLAP CLO
No
15945
Yes
No
15946
Yes
15950
Yes
15951
15952
Yes
Yes
15953
Yes
15956
Yes
15958
15999
Yes
Yes
EXC ISCHIAL ULCER W/FLAP; W/OSTECT
EXC ISCH ULCER-OSTECT PREPFLAP/GFT
EXC TROCH PRESS ULCER W/PRIM
SUTURE
EXC TROCH ULCER W/PRIM SUT;
W/OSTEC
EXC TROCH ULCER W/SKIN FLAP CLO
EXC TROCH ULCER W/FLAP CLO;
W/OSTEC
EXC TROCH ULCER PREP-FLAP/SKIN
GFT;
EXC TROCH ULCR PREP-FLP/GFT;
OSTECT
UNLISTED PROC EXC PRESS ULCER
No
No
16000
No
INIT TX 1ST DEGREE BURN W/LOCAL TX
No
16020
No
No
16025
No
DSG/DEBRID INIT/SUBSQT; WO ANES SM
DSG/DEBRID INIT/SUBSQT; WO ANES
MED
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
16030
16035
No
No
16036
No
17000
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
DSG/DEBRID INIT/SUBSQT; WO ANES LG
ESCHAROTOMY; INITIAL INCISION
ESCHAROTOMY; EA ADD INCISION (IN
CONJCTN W/ CPT 16035)
DESTRCT-ANY METHD-BEN LES; W/ANE;
1
No
No
No
17003
No
DESTRCT-ANY METHD-BEN LES; 2-14, EA
No
17004
Yes
DESTRCT-ANY METHD-BEN LES 15/> LES
No
17106
Yes
No
17107
Yes
DESTRCT CUT VASCUL LES; < 10 SQ CM
DESTRCT CUT VASCUL LES; 10-50 SQ
CM
17108
No
No
17110
No
DESTRCT CUT VASCUL LES; > 50 SQ CM
DESTRCT WARTS/MOLLUSCUM TO 14
LES
17111
17250
17260
No
No
No
DESTRCT WARTS/MOLLUSCUM; 15/> LES
CHEM CAUT GRANULATION TISS
DESTRCT MALIG LES TRUNK; 0.5/LESS
No
No
No
17261
No
DESTRCT MALIG LES TRUNK; 0.6-1.0 CM
No
17262
No
DESTRCT MALIG LES TRUNK; 1.1-2.0 CM
No
17263
No
DESTRCT MALIG LES TRUNK; 2.1-3.0 CM
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
17264
17266
No
No
DESTRCT MALIG LES TRUNK; 3.1-4.0 CM
DESTRCT MALIG LES TRUNK; > 4.0 CM
No
No
17270
17271
17272
17273
17274
No
No
No
No
No
DESTRCT MALIG LES SCLP; 0.5 CM/LESS
DESTRCT MALIG LES SCLP; 0.6-1.0 CM
DESTRCT MALIG LES SCLP; 1.1-2.0 CM
DESTRCT MALIG LES SCLP; 2.1-3.0 CM
DESTRCT MALIG LES SCLP; 3.1-4.0 CM
No
No
No
No
No
17276
No
DESTRCT MALIG LES SCLP; OVER 4.0 CM
No
17280
No
DESTRCT MALIG LES FACE; 0.5 CM/LESS
No
17281
No
DESTRCT MALIG LES FACE; 0.6-1.0 CM
No
17282
No
DESTRCT MALIG LES FACE; 1.1-2.0 CM
No
17283
No
DESTRCT MALIG LES FACE; 2.1-3.0 CM
No
17284
No
DESTRCT MALIG LES FACE; 3.0-4.0 CM
No
17286
No
No
17304
No
17305
No
17306
No
DESTRCT MALIG LES FACE; OVER 4.0 CM
CHEMOSURG (MOH'S); 1ST STAGE 5
SPEC
CHEMOSURG (MOH'S); 2ND STAGE 5
SPEC
CHEMOSURG (MOH'S); 3RD STAGE 5
SPEC
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
17307
No
17310
17311
17312
17313
17314
17315
17340
17360
17380
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
17999
19000
Yes
No
19001
No
19020
Yes
19030
No
19100
19101
No
No
19102
No
19103
19105
No
Not Reimbursable
Description
CHEMOSURG (MOH'S); AD STAGE 5
SPEC
CHEMOSURG (MOH'S); 5 SPEC ANY
STAGE
MOHS, 1 STAGE, H/N/HF/G
MOHS ADDL STAGE
MOHS, 1 STAGE, T/A/L
MOHS, ADDL STAGE, T/A/L
MOHS SURG, ADDL BLOCK
CRYOTHERAPY-ACNE
CHEM EXFOLIATION ACNE
ELECTROLYSIS EPILATION EA 1/2 HR
UNLISTED-SKIN/MUCOUS MEMB/SUBQ
TISS
PUNCT ASPIRAT CYST BREAST
PUNCT ASPIR CYST BREAST; EA AD
CYST
MASTOTOMY W/EXPLOR/DRAIN
ABSCESS
INJ PROC ONLY-MAMMARY
DUCT/GALACTGM
BX BREAST; NEEDLE CORE (SEP PROC)
BX BREAST; INCS
BX-BREAST; PERCUTANEOUS, NEEDLE
CORE
BX BREAST; PERCUTANEOUS, AUTO
VAC ASSIST OR ROT BX DEVICE
CRYOSURG ABLATE FA, EACH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
19110
19112
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
No
19120
Yes
19125
Yes
19126
19140
19160
No
Yes
Yes
19162
19180
19182
Yes
Yes
Yes
19200
Yes
19220
Yes
19240
19260
Yes
Yes
19271
Yes
19272
Yes
19290
No
19291
No
Description
NIPPLE EXPLOR W/WO EXC DUCT
EXC LACTIFEROUS DUCT FISTULA
EXC CYST/BEN-MALIG TISS/DUCT
1/MORE
EXC BREAST LES-ID RAD MARKER; 1 LES
EXC BREAST LES; EA ADD-ID RAD
MARKR
MASTEC GYNECOMASTIA
MASTECTOMY PARTIAL;
MASTECTOMY PARTIAL; W/AXILLARY
LYMPHADENECTOMY
MASTEC SIMPL COMPLT
MASTEC SUBQ
MASTEC RAD INCL PEC MUSCL AX
CYMPH
MASTEC RAD INCL MUSCL AX/INT
NODES
MASTEC MOD RAD EXCL PEC MAJOR
MUSCL
EXC CHEST WALL TUMOR INCL RIBS
EXC CHEST WALL TUMOR; WO
LYMPHADEN
EXC CHEST WALL TUMOR;
W/LYMPHADEN
PREOP PLCMT NEEDL LOCAL WIRE
BREAST
PREOP PLCMT NEEDLE BREAST; ADD
LES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
19295
No
19296
Yes
19297
Yes
19298
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
19324
Not Reimbursable
19325
19328
19330
Not Reimbursable
Yes
Yes
19340
Yes
19342
19350
Yes
Yes
Description
IMAGE GUIDED PLCMT; DURING BREAST
BX (IN CONJTN W/ CPT 19102
PLCMT RT BALLN CATH BRST; DATE SEP
PART MASTECT
PLCMT RT BALLN CATH BRST;
CONCURRNT PART MASTECT
PLCMT RT BRACHYTX CATH BRST FLW
PART MASTECT
REMOVAL OF BREAST TISSUE
PARTICAL MASTECTOMY
P-MASTECTOMY W/LN REMOVAL
MAST, SIMPLE, COMPLETE
MAST, SUBQ
MAST, RADICAL
MAST, RAD, URBAN TYPE
MAST, MOD RAD
MASTOPEXY
REDUCTION MAMMAPLASTY
MAMMAPLSTY AUGMEN; WO PROSTH
IMPLNT
MAMMAPLASTY AUGMEN; W/PROSTH
IMPLNT
REMOV INTACT MAMMARY IMPLNT
REMOV MAMMARY IMPLNT MAT
IMMED INSRT PROSTH AFTER
MASTOPEX
DELAYED INSRT PROSTH AFTER
MASTOPEX
NIPPLE/AREOLA RECON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
19355
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
19357
Yes
19361
19364
19366
Yes
Yes
Yes
19367
Yes
19368
Yes
19369
Yes
19370
Yes
19371
19380
Yes
Yes
19396
19499
20000
No
Yes
No
20005
No
20100
No
20101
No
Description
CORRECT INVERTED NIPPLES
BREAST RECON IMMED/DELAY
W/EXPANDR
BREAST RECON W/FLAP W/WO PROSTH
BREAST RECON W/FREE FLAP
BREAST RECON W/OTHER TECH
BREAST RECON W/TRAM FLAP-1
PEDICLE;
BRST RECON W/TRAM FLP; W/MICRO
ANAS
BREAST RECON W/TRAM FLAP-2
PEDICLE
OPEN PERIPROSTH CAPSULOTOMY
BREAST
PERIPROSTHETIC CAPSULECTOMY
BREAST
REVIS RECON BREAST
PREP MOULAGE CUSTOM BREAST
IMPLNT
UNLISTED PROC BREAST
INCS SOFT TISS ABSCESS; SUPERF
INCS SOFT TISS ABSCESS;
DEEP/COMPLI
EXPLOR PENETR WOUND (SEP PRO);
NECK
EXPLOR PENETR WOUND (SEP PRO);
CHST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
20102
No
20103
No
20150
20200
20205
20206
20220
20225
20240
20245
No
No
No
No
No
No
No
No
20250
No
20251
20500
20501
20520
No
No
No
No
20525
No
20526
No
20550
No
20551
No
Description
EXPLOR WOUND (SEP PRO);
ABD/FLNK/BK
EXPLO PENTR WOUND (SEP PRO);
EXTREM
EXC EPIPHYSEAL BAR W/WO AUTOG
GFT
BX MUSCL; SUPERF
BX MUSCL; DEEP
BX MUSCL PERCUT NEEDLE
BX BONE TROCAR/NEEDLE; SUPERF
BX BONE TROCAR/NEEDLE; DEEP
BIOPSY BONE OPEN; SUPERFICIAL
BIOPSY BONE OPEN; DEEP
BX VERTEBRAL BODY OPEN; THORACIC
BX VERTEBRAL BODY OPEN;
LUMBAR/CERV
INJ SINUS TRACT; THERAP (SEP PRO)
INJ SINUS TRACT; DX
REMOV FB MUSCL/TENDON; SIMPL
REMOV FB MUSCL/TENDON;
DEEP/COMPLI
INJECTION THERAPEUTIC CARPAL
TUNNEL
INJECTION; SINGLE TENDON SHEATH OR
LIGAMENT
INJECTION; SINGLE TENDON
ORIGIN/INSERTION
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
20552
20553
20555
20600
No
No
Not Reimbursable
No
20605
No
ARTHROCENTESIS/ASPIR/INJ; INTERM JT
No
20610
No
No
20612
20615
20650
20660
20661
20662
20663
No
No
No
No
No
No
No
20664
No
20665
No
20670
20680
20690
20692
No
No
No
No
20693
20694
No
No
ARTHROCENTESIS/ASPIR/INJ; MAJOR JT
ASPIRATION AND/OR INJECT OF
GANGLION CYST(S)
ASPIRAT & INJ TX BONE CYST
INSRT WIRE W/TRACT (SEPART PROC)
APPLIC CRAN TONGS (SEPART PROC)
APPLIC HALO INCL REMOV; CRANIAL
APPLIC HALO INCL REMOV; PELVIC
APPLIC HALO INCL REMOV; FEMORAL
APPLIC HALO INCL REMOV, CRAN
W/ANES
REMOV TONGS/HALO APPLIC BY
ANOTHER
REMOV IMPLNT; SUPERF (SEPART
PROC)
REMOV IMPLNT; DEEP
APPLIC UNIPLANE-UNILAT-EXT FIXA
APPLIC MULTIPLANE-UNILAT-EXT FIXA
ADJUST/REVIS EXT FIXA SYST REQ
ANES
REMOV UNDER ANES EXT FIXA SYST
Description
INJ; SINGLE/MX TRIGGER POINT 1/TWO
MUSCLE
INJ; 1/MX TRIG POINT 3/> MUSC GRP
PLACE NDL MUSC/TIS FOR RT
ARTHROCENTESIS/ASPIR/INJ; SM JT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
20802
Yes
20805
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
REPLANTATION ARM; COMPLT AMPUTA
REPLANTATION FOREARM; COMPLT
AMPUTA
20808
Yes
REPLANTATION HAND; COMPLT AMPUTA
No
20816
20822
20824
Yes
Yes
Yes
REPLANTATION DIGIT (MCP JT); COMPLT
REPLANT DIGIT (DISTAL TIP); COMPLT
REPLANT THUMB (CM-MP JT); COMPLT
No
No
No
20827
20838
Yes
Yes
REPLANT THUMB (DISTAL TIP); COMPLT
REPLANTATION FT; COMPLT AMPUTA
No
No
20900
Yes
BONE GFT ANY DONOR AREA; MINOR/SM
No
20902
20910
20912
20920
Yes
Yes
Yes
Yes
BONE GFT ANY DONOR AREA; MAJOR/LG
CARTILAGE GFT; COSTOCHONDRAL
CARTILAGE GFT; NASAL SEPTUM
FASCIA LATA GFT; BY STRIPPER
No
No
No
No
20922
20924
20926
Yes
Yes
Yes
No
No
No
20930
Bundled
20931
Yes
FASCIA LATA GFT; INCS & AREA EXPOSU
TENDON GFT FROM A DISTANCE
TISS GFT OTHER
ALLOGFT SPINE SURG ONLY;
MORSELIZED
ALLOGFT SPINE SURG ONLY;
STRUCTURAL
No
Bundled
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
20936
Bundled
20937
Yes
20938
Yes
20950
Yes
20955
Yes
20956
Yes
20957
Yes
20962
Yes
20969
20970
20972
20973
Yes
Yes
Yes
Yes
Description
AUTOGFT SPIN SURG; LOCAL-SAME
INCIS
AUTOGFT SPINE SURG ONLY;
MORSELIZED
AUTOGFT SPIN SURG; STRUC/BITRICORT
MONITOR PRESS-DETECT MUSCL
COMPARTM
BONE GFT W/MICROVASC ANASTOM;
FIBUL
BONE GFT W/MICROVASC ANASTOM;
ILIAC
BONE GFT W/MICROVAS ANAS;
METATARSL
BONE GFT W/MICROVASC ANASTOM;
OTHER
FREE OSTEOCUT FLAP; NOT ILIAC
CREST
FREE OSTEOCUT FLAP; ILIAC CREST
FREE OSTEOCUT FLAP; METATARS
FREE OSTEOCUT FLAP; GRT TOE
20974
20975
Yes
Yes
ELEC STIM-AID BONE HEAL; NONINVASIV
ELEC STIM-AID BONE HEAL; INVASIVE
20979
Not Reimbursable
20982
20985
Yes
Not Reimbursable
US STIM-AID BONE HEALING-NONINVAS
ABLATION BONE TUMOR RADIOFREQ
PERQ CT GUID
CPTR-ASST DIR MS PX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Bundled
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
20986
20987
20999
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Not Reimbursable
Yes
21010
Yes
21015
21025
21026
Yes
Yes
Yes
21029
Yes
21030
21031
21032
Yes
Yes
Yes
21034
Yes
21040
21044
Yes
Yes
21045
Yes
21046
Yes
21047
Yes
21048
Yes
Description
CPTR-ASST DIR MS PX IO IMG
CPTR-ASST DIR MS PX PRE IMG
UNLISTED PROC MS SYST GEN
ARTHROTOMY TEMPOROMANDIBULAR
JT
RAD RESEC TUMOR SOFT TISS
FACE/SCLP
EXC BONE; MANDIB
EXC BONE; FACIAL BONE
REMOV-CONTOURNG BEN TUMOR FACE
BONE
EXC BEN TUMOR FACE BONE NOT
MANDIB
EXC TORUS MANDIBULARIS
EXC MAXIL TORUS PALATINUS
EXC MALIG TUM FACE BONE NOT
MANDIB
EXC BEN CYST/TUMOR MANDIB; SIMPL
EXC MALIG TUMOR MANDIB
EXC MALIG TUMOR MANDIB; RAD
RESECT
EXC BEN CYST/TUMOR MANDIB; INTRAORAL OSTEOTOMY
EXC BEN CYST/TUMOR MANDIB; EXTRAORAL OSTEOTOMY
EXC BEN CYST/TUMOR MAXILLA; INTRAORAL OSTEOTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21049
21050
Yes
Yes
21060
21070
21073
Yes
Yes
No
21076
Yes
21077
Yes
21079
Yes
21080
Yes
Description
EXC BEN CYST/TUMOR MAXILLA; EXTRAORAL OSTEOTOMY
CONDYLECTOMY TMJ (SEPART PROC)
MENISCECT PART/COMPLT (SEPART
PROC)
CORONOIDECTOMY (SEPART PROC)
MNPJ OF TMJ W/ANESTH
IMPRES & CUSTM PREP; SUR OBTUR
PROS
IMPRESS & CUSTOM PREP; ORBIT
PROSTH
IMPRESS/CUST PREP; INTERIM
OBTURATR
IMPRESS/CUST PREP; DEFINIT
OBTURATR
21081
Yes
IMPRESS/CUST PREP; MANDIB RESECT
No
21082
21083
21084
Yes
Yes
Yes
No
No
No
21085
Yes
21086
Yes
IMPRESS/CUST PREP; PALATAL AUGMEN
IMPRESS/CUST PREP; PALATAL LIFT
IMPRESS/CUST PREP; SPEECH AID
IMPRESS/CUST PREP; ORAL SURG
SPLINT
IMPRESS/CUST PREP; AURICULAR
PROSTH
21087
Yes
IMPRESS/CUST PREP; NASAL PROSTH
No
21088
Yes
IMPRESS/CUST PREP; FACIAL PROSTH
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21089
21100
21110
21116
21120
21121
Yes
Yes
Yes
Yes
Yes
Yes
Description
UNLISTED MAXILLOFACIAL PROSTH
PROC
APPLIC HALO-MAXILLOFAC (SEP PRO)
APPLIC INTERDENTAL DEVICE-NOT FX
INJ PROC TMJ ARTHROGRAPHY
GENIOPLASTY; AUGMEN
GENIOPLASTY; SLIDING OSTEOTOMY 1
21122
Yes
GENIOPLASTY; SLIDING OSTEOT 2/MORE
No
21123
Yes
GENIOPLASTY; SLIDING AUGMEN W/GFT
No
21125
21127
Yes
Yes
No
No
21137
Yes
21138
Yes
21139
21141
21142
Yes
Yes
Yes
AUGMEN MANDIB BODY/ANGLE; PROSTH
AUGMEN MANDIB BODY; W/BONE GFT
REDUCTION FOREHEAD; CONTOURING
ONLY
REDUCT FOREHEAD; CONTOUR/BONE
GFT
REDUCT FOREHEAD; SETBACK SINUS
WALL
RECON MIDFACE LEFORT I; 1 WO GFT
RECON MIDFACE LEFORT I; 2 WO GFT
21143
Yes
RECON MIDFACE LEFORT I; 3/> WO GFT
No
21145
Yes
RECON MIDFACE LEFORT I; 1 REQ GFT
No
21146
Yes
RECON MIDFACE LEFORT I; 2 REQ GFT
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21147
Yes
RECON MIDFACE LEFORT I; 3/MORE-GFT
No
21150
21151
Yes
Yes
No
No
21154
Yes
RECON MIDFACE LEFORT II; ANT INTRUS
RECON MIDFACE LEFORT II; REQ GFT
RECON MIDFACE REQ GFT; WO LEFORT
I
21155
Yes
No
21159
Yes
21160
Yes
21172
Yes
21175
Yes
RECON MIDFACE REQ GFT; W/LEFORT I
RECON MIDFACE FOREHD ADV; WO
LFRT I
RECON MIDFACE FOREHD ADV;
W/LFORT I
RECON ORBITAL RIM/LO FORHD W/WO
GFT
RECON BIFRONTL ORBIT RIMS W/WO
GFTS
21179
Yes
21180
Yes
21181
Yes
21182
Yes
21183
21184
RECON MAJ FORHD/ORBIT RIMS; W/GFT
RECON MAJ FORHD/ORBIT RIM;
W/AUTOGT
RECON CONTOUR BEN TUMOR CRAN
BONE
No
No
No
No
No
No
No
No
Yes
RECON ORBIT-EXC BONE; GFT < 40 CM2
RECON ORBIT; BONE GFT >40 BUT
<80CM
No
No
Yes
RECON ORBIT-EXC BONE; GFT > 80 CM2
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21188
Yes
Description
RECON MIDFACE OSTEOTOMIES/BONE
GFT
21193
21194
Yes
Yes
RECON MANDIB RAMI OSTEOT; WO GFT
RECON MANDIB RAMI OSTEOT; W/GFT
No
No
21195
Yes
RECON MANDIB RAMI/BODY; WO INT FIX
No
21196
21198
Yes
Yes
No
No
21199
21206
Yes
Yes
RECON MANDIB RAMI/BODY; W/INT FIXA
OSTEOTOMY MANDIB SEGMT
OSTEOTOMY W/ GENIOGLOSSUS
ADVANCEMENT
OSTEOTOMY MAXIL SEGMT
21208
Yes
21209
No
No
No
Yes
OSTEOPLASTY FACIAL BONES; AUGMEN
OSTEOPLASTY FACIAL BONES;
REDUCTION
No
No
21210
21215
Yes
Yes
GFT BONE; NASAL/MAXIL/MALAR AREAS
GFT BONE; MANDIB
No
No
21230
Yes
No
21235
21240
21242
Yes
Yes
Yes
21243
Yes
GFT; RIB CARTIL AUTOG-FACE/CHIN/EAR
GFT; EAR CARTILAGE AUTOGEN
NOSE/EAR
ARTHROPLASTY TMJ W/WO AUTOGFT
ARTHROPLASTY TMJ W/ALLOGFT
ARTHROPLASTY TMJ W/PROSTH JT
REPLAC
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
21244
Yes
21245
Yes
21246
Yes
21247
Yes
21248
Yes
21249
Yes
21255
Yes
21256
Yes
21260
Yes
21261
Yes
21263
Yes
21267
Yes
21268
21270
Yes
Yes
21275
Yes
Description
RECON MANDIB EXTRAORAL W/BONE
PLATE
RECON MANDIB SUBPERIOST IMPLT;
PART
RECON MANDIB SUBPERIOST IMPLT;
COMP
RECON MANDIB CONDYLE W/BONE
AUTOGFT
RECON MANDIB ENDOSTEAL IMPLT;
PART
RECON MANDIB ENDOSTEAL IMPLT;
COMPL
RECON ZYGOMATIC ARCH W/BONE
CARTIL
RECON ORBIT W/OSTEOT & W/BONE
GFT
PERIORBIT OSTEOTOM W/GFT;
EXTRACRAN
PERIORBIT OSTEOTOM; INTRAEXTRACRAN
PERIORBIT OSTEOTOM; W/FORHD
ADVANCE
ORBIT REPOSIT-UNILAT; EXTRACRANIAL
ORBIT REPOSIT-UNILAT; INTRAEXTRACR
MALAR AUGMEN PROSTH MAT
SECNDRY REVIS ORBITOCRAN-FACE
RECON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
21280
21282
Yes
Yes
21295
Yes
21296
Yes
21299
21300
21310
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
MEDIAL CANTHOPEXY (SEPART PROC)
LAT CANTHOPEXY
REDUCTION MASSETER MUSCL & BONE;
EX
No
No
No
Yes
No
No
REDUCT MASSETER MUSCL; INTRAORAL
UNLISTED CRANIO-MAXILLOFACIAL
PROC
CLO TX SKULL FX WO OR
CLO TX NASAL BONE FX WO MANIP
21315
No
CLO TX NASAL BONE FX; WO STABILIZAT
No
21320
21325
No
No
CLO TX NASAL BONE FX; W/STABILIZAT
OPEN TX NASAL FX; UNCOMP
No
No
21330
No
No
21335
No
OPEN TX NAS FX; COMPL W/INT-EXT FIX
OPEN TX NASAL FX; W/CONCOM TX
SEPTM
21336
21337
No
No
21338
No
21339
No
21340
No
OPEN TX SEPTAL FX; W/WO STABILIZAT
CLO TX SEPTAL FX W/WO STABILIZAT
OPEN TX NASOETHMOID FX; WO EXT
FIXA
OPEN TX NASOETHMOID FX; W/EXT FIXA
PERCUT TX NASOETH FX W/FIXA
W/REPR
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21343
No
Description
OPEN TX DEPRESSED FRONTAL SINUS
FX
21344
21345
No
No
OPEN TX FRONT SINUS FX VIA CORONAL
CLO TX NASOMAXIL FX W/FIXA/SPLINT
No
No
21346
No
No
21347
No
OPEN TX NASOMAXIL FX; W/WIRING/FIXA
OPEN TX NASOMAX FX; REQ MX
APPROACH
21348
21355
No
No
21356
No
21360
21365
21366
No
No
No
21385
No
21386
No
OPEN TX NASOMAXIL FX; W/BONE GFT
PERCUT TX FX MALAR AREA W/MANIP
OPEN TX DEPRESSED ZYGOMATIC ARCH
FX
OPEN TX DEPRESS MALAR FX INCL
ZYGOM
OPEN TX FX MALAR AREA; W/INT FIX
OPEN TX FX MALAR AREA; W/GFT
OPEN TX ORBIT BLOWOUT FX;
TRNSANTRL
OPEN TX ORBIT BLOWOUT FX;
PERIORBIT
21387
No
OPEN TX ORBIT "BLOWOUT" FX; COMBO
No
21390
No
OPEN TX ORBIT BLOWOUT FX; W/IMPLNT
No
21395
No
OPEN TX ORBIT "BLOWOUT" FX; W/GFT
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
21400
No
21401
No
21406
No
21407
No
Description
CLO TX FX ORBIT EX BLOWOUT; WO
MANI
CLO TX FX ORBIT EX BLOWOUT;
W/MANIP
OPEN TX FX ORB EX BLOWOUT; WO
IMPLT
OPEN TX FX ORB EX BLOWOUT;
W/IMPLNT
21408
No
OPEN TX FX ORBIT EX BLOWOUT; W/GFT
No
21421
21422
No
No
CLO TX PALATAL FX W/INTERDENT FIXA
OPEN TX PALATAL/MAXIL FX
No
No
21423
No
OPEN TX PALATAL/MAXIL FX; COMPLIC
No
21431
No
CLO TX CRANIOFAC SEPART W/WIRE FIX
No
21432
No
OPEN TX CRANIOFAC SEPAR; W/INT FIXA
No
21433
No
OPEN TX CRANIOFAC SEPART; COMPLIC
No
21435
No
No
21436
21440
21445
21450
21451
No
No
No
No
No
OPEN TX CRANIFAC SEPAR; INT-EXT FIX
OPEN TX CRANIFAC SEPAR; W/FIX
W/GFT
CLO TX MAXIL RIDGE FX (SEP PRO)
OPEN TX MAXIL RIDGE FX (SEP PRO)
CLO TX MANDIB FX; WO MANIP
CLO TX MANDIB FX; W/MANIP
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21452
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
21453
21454
No
No
21461
No
21462
21465
No
No
21470
21480
No
No
21485
No
21490
21495
Description
PERCUT TX MANDIB FX W/EXT FIXA
CLO TX MANDIB FX W/INTERDENTAL
FIXA
OPEN TX MANDIB FX W/EXT FIXA
OPEN TX MANDIB FX; WO INTERDENT
FIX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
OPEN TX MANDIB FX; W/INTERDENT FIXA
OPEN TX MANDIB CONDYLAR FX
OPEN TX MANDIB FX MX APPROACH
W/FIX
CLO TX TM DISLOC; INIT/SUBSQT
No
No
No
No
No
CLO TX TM DISLOC; COMPLIC INIT/SUBS
OPEN TX TEMPOROMANDIBULAR
DISLOC
OPEN TX HYOID FX
No
No
21497
21499
21501
No
Yes
Yes
INTERDENT WIRING-CONDITION NOT FX
UNLISTED MS PROC HEAD
I&D DEEP ABSCESS SOFT TISS NECK
No
No
No
21502
Yes
No
21510
21550
21555
Yes
Yes
Yes
I&D DEEP ABSCESS NECK; W/PART RIB
INCS DEEP W/OPEN BONE CORTEX
THORAX
BX SOFT TISS NECK/THORAX
EXC TUMOR SOFT TISS NECK; SUBQ
21556
Yes
EXC TUMOR SOFT TISS NECK; DEEP/IM
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
21557
21600
Yes
Yes
21610
21615
Yes
Yes
21616
21620
21627
21630
Yes
Yes
Yes
Yes
21632
21685
Yes
Yes
21700
Yes
21705
Yes
21720
Yes
21725
Yes
21740
21742
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
RAD RESECT TUMOR SOFT TISS NECK
EXC RIB PART
COSTOTRANSVERSECTOMY (SEPART
PROC)
EXC 1ST &/OR CERV RIB;
No
No
EXC 1ST &/OR CERV RIB; W/SYMPATHEC
OSTECTOMY STERNUM PART
STERNAL DEBRID
RADICAL RESECT STERNUM;
RAD RESECT STERNUM;
W/LYMPHADENECT
HYOID MYOTOMY AND SUSPENSION
DIVIS SCALENUS ANTICUS; WO CERV
RIB
No
No
No
No
DIVIS SCALENUS ANTICUS; W/CERV RIB
DIVIS STERNOCLEIDOMASTOID; WO
CAST
No
No
Yes
DIVIS STERNOCLEIDOMASTOID; W/CAST
RECON REPR PECTUS
EXCAVAT/CARINATUM
No
Yes
RECON REP PECTUS
EXCAVATM/CARINATM;NO THORACSCPY
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
21743
Yes
21750
21800
21805
21810
21820
Yes
No
No
No
No
21825
21899
21920
21925
21930
No
Yes
Yes
Yes
Yes
21935
22010
22015
Yes
Yes
Yes
22100
Yes
22101
Yes
22102
Yes
22103
Yes
22110
Yes
Description
RECON REP PECTUS
EXCAVATM/CARINATM; W/THORACSCPY
CLO STERNOTMY W/WO DEBRID (SEP
PRO)
CLO TX RIB FX UNCOMP EA
OPEN TX RIB FX WO FIXA EA
TX RIB FX REQUIRING EXT FIXA
CLO TX STERNUM FX
OPEN TX STERNUM FX W/WO SKELET
FIXA
UNLISTED PROC NECK/THORAX
BX SOFT TISS BACK/FLANK; SUPERF
BX SOFT TISS BACK/FLANK; DEEP
EXC TUMOR SOFT TISS BACK/FLANK
RAD RESECT TUMOR TISS BACK/FLANK
I&D, P-SPINE, C/T/CERV-THOR
I&d, P-SPINE, L/S/LS
PART EXC POST VERTEB COMPON-1;
CERV
PART EXC POST VERTEB COMPON-1;
THOR
PART EXC POST VERTEB COMPON-1;
LUMB
PART EXC POST VERTEB COMPON; EA
ADD
PART EXC VERT BODY WO DECOM-1;
CERV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
22112
Yes
22114
Yes
Description
PART EXC VERT BODY WO DECOM-1;
THOR
PART EXC VERT BODY WO DECOM-1;
LUMB
22116
22206
22207
22208
22210
22212
22214
22216
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
PART EXC VERT BODY; EA ADD SEGMT
CUT SPINE 3 COL, THOR
CUT SPINE 3 COL, LUMB
CUT SPINE 3 COL, ADDL SEG
OSTEOT SPINE-VIA POST/LAT-1; CERV
OSTEOT SPINE-VIA POST/LAT-1; THOR
OSTEOT SPINE-VIA POST/LAT-1; LUMB
OSTEOT SPINE VIA POST/LAT; EA ADD
No
No
No
No
No
No
No
No
22220
Yes
OSTEOT SPINE W/DISKECT-ANT-1; CERV
No
22222
Yes
OSTEOT SPINE W/DISKECT-ANT-1; THOR
No
22224
Yes
OSTEOT SPINE W/DISKECT-ANT-1; LUMB
No
22226
22305
Yes
No
No
No
22310
No
OSTEOT SPINE W/DISKECT-ANT; EA ADD
CLO TX VERTEBRAL PROCESS FX
CLO TX VERT BODY FX WO MANIPW/CAST
22315
22318
22319
No
No
No
CLO TX VERT FX/DISLOC W/CAST-MANIP
OP TX ODONTOID FX/DISLOC; WO GFT
OP TX ODONTOID FX/DISLOC; W/GFT
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
22325
No
22326
No
22327
No
Description
OPEN TX VERT FX/DISLOC-POST-1;
LUMB
OPEN TX VERT FX/DISLOC-POST-1;
CERV
OPEN TX VERT FX/DISLOC-POST-1;
THOR
22328
No
OP TX VERT FX/DISLOC-POST; EA ADD
22505
22520
22521
Yes
Not Reimbursable
Not Reimbursable
22522
Not Reimbursable
22523
Yes
22524
Yes
22525
22526
22527
Yes
Yes
Yes
22532
Yes
22533
Yes
22534
Yes
MANIP SPINE REQUIR ANES ANY REGION
PERCTANEOUS VERTEBROPLASTY
PERC VERTEBROPLASTY-LUMBAR
PERC VERTEBROPLASTY-EA ADD
THORACIC OR LUMBAR VERT
PRQ VRT AGMNTJ MCHNL DEV 1 VRT
BDY THRC
PRQ VRT AGMNTJ MCHNL DEV 1 VRT
BDY LMBR
PRQ VRT AGMNTJ MCHNL DEV 1 VRT
BDY EA THRC/LMBR
IDET, SINGLE LEVEL
IDET, 1 OR MORE LEVELS
ARTHRDSIS LAT XTRACAVITARY MINI
DISKECT; THOR
ARTHRDSIS LAT XTRACAVITARY MINI
DISKECT; LUMB
ARTHRDSIS LAT XTRACAVTRY MINI
DISKECT;T/L EA ADD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
22548
22554
22556
22558
Yes
Yes
Yes
Yes
22585
Yes
22590
Description
ARTHRODESIS-C1 C2-W/WO EXC
ODONTOID
ARTHRODESIS W/MINI DISKECT; C3-C7
ARTHRODESIS W/MINI DISKECT; THOR
ARTHRODESIS W/MINI DISKECT; LUMB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Yes
ARTHRODESIS W/MINI DISKECT; EA ADD
ARTHRODESIS-POST TECH,
CRANIOCERV
No
No
22595
Yes
ARTHRODESIS-POST TECH, ATLAS-AXIS
No
22600
Yes
ARTHRODESIS-POST/POSTLAT-1; C3-C7
No
22610
Yes
ARTHRODESIS-POST/POSTLAT-1; THOR
No
22612
Yes
No
22614
Yes
22630
Yes
22632
Yes
22800
Yes
22802
Yes
22804
Yes
ARTHRODESIS-POST/POSTLAT-1; LUMB
ARTHRODESIS-POST/LAT; EA ADD
SEGMT
ARTHRODESIS-POST-W/ LAMINEC-1;
LUMB
ARTHRODES-POST-W/ LAMINEC-1; EA
ADD
ARTHRODESIS-POST; 6/LESS VERT
SEGMT
ARTHRODESIS-POST; 7-12 VERTEB
SEGMT
ARTHRODESIS-POST; 13/> VERTEB
SEGMT
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
22808
Yes
ARTHRODESIS-ANT; 2 TO 3 VERT SEGMT
No
22810
Yes
No
22812
Yes
22818
Yes
22819
22830
Yes
Yes
22840
Yes
22841
Bundled
22842
Yes
22843
Yes
22844
22845
22846
Yes
Yes
Yes
ARTHRODESIS-ANT; 4-7 VERTEB SEGMT
ARTHRODESIS-ANT; 8/MORE VERT
SEGMT
KYPHECTOMY, RESECT VERT SEGMT; 12
KYPHECTOMY, RESECT VERT SEGMT;
3/>
EXPLOR SPINAL FUSION
POST NON-SEG INSTRUMPEDICLE/SCREW
INT SPINAL FIX-WIRE SPINOUS
PROCESS
POST SEGMT INSTRUM; 3 TO 6 VERT
SEG
POST SEGMT INSTRUM; 7-12 VERT
SEGMT
POST SEGMT INSTRUM; 13/> VERT
SEGMT
ANT INSTRUM; 2 TO 3 VERTEB SEGMT
ANT INSTRUM; 4 TO 7 VERTEB SEGMT
22847
22848
22849
Yes
Yes
Yes
22850
Yes
ANT INSTRUM; 8/MORE VERTEB SEGMT
PELV FIX OTH THAN SACRUM
REINSERTION SPINAL FIXA DEVICE
REMOV POST NONSEGMENTAL
INSTRUM
No
No
No
No
No
Bundled
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
22851
22852
22855
22857
22862
22865
22899
22900
22999
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
23000
23020
Yes
Yes
23030
23031
23035
No
No
Yes
23040
Yes
23044
Yes
23065
Yes
23066
23075
23076
Yes
Yes
Yes
23077
Yes
Description
APPLIC INTERVERT BIOMECHAN DEVICE
REMOV POST SEGMT INSTRUM
REMOV ANT INSTRUM
LUMBAR ARTIF DISKECTOMY
REVISE LUMBAR ARTIF DISC
REMOVE LUMB ARTIF DISC
UNLISTED PROC SPINE
EXC ABD WALL TUMOR SUBFASCIAL
UNLISTED PROC ABD MS SYST
REMOV SUBDELT CALC DEPOS ANY
METHD
CAPSULAR CONTRACTURE RELEASE
I&D SHOULDER; DEEP
ABSCESS/HEMATOMA
I&D SHOULDER AREA; INFEC BURSA
INCS BONE CORTEX SHLDR AREA
ARTHROT GLENOHUMERAL JT
W/EXPLOR
ARTHROT AC/STERNOCLAV JT
W/EXPLOR
BX SOFT TISS SHOULDER AREA;
SUPERF
BX SOFT TISS SHOULDER AREA; DEEP
EXC SOFT TISS TUMOR SHLDR; SUBQ
EXC SOFT TISS TUMOR SHLDR; DEEP
RAD RESECT TUMOR SOFT TISS
SHOULDER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
23100
23101
Yes
Yes
23105
Yes
23106
Yes
23107
23120
23125
23130
Yes
Yes
Yes
Yes
23140
Yes
23145
Yes
23146
Yes
23150
Yes
23155
Yes
23156
23170
23172
Yes
Yes
Yes
23174
23180
Yes
Yes
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
ARTHROT GLENOHUMERAL JT INCL BX
ARTHROT AC/SC JT W/BX/EXC CARTIL
ARTHROT; GLENOHUM JT-SYNVCT
W/WO BX
No
No
ARTHROT; SC JT W/SYNOVECT W/WO BX
ARTHROTOMY-GLENOHUMERAL JT
W/EXPLOR
CLAVICULECTOMY; PART
CLAVICULECTOMY; TOT
ACROMIOPLAS/ACROMIONECT PART
EXC/CURET BONE CYST/TUMOR
CLAV/SCAP
EXC/CURET BONE CYST/CLAV;
W/AUTOGFT
EXC/CURET BONE CYST CLAV;
W/ALLOGFT
EXC/CURET BONE CYST/TUMOR PROX
HUME
EXC BONE CYST PROX HUMERUS;
W/AUTOG
EXC BONE CYST PROX HUMERUS;
W/ALLOG
SEQUESTRECTOMY CLAV
SEQUESTRECTOMY SCAPULA
SEQUEST HUMERAL HEAD TO SURG
NECK
PART EXC BONE CLAV
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
23182
23184
23190
23195
23200
23210
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
Yes
Yes
23220
Yes
23221
Yes
23222
23330
23331
Yes
No
Yes
23332
Yes
23350
No
23395
Description
PART EXC BONE SCAPULA
PART EXC BONE PROX HUMERUS
OSTECTOMY SCAPULA PART
RESECT HUMERAL HEAD
RADICAL RESECT TUMOR; CLAV
RADICAL RESECT TUMOR; SCAPULA
RAD RESECT BONE TUMOR PROX
HUMERUS;
RAD RESCT BNE TUMR PROX HUMER;
GFT
RAD RESECT TUMOR PROX HUMER;
PROSTH
REMOV FB SHOULDER; SUBQ
REMOV FB SHLDR; DEEP
REMOV FB SHLDR; COMPLIC (TOT
SHLDR)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
INJ PROC SHOULDER ARTHROGRAPHY
MUSCL TRANSF-SHOULDER/UP ARM;
SNGL
23397
23400
23405
Yes
Yes
Yes
MUSCL TRANSF-SHOULDER/UP ARM; MX
SCAPULOPEXY
TENOT SHLDR AREA; SNGL TENDON
No
No
No
23406
Yes
No
23410
Yes
TENOT SHLDR; MX TENDONS-SAME INCS
REPR RUPT MUSCULOTENDIN CUFF;
ACUTE
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
23412
Yes
23415
Yes
23420
23430
Yes
Yes
23440
Yes
23450
Yes
23455
Yes
23460
Yes
23462
23465
Yes
Yes
23466
Yes
23470
23472
23480
Yes
Yes
Yes
23485
Yes
23490
23491
Yes
Yes
Description
REPR RUPT MUSCULOTENDIN CUFF;
CHRON
CORACOACROM LIG REL W/WO
ACROMIOPLA
RECONS SHLDR CUFF AVULS CHRONIC
TENODESIS LONG TENDON BICEPS
RESECT/TRANSPL LONG TENDON
BICEPS
CAPSULORRHAPHY ANT; PUTTI-PLATT
TYP
CAPSULORRHAPHY ANT; W/LABRAL
REPR
CAPSULORRHAPHY ANT; W/BONE
BLOCK
CAPSULORRHAPHY ANT; W/CORACOID
TRNS
CAPSULORRHAPY GH JT POST BLOCK
CAPSULORRHAPHY GH JT MX
INSTABILITY
ARTHROPLASTY GH JT;
HEMIARTHROPLAST
ARTHROPLASTY GH JT; TOT SHLDR
OSTEOTOMY CLAV W/WO INT FIXA
OSTEOTOMY CLAV W/WO INT FIXA;
W/GFT
PROPHYL TX W/WO
METHYLMETHACRY;CLAV
PROPHYLACTIC TX; PROX HUMERUS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
23500
23505
23515
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
23520
No
23525
No
23530
No
23532
No
23540
No
23545
23550
23552
23570
Description
CLO TX CLAV FX; WO MANIP
CLO TX CLAV FX; W/MANIP
OPEN TX CLAV FX W/WO INT/EXT FIXA
CLO TX STERNOCLAV DISLOC; W/O
MANIP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
CLO TX STERNOCLAV DISLOC; W/MANIP
OPEN TX STERNCLAV DISLOC
ACUTE/CHRO
OPEN TX STRNCLAV DISLOC; W/FASC
GFT
CLO TX ACROMIOCLAV DISLOC; WO
MANIP
CLO TX ACROMIOCLAV DISLOC;
W/MANIP
OPEN TX AC DISLOC ACUTE/CHRONIC
OPEN TX AC DISLOC; W/FASCIAL GFT
CLO TX SCAPULAR FX; WO MANIP
No
No
No
No
No
23575
No
CLO TX SCAP FX; W/MANIP W/WO TRACT
No
23585
No
OPEN TX SCAPULAR FX W/WO INT FIXA
No
23600
23605
No
No
No
No
23615
No
23616
No
CLO TX PROX HUMERAL FX; WO MANIP
CLO TX PROX HUMER FX; W/MANIP
OPEN TX PROX HUMER FX W/WO FIXREPR
OPEN TX PROX HUMER FX; W/PROS
REPLA
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
23620
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
23625
23630
No
No
23650
No
23655
23660
No
No
23665
23670
23675
No
No
No
23680
23700
Description
CLO TX GR HUMERAL TUBER FX; WO
CLO TX GR HUMERAL TUBER FX;
W/MANIP
OP TX GR HUMERAL TUBER FX W/WO
CLO TX SHLDR DISLOC W/MANIP;WO
ANES
CLO TX SHLDR DISLOC W/MANIP;
W/ANES
OPEN TX ACUTE SHOULDER DISLOC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
CLO TX SHLDR DISLOC-FX GR HUMERAL
OP TX SHLDR DISLC-FX GR HUMER
CLO TX SHLDR DISLOC W/FX W/MANIP
OPEN TX SHLDR DISLOC W/FX SURG
NECK
MANIP W/ANES SHLDR JT INCL FIXA
23800
Yes
ARTHRODESIS GLENOHUMERAL JOINT;
No
23802
23900
23920
Yes
Yes
Yes
No
No
No
23921
23929
Yes
Yes
ARTHRODESIS GH JOINT; W/AUTOG GFT
INTERTHORACOSCAPULAR AMPUTA
DISART SHOULDER
DISART SHLDR; SECNDRY CLO/SCAR
REVI
UNLISTED PROC SHOULDER
No
No
23930
Yes
I&D UPPER ARM/ELBOW; DEEP ABSCESS
No
23931
Yes
I&D UPPER ARM/ELBOW AREA; BURSA
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
23935
24000
Yes
Yes
24006
Yes
24065
Yes
24066
Yes
24075
Yes
24076
Yes
24077
Yes
24100
24101
Yes
Yes
24102
24105
Yes
Yes
24110
Yes
EXC TUMOR UPPER ARM/ELBOW; SUBQ
EXC TUMOR UP ARM/ELBOW;
DEEP/SUBFAS
RAD RESECT TUMOR TISS UP
ARM/ELBOW
ARTHROTOMY ELB; W/SYNOVIAL BX
ONLY
ARTHROTOMY ELBOW; W/JT EXPLOR
ARTHROTOMY ELBOW;
W/SYNOVECTOMY
EXC OLECRANON BURSA
EXC/CURET BONE CYST/TUMOR
HUMERUS
24115
Yes
EXC BONE CYST HUMERUS; W/AUTOGFT
No
24116
24120
Yes
Yes
EXC BONE CYST HUMERUS; W/ALLOGFT
EXC BONE CYST-HEAD/NECK RADIUS
No
No
Description
INCS DEEP W/OPEN BONE CORTEX
HUMER
ARTHROT ELBOW EXPLOR/REMOV FB
ARTHROTOMY ELBO W/CAP EXC (SEP
PRO)
BX SOFT TISS UP ARM/ELBOW; SUPERF
BX SOFT TISS UPPER ARM/ELBOW;
DEEP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24125
Yes
24126
24130
Yes
Yes
24134
Yes
24136
Yes
24138
24140
24145
Yes
Yes
Yes
24147
Yes
24149
Yes
24150
Yes
24151
Yes
24152
Yes
24153
24155
24160
24164
Yes
Yes
Yes
Yes
Description
EXC BONE CYST-HEAD RADIUS;
W/AUTOGF
EXC BONE CYST-HEAD RADIUS;
W/ALLOGF
EXC RADIAL HEAD
SEQUESTRECTOMY SHAFT/DISTAL
HUMERUS
SEQUESTRECTOMY RADIAL HEAD/NECK
SEQUESTRECTOMY OLECRANON
PROCESS
PART EXC BONE HUMERUS
PART EXC BONE RADIAL HEAD/NECK
PART EXC BONE OLECRANON PROCESS
RAD RESECT TISS-BONE ELB (SEP
PROC)
RAD RESEC TUMOR SHAFT/DISTAL
HUMERU
RAD RESECT TUMOR HUMERUS;
W/AUTOGFT
RAD RESECT TUMOR RADIAL
HEAD/NECK
RAD RESECT TUM RAD HEAD;
W/AUTOGFT
RESECT ELBOW JT
IMPLNT REMOV; ELBOW JT
IMPLNT REMOV; RADIAL HEAD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24200
Yes
REMOV FB UPPER ARM/ELBOW; SUBQ
No
24201
24220
Yes
Yes
No
No
24300
Yes
24301
Yes
24305
Yes
REMOV FB UPPER ARM/ELBOW; DEEP
INJ PROC ELBOW ARTHROGRAPHY
MANIPULATION ELBOW UNDER
ANESTHESIA
MUSCL/TENDON TRANSF UP
ARM/ELBOW 1
TENDON LENGTH UP ARM/ELBOW EA
TEND
24310
Yes
No
24320
24330
Yes
Yes
24331
24332
Yes
Yes
24340
Yes
24341
Yes
TENOT OP ELBOW-SHLDR EA TENDON
TENOPLSTY W/MUSCL TRNSF ELBOSHDL 1
FLEXOR-PLASTY ELBOW
FLEXOR-PLASTY ELBOW; W/EXTENSOR
ADV
TENOLYSIS TRICEPS
TENODESIS BICEPS TEND ELB (SEP
PRO)
REPR TEND/MUSC-ARM/ELB-EAPRI/SECND
24342
Yes
REINSRT RUPT BICEPS/TRICEPS DISTAL
No
24343
Yes
No
24344
Yes
REPR LAT COLLAT LIG ELB W/LOC TISS
RECON LAT COLLAT LIG ELB W/TEND
GFT
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24345
Yes
24346
24350
Yes
Yes
24351
Yes
24352
Yes
24354
Yes
24356
24357
24358
24359
24360
Yes
Yes
Yes
Yes
Yes
24361
Yes
24362
Yes
24363
24365
Yes
Yes
24366
24400
Description
REPAIR MCL ELBOW WITH LOCAL
TISSUE
RECONSTRUCT MCL ELB W/TENDON
GRAFT
FASCIOTOMY LAT/MEDIAL
FASCIOTOMY LAT/MED; W/EXTEN
ORIGIN
FASCIOTOMY LAT/MED; W/ANNULAR
LIGA
FASCIOTOMY LAT/MEDIAL; W/STRIPPING
FASCIOT LAT/MEDIAL; W/PART
OSTECTOM
REPAIR ELBOW, PERC
REPAIR ELBOW W/DEB, OPEN
REPAIR ELBOW DEB/ATTCH OPEN
ARTHROPLASTY ELBOW; W/MEMBRN
ARTHROPLSTY ELBO; W/HUMERAL
PROSTH
ARTHROPLSTY ELBO; W/IMPLNT &
RECON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
ARTHROPLASTY ELBOW; (TOT ELBOW)
ARTHROPLASTY RADIAL HEAD
ARTHROPLASTY RADIAL HEAD;
W/IMPLNT
Yes
OSTEOTOMY HUMERUS W/WO INT FIXA
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24410
24420
Yes
Yes
24430
Yes
24435
24470
Yes
Yes
24495
24498
Yes
Yes
24500
No
24505
No
24515
No
24516
No
24530
No
24535
No
24538
No
24545
No
24546
No
Description
MX OSTEOTOMIES W/REALIGNHUMERAL
OSTEOPLASTY HUMERUS
REPR NON-MALUNION HUMERUS; WO
GFT
REPR NON-MALUNION HUMERUS;
W/AUTOGF
HEMIEPIPHYSEAL ARREST
DECOMP FASCIOT FOREARM W/BRACH
ART
PROPHYLACTIC TX HUMERAL SHAFT
CLO TX HUMERAL SHAFT FX; WO MANIP
CLO TX HUMERAL FX; W/MANIP W/WO
TRA
OPEN TX HUMER FX W/PLATE
W/CERCLAGE
OPEN TX HUMER FX W/IMPLNT W/WO
CERC
CLO TX SUPRACONDYL HUMER FX; WO
MAN
CLO TX SUPRACONDYL HUMER FX;
W/MANI
PERCUT FIX SUPRACOND FX; W/WO
INTER
OPEN TX HUM SUPRACON FX; WO
INTERCO
OPEN TX HUM SUPRACON FX;
W/INTERCON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24560
24565
No
No
24566
No
24575
No
24576
No
24577
No
24579
24582
No
No
24586
No
24587
24600
No
No
24605
No
24615
No
24620
No
24635
24640
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
CLO TX HUMER EPICOND FX; WO MANIP
CLO TX HUMER EPICOND FX; W/MANIP
PERQ SKELET FIX HUMRL EPICONDYL
FX
OPEN TX HUMER EPICOND FX; W/WO
FIXA
CLO TX HUMERAL CONDYL FX; WO
MANIP
No
No
No
No
CLO TX HUMERAL CONDYL FX; W/MANIP
OPEN TX HUMER CONDYL FX; W/WO
FIXA
PERQ SKELET FIX HUMRL CONDYL FX
OPEN TX PERIARTICUL FX/DISLOC
ELBOW
OPEN TX PERIART FX ELB;
W/ARTHROPLS
TX CLO ELBOW DISLOC; WO ANES
TX CLO ELBOW DISLOC; REQUIRING
ANES
OPEN TX ACUTE/CHRONIC ELBOW
DISLOC
CLO TX MONTEGGIA FX ELBOW
W/MANIP
OPEN TX MONTEGGIA FX ELBOW W/WO
FIX
No
CLO TX RADIAL HEAD SUBLUXA CHILD
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24650
No
24655
No
24665
No
24666
Description
CLO TX RADIAL HEAD/NECK FX;WO
MANIP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
CLO TX RADIAL HEAD/NECK FX; W/MANIP
OPEN TX RAD'L HEAD/NECK FX W/WO
FIX
OPEN TX RAD'L HEAD FX; PROSTH
REPLC
No
No
24670
No
CLO TX ULNAR FX PROX END; WO MANIP
No
24675
No
No
24685
24800
No
Yes
24802
Yes
24900
Yes
24920
Yes
24925
Yes
24930
Yes
24931
24935
Yes
Yes
CLO TX ULNAR FX PROX END; W/MANIP
OPEN TX ULNAR FX PROX END W/WO
FIXA
ARTHRODESIS ELBOW JT; LOCAL
ARTHRODESIS ELBOW JT; W/AUTOG
GFT
AMPUTA ARM THRU HUMERUS; W/PRIM
CLO
AMPUTA ARM THRU HUMERUS; OPEN
CIRC
AMPUTA ARM THRU HUMERUS; SCAR
REVIS
AMPUTA ARM THRU HUMERUS; REAMPUTA
AMPUTA ARM THRU HUMERUS;
W/IMPLNT
STUMP ELONGATION UPPER EXTREM
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
24940
24999
25000
Yes
Yes
Yes
25001
Yes
25020
Yes
25023
Yes
25024
Yes
25025
Yes
25028
25031
Yes
Yes
25035
Yes
25040
Yes
25065
25066
No
No
25075
Yes
Description
CINEPLASTY UPPER EXTREM COMPLT
PROC
UNLISTED PROC HUMERUS/ELBOW
INCIS EXTEN TENDON SHEATH WRIST
INCISION FLEXOR TENDON SHEATH
WRIST
DECOMP FASCIOT FOREARM;
FLEX/EXTENS
DECOMP FASCIOT FOREARM; DEBRID
MUSC
DECOMP FASC FORARM FLX&EXT;NO
DEBRD
DECOMP FASC FORARM
FLX&EXT;W/DEBRID
I&D FOREARM; DEEP
ABSCESS/HEMATOMA
I&D FOREARM &/OR WRIST; BURSA
INCS DEEP BONE CORTEX
FOREARM/WRIST
ARTHROT RADIO/MIDCARPAL
W/XPLOR/DRN
BX SOFT TISS FOREARM/WRIST;
SUPERF
BX SOFT TISS FOREARM/WRIST; DEEP
EXC TUMOR FOREARM/WRIST AREA;
SUBQ
25076
Yes
EXC TUMOR FOREARM/WRIST; DEEP/IM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25077
25085
25100
25101
Yes
Yes
Yes
Yes
25105
25107
25109
Yes
Yes
Yes
25110
25111
25112
Yes
Yes
Yes
25115
25116
Yes
Yes
25118
Yes
25119
Yes
25120
Yes
25125
Yes
25126
25130
Description
RAD RESECT TUMOR TISS
FOREARM/WRIST
CAPSULOTOMY WRIST
ARTHROTOMY WRIST JT; W/BX
ARTHROTOMY WRIST JT; W/EXPLOR
ARTHROTOMY WRIST JT;
W/SYNOVECTOMY
ARTHROT DIST RADIOULNAR JT
EXCISE TENDON FOREARM/WRIST
EXC LES TENDON SHEATH
FOREARM/WRIST
EXC GANGLION WRIST; PRIM
EXC GANGLION WRIST; RECURRENT
RAD EXC BURSA WRIST TENDON;
FLEXORS
RAD EXC BURSA WRIST; EXTENSORS
SYNOVECTOMY EXTENSOR WRIST SNGL
SYNOVECTMY EXTENSR WRIST; RESC
ULNA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
EXC BONE CYST/TUMOR RADIUS/ULNA
EXC BONE CYST RADIUS/ULNA;
W/AUTOGF
EXC BONE CYST RADIUS/ULNA;
W/ALLOGF
Yes
EXC BONE CYST/TUMOR CARPAL BONES
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
25135
Yes
25136
Yes
25145
25150
25151
Yes
Yes
Yes
Description
EXC BONE CYST CARPAL BONES;
W/AUTOG
EXC BONE CYST CARPAL BONES;
W/ALLOG
SEQUESTRECTOMY FOREARM &/OR
WRIST
PART EXC BONE; ULNA
PART EXC BONE; RADIUS
25170
25210
Yes
Yes
RADICAL RESECT TUMOR RADIUS/ULNA
CARPECTOMY; 1 BONE
No
No
25215
Yes
No
25230
25240
25246
Yes
Yes
No
No
No
No
25248
Yes
CARPECTOMY; ALL BONES PROX ROW
RADIAL STYLOIDECTOMY (SEPART
PROC)
EXC DISTAL ULNA PART/COMPLT
INJ PROC WRIST ARTHROGRAPHY
EXPLOR W/REMOV DEEP FB
FORARM/WRIST
25250
No
REMOV WRIST PROSTH; (SEPART PROC)
No
25251
Yes
No
25259
Yes
25260
Yes
25263
Yes
REMOV PROSTH; COMPLIC-"TOT WRIST"
MANIPULATION WRIST UNDER
ANESTHESIA
REPR TENDON-FLEXOR-WRIST; PRIM
SNGL
REPR TENDON-FLEXOR-WRIST; 2ND 1
EA
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25265
Yes
25270
Yes
25272
Yes
25274
Yes
25275
Yes
25280
Yes
25290
Yes
25295
Yes
25300
Yes
25301
25310
Yes
Yes
25312
Yes
25315
Yes
25316
25320
Description
REPR TENDON-FLEXOR-WRIST; 2ND
W/GFT
REPR TENDON-EXTENSOR-WRIST; PRIM
EA
REPR TENDON-EXTENSOR-WRIST;
SECNDRY
REPR TENDON EXTENSR 2ND W/GFT
WRIST
REP TEND EXT FORARM&/WRST FREE
GFT
LENGTH/SHORT TENDON-WRIST 1 EA
TEND
TENOTOMY OPEN FLEX/EXTEN WRIST
SNGL
TENOLYSIS FLEX/EXTEN-WRIST SNGL
EA
TENODESIS @ WRIST; FLEXORS
FINGERS
TENODESIS @ WRIST; EXTENSORS
FINGER
TENDON TRANSPL WRIST; SNGL EA
TENDON TRANSPL WRIST; W/TENDON
GFT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
Yes
FLEXOR ORIGIN SLIDE FOREARM/WRIST;
FLEXOR SLIDE WRIST; W/TENDON
TRANSF
No
No
Yes
CAPSULOR/RECON WRIST ANY METHOD
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25332
25335
Yes
Yes
25337
25350
Yes
Yes
25355
25360
25365
25370
25375
Yes
Yes
Yes
Yes
Yes
25390
Yes
25391
Yes
25392
Yes
25393
Yes
25394
Yes
25400
Yes
25405
25415
Description
ARTHROPLASTY WRIST; W/WO
INTERPOSIT
CENTRALIZATION WRIST ULNA
RECON WRST-SCND-W/WO OPEN RED
RU JT
OSTEOTOMY RADIUS; DISTAL THIRD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
OSTEOTOMY RADIUS; MID/PROX THIRD
OSTEOTOMY; ULNA
OSTEOTOMY; RADIUS & ULNA
MX OSTEOTOMIES; RADIUS/ULNA
MX OSTEOTOMIES; RADIUS & ULNA
OSTEOPLASTY RADIUS/ULNA;
SHORTENING
OSTEOPLSTY RAD/ULNA;LENGTH
W/AUTOGT
OSTEOPLASTY RAD & ULNA;
SHORTENING
OSTEOPLASTY RAD & ULNA; LENGTH
W/GF
OSTEOPLASTY CARPAL BONE
SHORTENING
REPR NON/MALUNION RAD/ULNA; WO
GFT
REPR NON/MALUNION RAD/ULNA;
W/AUTOG
Yes
REPR NONUNION RAD & ULNA; WO GFT
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25420
Yes
25425
Yes
25426
Yes
25430
Yes
25431
Yes
25440
Yes
25441
Yes
25442
Yes
25443
Yes
25444
Yes
25445
Yes
25446
Yes
25447
Yes
25449
Yes
Description
REPR NONUNION RAD & ULNA;
W/AUTOGFT
REPR DEFECT W/AUTOGFT;
RADIUS/ULNA
REPR DEFECT W/AUTOGFT; RAD & ULNA
INSERTION VASC PEDICLE IN CARPAL
BN
REPAIR NONUNION CARPAL BONE EA
BONE
REPR NONUNION SCAPHOID W/WO
STYLOID
ARTHROPLSTY W/PROS REPLAC; DIST
RAD
ARTHROPLSTY W/PROS REPLAC;DIST
ULNA
ARTHROPLSTY W/PROS REPLAC;
SCAPHOID
ARTHROPLSTY W/PROS REPLAC;
LUNATE
ARTHROPLSTY W/PROS
REPLAC;TRAPEZIUM
ARTHROPLASTY W/PROS; PART CARPUS
ARTHROPLAS INTERPOSITCARPOMETACAR
REVIS ARTHROPLSTY REMOV IMPLT
WRIST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
25450
25455
Yes
Yes
25490
Yes
25491
Yes
25492
25500
25505
Yes
No
No
Description
EPIPHYSEAL ARREST; DIST
RADIUS/ULNA
EPIPHYSEAL ARREST; RADIUS & ULNA
PROPHYLC TX W/WO
METHYLMETHACRY;RAD
PROPHYLC TX W/WO
METHYLMETHACR;ULNA
PROPHYLAC TX W/WO METHYL; RAD &
ULN
CLO TX RADIAL SHAFT FX; WO MANIP
CLO TX RADIAL SHAFT FX; W/MANIP
25515
No
OPEN TX RADIAL SHAFT FX W/WO FIXA
No
25520
25525
No
No
CLO TX RADIAL FX W/DISLOC RAD/ULNA
OPEN TX RAD FX W/FIX-CLO TX RU JT
No
No
25526
25530
25535
No
No
No
OPEN TX RAD FX W/FIX-OPEN TX RU JT
CLO TX ULNAR SHAFT FX; WO MANIP
CLO TX ULNAR SHAFT FX; W/MANIP
No
No
No
25545
No
OPEN TX ULNAR SHAFT FX W/WO FIXA
No
25560
No
CLO TX RAD & ULNA SHAFT FX; WO MANI
No
25565
No
CLO TX RAD & ULNA SHAFT FX; W/MANIP
No
25574
No
OPEN TX RAD & ULNA FX; RADIUS/ULNA
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25575
25600
25605
25606
25607
25608
25609
25611
25620
No
No
No
No
No
No
No
No
No
25622
No
25624
No
25628
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
OPEN TX RAD & ULNA FX; RAD & ULNA
CLO TX DIST RAD FX; WO MANIP
CLO TX DIST RAD FX; W/MANIP
TREAT FX DISTAL RADIAL
TREAT FX RAD EXTRA-ARTICUL
TREAT FX RAD INTRA-ARTICUL
TREAT FX RADIAL 3+ FRAG
PERCUT FIX DISTAL RAD FX W/MANIP
OPEN TX DIST RAD FX W/WO FIXA
CLO TX CARPAL SCAPHOID FX; WO
MANIP
No
No
No
No
No
No
No
No
No
No
No
CLO TX CARPAL SCAPHOID FX; W/MANIP
OPEN TX CARPAL SCAPHOID FX W/WO
FIX
25630
No
CLO TX CARPAL BONE FX; WO MANIP EA
No
25635
25645
25650
25651
25652
No
No
No
No
No
CLO TX CARPAL BONE FX; W/MANIP EA
OPEN TX CARPAL BONE FX EA BONE
CLO TX ULNAR STYLOID FX
PERCUT SKEL FIX ULNAR STYLOID FX
OPEN TX ULNAR STYLOID FRACTURE
No
No
No
No
No
25660
No
CLO TX RADIOCARPAL DISLOC W/MANIP
No
25670
No
OPEN TX RADIOCARPAL DISLOC 1/MORE
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
25671
No
25675
No
25676
No
25680
No
25685
25690
25695
No
No
No
25800
25805
Yes
Yes
25810
Yes
25820
25825
Yes
Yes
25830
Yes
25900
25905
Yes
Yes
25907
25909
25915
Yes
Yes
Yes
Description
PERQ SKEL FIX DIST RADIOULNR
DISLOC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
CLO TX RADIOULNAR DISLOC W/MANIP
OPEN TX RADIOULN DISLOC
ACUTE/CHRON
CLO TX TRANS-SCAPHOPERILUNAR
W/MANI
OPEN TX TRANS-SCAPHOPERILUN FX
DISL
CLO TX LUNATE DISLOC W/MANIP
OPEN TX LUNATE DISLOC
No
ARTHRODESIS WRIST; COMPLT WO GFT
ARTHRODESIS WRIST;W/SLIDING GFT
ARTHRODESIS WRIST JT;
W/ILIAC/AUTOG
No
No
ARTHRODESIS WRIST; LIMITED WO GFT
ARTHRODESIS WRIST; W/AUTOGFT
ARTHRODES DIST RADIOULNA-RESCT
ULNA
AMPUTA FOREARM THRU RADIUS &
ULNA
AMPUTA FOREARM; OPEN CIRCULAR
AMPUTA FOREARM; 2ND CLO/SCAR
REVIS
AMPUTA FOREARM; RE-AMPUTA
KRUKENBERG PROC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
25920
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
25922
25924
25927
Yes
Yes
Yes
25929
Yes
25931
25999
26010
Yes
Yes
No
26011
Yes
26020
26025
26030
26034
Yes
Yes
Yes
Yes
26035
26037
26040
26045
26055
26060
Yes
Yes
Yes
Yes
Yes
Yes
26070
Yes
DRAINAGE FINGER ABSCESS; COMPLIC
DRAIN TENDON SHEATH/DIGIT &/PALM
EA
DRAIN PALMAR BURSA; SNGL BURSA
DRAIN PALMAR BURSA; MX BURSA
INCS BONE CORTEX HAND/FINGR
DECOMP FINGERS &/OR HAND INJ
INJURY
DECOMP FASCIOTOMY HAND
FASCIOT PALMAR; PERCUT
FASCIOT PALMAR; OP PART
TENDON SHEATH INCS
TENOTOMY PERCUT SNGL EA DIGIT
ARTHROT W/EXPLOR; CARPOMETACARP
JT
26075
Yes
ARTHROT W/EXPLOR/DRAIN; MCP JT EA
Description
DISART THRU WRIST
DISART THRU WRIST; 2ND CLO/SCAR
REV
DISART THRU WRIST; RE-AMPUTA
TRANSMETACARPAL AMPUTA
TRANSMETACARPAL AMPUT; SCAR
REVIS
TRANSMETACARPAL AMPUTA; REAMPUTA
UNLISTED PROC FOREARM/WRIST
DRAINAGE FINGER ABSCESS; SIMPL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26080
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
26100
26105
No
No
26110
26115
26116
Description
ARTHROT W/EXPLOR/DRAIN; IP JT EA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
No
No
ARTHROT-BX; CARPOMETACARP JT EA
ARTHROT W/BX; MCP JT EA
ARTHROT W/BX; INTERPHALANGEAL JT
EA
EXC TUMOR HAND/FINGER; SUBQ
EXC TUMOR HAND/FINGER; DEEP/IM
No
No
No
No
No
26117
26121
26123
No
No
No
RAD RESECT TUMOR TISS HAND/FINGER
FASCIECT PALM W/WO Z-PLASTY/GFT
FASCIECT PART PALM W/REL 1 DIGIT;
No
No
No
26125
Yes
FASCIECT PART PALM W/REL; EA ADD
No
26130
26135
No
No
No
No
26140
No
26145
No
26160
No
SYNOVECTOMY CARPOMETACARPAL JT
SYNOVECTOMY MCP JT EA DIGIT
SYNOVECTOMY PROX IP JT W/RECON
EA
SYNOVECT FLEX TENDON PALM/FINGR
EA
EXC LES TENDON SHEATH
HAND/FINGER
26170
26180
No
No
No
No
26185
No
EXC TENDON PALM SNGL (SEP PRO) EA
EXC TEND FINGR FLEX (SP) EA TEND
SESAMOIDECTMY THUMB/FING (SEP
PROC)
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
26200
No
26205
No
26210
No
Description
EXC/CURET BONE CYST/TUMOR
METACARPA
EXC BONE CYST METACARPAL;
W/AUTOGFT
EXC BONE CYST PROX/MID/DIST
PHALANX
26215
26230
No
No
EXC BONE CYST PHALANX; W/AUTOGFT
PART EXC BONE; METACARPAL
No
No
26235
No
PART EXC BONE; PROX/MID PHAL-FINGR
No
26236
26250
26255
No
No
No
PART EXC BONE; DIST PHALANX-FINGR
RAD RESECT METACARPAL; (TUMOR)
RAD RESECT METACARP; AUTOGFT
No
No
No
26260
No
No
26261
26262
26320
No
No
Yes
RAD RESECT PROX/MID FINGR (TUMOR);
RAD RESECT PROX/MID FINGR;
AUTOGFT
RAD RESECT DISTAL FINGR (TUMOR)
REMOV IMPLNT FROM FINGER/HAND
No
No
No
26340
Yes
MANIP FNGR JNT UNDER ANES-EA JNT
No
26350
Yes
No
26352
Yes
26356
Yes
REPR FLEX TENDON; PRIM/2ND EA TEND
REPR FLEX TEND; SECND W/GFT-EA
TEND
REP/ADV FLX TEND ZONE 2 DIGTL; W/O
FREE GFT EA
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
26357
Yes
26358
Yes
26370
Yes
26372
Yes
26373
Yes
26390
Yes
26392
Description
REP/ADV FLX TEND ZONE 2 DIGTL; SEC
W/O GRAFT EA
REPR FLEX TEND; SECND W/GFT EA
TEND
REPR PROFUNDUS TENDON; PRIM EA
TEND
REPR PROFND TEND; SECND FREE GFT
EA
REPR PROFUND TEND; SECND WO GFT
EA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
EXC FLEX TEND W/ROD HAND/FINGR EA
REMOV ROD-INSRT FLX GFT HND/FING
EA
26410
Yes
REPR EXTEN TEND HND PRIM/SEC; EA
No
26412
Yes
REPR EXTEN TEND HAND PRIM; GFT-EA
No
26415
Yes
EXC EXTEN TEND-ROD-GFT HAND/FINGR
No
26416
Yes
REMOV ROD-INSRT TEND GFT HAND-EA
No
26418
Yes
REPR EXTEN TEND FINGR; WO-EA TEND
No
26420
Yes
No
26426
Yes
REPR EXTEN TEND FINGR; GFT EA TEND
REPR EXTEN TEND-CNTRL SLIP-SCND;
EA
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
26428
26432
Yes
Yes
Description
REPR EXTEN TEND-CENTRL-SEC; GFT
EA
CLO TX DIST EXTEN TEND INSRT-PIN
26433
26434
26437
Yes
Yes
Yes
REPR EXTEN TEND-DIST INSRT; WO GFT
REPR EXTEN TEND-DIST INSRT; W/GFT
REALIGN EXTEN TEND HAND EA TEND
No
No
No
26440
Yes
TENOLYSIS FLEX; PALM/FINGR EA TEND
No
26442
Yes
TENLYSIS FLEX; PALM & FINGR EA TEND
No
26445
Yes
No
26449
26450
26455
Yes
Yes
Yes
TENLYSIS EXTEN TEND HAND/FINGR EA
TENOLYS COMPLX-EXTEN-FINGRFOREARM
TENOT FLEX PALM OP EA TENDON
TENOT FLEX FINGR OP EA TENDON
26460
26471
26474
Yes
Yes
Yes
TENOT EXTEN HAND/FINGR OP EA TEND
TENODESIS; PROX IP JT EA JT
TENODESIS; DIST JT EA JT
No
No
No
26476
Yes
No
26477
Yes
LENGTHEN TEND EXTEN HAND/FINGR EA
SHORTEN TENDON EXTEN HAND/FINGR
EA
26478
Yes
No
26479
Yes
LENGTHEN TEND FLEX HAND/FINGR EA
SHORTEN TENDON FLEX HAND/FINGR
EA
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
26480
Yes
26483
Yes
26485
Yes
26489
Yes
26490
Yes
26492
Yes
26494
26496
Yes
Yes
26497
Yes
26498
Yes
Description
TRANSF/TEND DORSUM HAND; WO GFT
EA
TRANSF TEND DORSUM HAND; W/GFT
EA
TRANSF TEND PALMAR; WO GFT EA
TEND
TRANSF TENDON PALMAR; W/GFT EA
TEND
OPPONENSPLAS; SUPERFICIALIS
TRANSF
OPPONENSPLASTY; TEND TRANSF-GFT
EA
OPPONENSPALSTY; HYPOTHENAR
MUSCL
OPPONENSPLASTY; OTHER METHD
TRANSF TEND-RESTORE; RING-SM
FINGR
TRANSF TENDON -RESTORE; ALL 4
FINGR
26499
Yes
CORRECT CLAW FINGER OTHER METHD
No
26500
Yes
RECONS TEND PULLEY EA; LOC TISS (SP
No
26502
Yes
RECONS TENDON PULLEY EA; GFT (SP)
No
26504
26508
26510
Yes
Yes
Yes
RECONS TEND PULLEY EA; PROSTH (SP)
RELEASE THENAR MUSCL
CROSS INTRINSIC TRANSF
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26516
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
26517
Yes
26518
Yes
Description
CAPSULODESIS MCP JT; SINGL DIGIT
CAPSULODES METACARPOPHALANG JT;
2
CAPSULODES METACARPOPHAL JT; 3
OR 4
26520
26525
26530
Yes
Yes
Yes
CAPSULECT/CAPSULOT; MCP JT EA JT
CAPSULECT/CAPSULOT; IP JT EA JT
ARTHROPLASTY MCP JT; EA JT
No
No
No
26531
26535
Yes
Yes
ARTHROPLASTY MCP JT; PROSTH EA JT
ARTHROPLASTY IP JT; EA JT
No
No
26536
26540
Yes
Yes
ARTHROPLASTY IP JT; W/PROSTH EA JT
REPR COLLAT LIGAMNT MCP/IP JT
No
No
26541
Yes
RECON LIGAMNT MCP JT-1; W/TEND GFT
No
26542
26545
Yes
Yes
No
No
26546
Yes
RECON LIGAMNT MCP JT-1; W/LOC TISS
RECON LIG IP JT SNGL INCL GFT EA JT
REPR NON-UNION
METACARPAL/PHALYNX
No
26548
26550
Yes
Yes
REPR & RECON FING VOLAR PLATE IP JT
POLLICIZATION A DIGIT
No
No
26551
Yes
No
26553
Yes
TRANSF TOE-HAND-ANASTOM; GR TOE
TRANSF TOE-HAND-ANAS; NOT GR TOE1
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
26554
26555
Yes
Yes
26556
Yes
26560
Yes
26561
Yes
26562
26565
26567
Yes
Yes
Yes
26568
26580
Yes
Yes
26587
26590
Yes
Yes
26591
Yes
26593
Yes
26596
Yes
TRANS TOE-HAND-ANAS; NOT GR TOE-2
TRANSF FINGR OTH POSIT WO ANAS
TRANSF FREE TOE JT W/MICROVAS
ANAS
REPR SYNDACTYLY EA WEB; W/SKIN
FLAP
REPR SYNDACTYLY; W/SKIN FLAPS &
GFT
REPR SYNDACTYLY EA WEB SPACE;
COMPL
OSTEOT; METACARPAL EA
OSTEOT; PHALANX FINGR EA
OSTEOPLAS LENGTHEN
METACARP/PHALANX
REPR CLEFT HAND
RECON SUPERNUMER DIGIT TISS &
BONE
REPR MACRODACTYLIA
REPR INTRINSIC MUSCL HAND EA
MUSCL
RELEASE INTRINS MUSCL HAND EA
MUSCL
EXC CONSTRICT OF FINGR W/ZPLASTIES
26600
26605
No
No
CLO TX METACARP FX 1; WO MANIP EA
CLO TX METACARP FX 1; W/MANIP EA
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
26607
No
26608
No
26615
No
26641
No
26645
No
26650
Description
CLO TX METACARPAL FX W/MANIP
W/FIXA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
PERCUT FIXA METACARPAL FX EA BONE
OPEN TX METACARPAL FX SNGL W/WO
FIX
CLO TX CARPOMETA DISLOC THUMB
W/MAN
CLO TX CARPOMETACAR FX THUMB
W/MANI
PERCUT SKELE FIX FX THUMB W/WO
EXT
26665
No
OPEN TX FX DISLOC THUMB W/WO FIXA
No
26670
No
CLO TX DISLOC-NOT THUMB; WO ANES
No
26675
No
No
26676
No
CLO TX DISLOC-NOT THUMB; REQ ANES
PERCUT SKELET FIX-NOT THUMB;
W/MANI
26685
No
No
26686
No
26700
No
26705
No
OPEN TX DISLOC-EX THUMB; 1 W/WO FIX
OPEN TX DISLOC-NOT THUMB;
COMPLX/MX
CLO TX MCP DISLOC-1-W/MANIP; WO
ANE
CLO TX MCP DISLOC-1-W/MANIP;
W/ANES
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
26706
No
Description
PERCUT FIXA MCP DISLOC SNGL
W/MANIP
26715
No
OPEN TX MCP DISLOC SNGL W/WO FIXA
No
26720
No
CLO TX PHALANGEAL FX; WO MANIP EA
No
26725
No
CLO TX PHALANGEAL FX; W/WO TRACT
No
26727
No
No
26735
No
PERCUT FIXA FX PROX/MID W/MANIP EA
OPEN TX PHALANGEAL FX W/WO FIXA
EA
No
26740
26742
No
No
CLO TX ARTIC FX MCP/IP JT; WO MANIP
CLO TX ARTIC FX MCP/IP JT; W/MANIP
No
No
26746
No
No
26750
No
OPEN TX ARTIC FX MCP/IP JT W/WO FIX
CLO TX DIST PHALANGEAL FX; WO
MANIP
26755
No
26756
No
26765
No
No
No
No
CLO TX DIST PHALANGEAL FX; W/MANIP
PERCUT SKELETAL FIX DIST PHALANG
FX
OPEN TX DIST PHALANG FX W/WO FIX
EA
No
26770
No
CLO TX IP JT DISLOC W/MANIP; WO ANE
No
26775
No
CLO TX IP JT DISLOC W/MANIP; W/ANES
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26776
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Description
PERCUT FIXA IP JT DISLOC 1 W/MANIP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
26785
No
OPEN TX IP JT DISLOC W/WO FIX SNGL
No
26820
26841
26842
26843
26844
26850
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
26852
26860
Yes
Yes
FUSION IN OPPOSIT THUMB W/AUTOGFT
ARTHRODESIS JT THUMB W/WO FIXA
ARTHRODESIS JT THUMB; W/AUTOGFT
ARTHRODESIS JT DIGITS NOT THUMB
ARTHRODESIS JT DIGITS; W/AUTOGFT
ARTHRODESIS MCP JT W/WO INT FIXA
ARTHRODES MCP JT W/WO FIX;
W/AUTOGF
ARTHRODESIS IP JT W/WO INT FIXA
26861
Yes
No
26862
Yes
26863
Yes
ARTHRODESIS IP JT W/WO FIX; EA ADD
ARTHRODESIS IP JT W/WO FIX;
W/AUTOG
ARTHRODESIS IP JT; W/AUTOGFT EA
ADD
No
26910
Yes
AMPUTA METACARPAL 1 W/WO TRANSF
No
26951
Yes
No
26952
26989
26990
Yes
Yes
Yes
AMPUTA FINGER ANY JT; W/DIRECT CLO
AMPUTA FINGER ANY JT; W/ADVANC
FLAP
UNLISTED PROC HANDS/FINGERS
I&D PELVIS/HIP JT; DEEP ABSCESS
No
No
No
26991
Yes
I&D PELVIS/HIP JT AREA; INFEC BURSA
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26992
27000
27001
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
27003
27005
Yes
Yes
27006
27025
27030
27033
27035
Yes
Yes
Yes
Yes
Yes
27036
27040
27041
27047
27048
Description
INCIS BONE CORTEX PELVIS &/HIP JT
TENOT ADDUCTOR HIP PERCUT (SP)
TENOT ADDUCTOR HIP OP
TENOTOMY ADDUCT OPEN
W/NEURECTOMY
TENOT HIP FLEX OP (SEPART PROC)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
TENOT ABDUCT &/OR EXTEN HIP OP (SP)
FASCIOTOMY HIP/THIGH ANY TYPE
ARTHROT HIP W/DRAINAGE
ARTHROT HIP-EXPLOR/REMOV FB
DENERVAT HIP JT SCIATIC NERV
CAPSULECT/CAPSULOT HIP-RELEASE
FLEX
BX SOFT TISS PELVIS & HIP; SUPERF
BX SOFT TISS PELVIS & HIP; DEEP
EXC TUMOR PELVIS & HIP; SUBQ TISS
EXC TUMOR PELVIS & HIP; DEEP/IM
27049
27050
27052
Yes
Yes
Yes
RAD RESECT TUMOR SOFT TISS PELVIS
ARTHROTOMY W/BX; SACROILIAC JT
ARTHROTOMY W/BX; HIP JT
No
No
No
27054
27060
27062
Yes
Yes
Yes
No
No
No
27065
Yes
ARTHROTOMY W/SYNOVECTOMY HIP JT
EXC; ISCHIAL BURSA
EXC; TROCH BURSA/CALCIFICATION
EXC BONE CYST; SUPERF W/WO
AUTOGFT
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27066
Yes
27067
27070
27071
Yes
Yes
Yes
27075
Yes
27076
Yes
27077
Yes
27078
Yes
27079
27080
27086
27087
27090
Yes
Yes
Yes
Yes
Yes
27091
Yes
27093
Description
EXC BONE CYST; DEEP W/WO AUTOGFT
EXC BONE CYST; W/AUTOGFT-SEPAR
INCS
PART EXC; SUPERF
PART EXC; DEEP
RAD RESECT TUMOR; WING ILIUM/PUBIS
RAD RESECT TUMOR; ILIUM
W/ACETABULM
RAD RESECT TUMOR; INNOMINATE
BONE
RAD RESECT TUMOR; ISCH TUB GRT
TROC
RAD RESECT TUMR; ISCH TUBEROS
W/FLP
COCCYGECTOMY PRIM
REMOV FB PELVIS/HIP; SUBQ TISS
REMOV FB PELVIS/HIP; DEEP
REMOV HIP PROSTH; (SEPART PROC)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
REMOV HIP PROSTH; COMPLIC TOT HIP
INJ PROC HIP ARTHROGRAPHY; WO
ANES
No
No
27095
27096
Yes
Yes
INJ PROC HIP ARTHROGRAPHY; W/ANES
INJ-S I JT ARTHROG &/ ANES/STEROID
No
No
27097
Yes
RELEASE/RECESSION HAMSTRING PROX
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27098
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
27100
27105
Yes
Yes
27110
Description
TRANSF ADDUCTOR TO ISCHIUM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
TRANSF EXT OBLIQ MUSCL-GR TROCH
TRANSF PARASPINAL MUSCL TO HIP
TRANSF ILIOPSOAS; TO GREATER
TROCH
27111
27120
Yes
Yes
TRANSF ILIOPSOAS; TO FEMORAL NECK
ACETABULOPLASTY
No
No
27122
27125
Yes
Yes
ACETABULOPLASTY; RESECT FEM HEAD
HEMIARTHROPLASTY HIP PART
No
No
27130
Yes
No
27132
Yes
27134
Yes
27137
Yes
No
27138
Yes
27140
Yes
27146
Yes
ARTHROPLASTY ACETAB & FEM PROSTH
CONVERSION PREV HIP-TOT HIP W/WO
GF
REVIS TOT HIP; BOTH COMPON W/WO
GFT
REVIS TOT HIP ARTHROPLSTY;
ACETABUL
REVIS TOT HIP ARTHROPALSTY;
FEMORAL
OSTEOT & TRANSF GRT TROCH (SEP
PRO)
OSTEOTMY ILIAC/ACETAB/INNOMIN
BONE
27147
Yes
OSTEOTOMY ILIAC; W/OPEN REDUC HIP
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27151
Yes
27156
27158
Yes
Yes
27161
Yes
27165
Yes
OSTEOTOMY ILIAC; W/FEM OSTEOTOMY
OSTEOT; W/FEM OSTEOT/OPEN REDUC
HIP
OSTEOT PELVIS BILAT
OSTEOTOMY FEMORAL NECK (SEP
PROC)
OSTEOTOMY INTER-/SUBTROCH INCL
FIXA
27170
Yes
BONE GFT FEM HEAD/INTER-SUBTROCH
No
27175
27176
Yes
Yes
TX SLIPPED FEM EPIPHYSIS; BY TRACT
TX SLIPPED FEM EPIPHYSIS; BY PIN
No
No
27177
Yes
OPEN TX SLIP'D FEM EPIPHYS; PIN/GFT
No
27178
Yes
OPEN TX SLIP'D FEM EPIPHYS; CLO MAN
No
27179
Yes
OPEN TX SLIP'D FEM EPIPHYS; OSTEOPL
No
27181
Yes
OPEN TX SLIP'D FEM EPIPHYS; OSTEOT
No
27185
Yes
EPIPHYSEAL ARREST-EPIPHYSIODESIS
No
27187
27193
Yes
No
PROPHYLACTIC TX FEM NECK & FEMUR
CLO TX PELVIC RING FX; WO MANIP
No
No
27194
No
CLO TX PELVIC RING FX; W/MANIP-ANES
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27200
27202
27215
27216
27217
27218
27220
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
27222
27226
27227
No
No
No
27228
No
27230
No
27232
No
27235
Description
CLO TX COCCYGEAL FX
OPEN TX COCCYGEAL FX
OPEN TX ILIAC SPI/WING FX W/INT FIX
PERCUT FIX POST PELVIC RING FX
OPEN TX ANT RING FX/DISLO W/INT FIX
OPEN TX POST RING FX/DISL W/INT FIX
CLO TX ACETABULUM FX; WO MANIP
CLO TX ACETAB FX; W/MANIP W/WO
TRAC
OPEN TX POST/ANT ACETAB FX W/FIX
OPEN TX ACETAB FX W/INT FIX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
OPEN TX ACETAB FX W/T-FX W/INT FIXA
CLO TX FEM FX PROX END NECK; WO
MAN
CLO TX FEM FX PROX END NECK;
W/MANI
PERCUT FIX FEM FX PROX ENDDISPLACE
No
No
27236
No
OPEN TX FEM FX PROX END FIX/PROSTH
No
27238
No
CLO TX INTERTROCH FEM FX; WO MANIP
No
27240
No
No
27244
No
27245
No
CLO TX -TROCHANTER FEM FX; W/MANIP
OPEN TX FEM FX; W/IMPLNT W/WO
CERCL
OPEN TX FEM FX; W/IMPLNT W/WO
SCREW
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27246
No
CLO TX GREATER TROCH FX WO MANIP
No
27248
No
OPEN TX GR TROC FX W/WO INT/EXT FIX
No
27250
27252
No
No
CLO TX HIP DISLOC TRAUMA; WO ANES
CLO TX HIP DISLOC TRAUMA; W/ANES
No
No
27253
No
OPEN TX HIP DISLO TRAUMA WO INT FIX
No
27254
No
OPEN TX HIP DISLOC TRAUMA W/FEM FX
No
27256
No
TX SPON HIP DISLOC; WO ANES/MANIP
No
27257
No
No
27258
No
27259
No
27265
No
TX SPON HIP DISLOC; W/MANIP W/ANES
OPEN TX SPON HIP DISLO RPL FEM
HEAD
OPEN TX SPON HIP DISLO; W/FEM
SHORT
CLO TX HIP ARTHROPL DISLOC; WO
ANES
27266
27267
27268
27269
27275
27280
27282
No
No
No
No
No
Yes
Yes
CLO TX HIP ARTHROPL DISLOC; W/ANES
CLTX THIGH FX
CLTX THIGH FX W/MNPJ
OPTX THIGH FX
MANIP HIP JT REQUIRING GEN ANES
ARTHRODESIS SACROILIAC JT
ARTHRODESIS SYMPHYSIS PUBIS
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27284
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
27286
27290
27295
27299
Yes
Yes
Yes
Yes
Description
ARTHRODESIS HIP JT;
ARTHRODES HIP JT; W/SUBTROCH
OSTEOT
INTERPELVIABDOMINAL AMPUTA
DIASART HIP
UNLISTED PROC PELVIS/HIP JT
27301
No
I&D DEEP ABSCESS BURSA THIGH/KNEE
No
27303
27305
No
No
No
No
27306
No
27307
No
27310
27315
27320
27323
No
No
No
Yes
INCS DEEP OP BONE CORTEX FEM/KNEE
FASCIOTOMY ILIOTIBIAL OPEN
TENOT PERCUT HAMSTRING; 1 TEND
(SP)
TENOT PERCUT HAMSTRINGS; MX
TENDONS
ARTHROT KNEE EXPLOR/DRAIN/REMOV
FB
NEURECTOMY HAMSTRING MUSCL
NEURECTOMY POP
BX SOFT TISS THIGH/KNEE SUPERF
27324
27325
27326
27327
27328
Yes
Yes
Yes
Yes
Yes
27329
Yes
BX SOFT TISS THIGH/KNEE AREA; DEEP
NEURECTOMY, HAMSTRING
NEURECTOMY, POPLITEAL
EXC TUMOR THIGH/KNEE AREA; SUBQ
EXC TUMOR THIGH/KNEE; DEEP/IM
RAD RESEC TUMOR SOFT TISS
THIGH/KNE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
27330
Yes
27331
Yes
27332
Yes
27333
Yes
27334
Yes
27335
27340
27345
27347
27350
Yes
Yes
Yes
Yes
Yes
27355
Yes
27356
Yes
27357
Yes
Description
ARTHROTOMY KNEE; W/SYNOVIAL BX
ONLY
ARTHROT KNEE; JT EXPLOR BX/REMOV
FB
ARTHROT EXCIS SEMILUN-KNEE;
MED/LAT
ARTHROT EXCS SEMILUNR KNEE; MEDLAT
ARTHROT W/SYNOVECT KNEE;
ANT/POST
ARTHROT-SYNOVECT KNEE; ANT-POSTPOP
EXC PREPATELLAR BURSA
EXC SYNOVIAL CYST POP SPACE
EXC LES MENISCUS/CAPSULE KNEE
PATELLECTOMY/HEMIPATELLECTOMY
EXC/CURET BONE CYST/BEN TUMOR
FEMUR
EXC BONE CYST/TUM FEMUR;
W/ALLOGFT
EXC BONE CYST/TUM FEMUR;
W/AUTOGFT
27358
Yes
EXC CYST/BENIGN TUMOR FEM; INT FIXA
No
27360
Yes
No
27365
27370
Yes
No
PART EXC BONE FEM/PROX TIB/FIBULA
RAD RESECT TUMOR BONE
FEMUR/KNEE
INJ PROC KNEE ARTHROGRAPHY
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27372
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
27380
Yes
27381
Yes
27385
Yes
27386
27390
Yes
Yes
27391
Yes
27392
Yes
27393
27394
Yes
Yes
27395
Yes
27396
Yes
27397
Yes
27400
27403
Yes
Yes
27405
Yes
Description
REMOV FB DEEP THIGH REGION/KNEE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
SUTURE INFRAPATELLAR TENDON; PRIM
SUTURE INFRAPATELL TEND; 2ND
RECON
No
SUTURE QUAD/HAM MUSCL RUPT; PRIM
SUTURE QUAD MUSCL RUPT; 2ND
RECON
TENOT OP HAMSTRING KNEE TO HIP; 1
TENOT OP HMSTRNG KNEE-HIP; MX 1
LEG
TENOT OP HMSTRNG KNEE-HIP; MX
BILAT
LENGTHEN HAMSTRING TENDON; 1
TEND
LENGTHEN HMSTRNG TEND; MX 1 LEG
LENGTHN HMSTRNG TEND; MX TEND
BILAT
No
TRANSPL HAMSTRING TEND-PATELLA; 1
TRANSPL HAMSTRING TEND-PATELLA;
MX
No
TRANSF TEND/MUSCL HAMSTRINGS-FEM
ARTHROT W/MENISCUS REPR KNEE
REPR PRIM TORN LIGAM KNEE;
COLLATER
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27407
Yes
27409
Yes
27412
Yes
27415
27416
27418
27420
Yes
Yes
Yes
Yes
27422
Yes
27424
27425
Yes
Yes
27427
Yes
27428
Yes
27429
27430
Yes
Yes
27435
Yes
Description
REPR PRIM TORN LIGAM KNEE;
CRUCIATE
REPR TORN LIG KNEE; COLLAT &
CRUCIA
AUTOLOGOUS CHONDROCYTE
IMPLANTATION KNEE
OSTEOCHONDRAL ALLOGRAFT KNEE
OPEN
OSTEOCHONDRAL KNEE AUTOGRAFT
ANT TIBIAL TUBERCLEPLASTY
RECON DISLOC PATELLA;
RECON DISLOC PATLLA; EXTEN
REALIGN
RECON RECUR DISL PATEL;
W/PATELLECT
LAT RETINACULAR RELEASE
LIGAMNT RECON KNEE; EXTRAARTICULAR
LIGAMNT RECON KNEE; INTRAARTICULAR
LIG RECON KNEE; INTRA/EXTRAARTICUL
QUADRICEPSPLASTY
CAPSULOT POST CAPSULAR RELEASE
KNEE
27437
27438
Yes
Yes
ARTHROPLASTY PATELLA; WO PROSTH
ARTHROPLASTY PATELLA; W/PROSTH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27440
Yes
27441
Yes
27442
Yes
27443
27445
Yes
Yes
27446
Yes
27447
27448
27450
Yes
Yes
Yes
27454
Yes
27455
Yes
27457
27465
27466
Yes
Yes
Yes
27468
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
ARTHROPLASTY KNEE TIBIAL PLATEAU
ARTHROPLSTY TIB;
W/DEBRID/SYNOVECT
No
ARTHROPLASTY FEM CONDYLE KNEES;
ARTHROPLAS FEM CONDYLE KNEE;
DEBRID
ARTHROPLASTY KNEE HINGE PROSTH
ARTHROPLSTY KNEE CONDYL;
MEDIAL/LAT
ARTHROPLSTY KNEE CONDYL; MED &
LAT
OSTEOTOMY FEMUR SHAFT; WO FIXA
OSTEOTOMY FEMUR SHAFT; W/FIXA
OSTEOT MX REALGN INTRAMEDUL ROD
FEM
OSTEOT PROX TIB; BEFORE EPIPHYS
CLO
No
No
No
No
Yes
OSTEOT PROX TIB; AFTER EPIPHYS CLO
OSTEOPLASTY FEMUR; SHORTENING
OSTEOPLASTY FEMUR; LENGTHENING
OSTEOPLSTY FEM; COMBO
LENGTH/SHORT
27470
Yes
REPR NON-MALUNION FEMUR; WO GFT
No
27472
Yes
REPR NON-/MALUNION FEM; W/ILIAC GFT
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27475
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
27477
Yes
27479
27485
Description
ARREST EPIPHYSEAL; DIST FEM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
Yes
ARRST EPIPHYSEAL; TIBIA-FIBULA PROX
ARRST EPIPHYSEAL; COMBO FEMTIB/FIB
ARREST HEMIEPIPHYSEAL DIST FEM
No
No
27486
Yes
REVIS TOT KNEE ARTHROPL; 1 COMPON
No
27487
Yes
No
27488
Yes
27495
Yes
27496
Yes
27497
Yes
27498
Yes
27499
Yes
REVIS TOT KNEE ARTHROPLAS; FEM-TIB
REMOV TOTAL KNEE PROSTH W/WO
SPACER
PROPHYLAC TX W/WO
METHYLMETHACR FEM
DECOMP FASCIOT THIGH/KNEE 1
COMPART
DECOMP FASCIOT 1 COMPART;
W/DEBRID
DECOMP FASCIOT THIGH/KNEE MX
COMPAR
DECOMP FASCIOT MX COMPART;
W/DEBRID
27500
No
27501
No
27502
27503
No
No
CLO TX FEMORAL SHAFT FX WO MANIP
CLO TX SUPRACONDYL FEM FX WO
MANIP
CLO TX FEM FX W/MANIP W/WO
TRACTION
CLO TX CONDYLAR FEM FX W/MANIP
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27506
No
27507
27508
No
No
27509
27510
No
No
27511
No
27513
27514
No
No
27516
No
27517
No
27519
27520
Description
OPEN TX FEM SHAFT FX W/WO
FIX/SCREW
OPEN TX FEM SHAFT FX
W/PLATE/SCREWS
CLO TX FEM FX DIST END WO MANIP
PERQ FIX FEM FX DISTAL/FEM EPIPHYSL
CLO TX FEM FX DIST END W/MANIP
OPEN TX FEM SUPRACONDYL FX WO
EXTEN
OPEN TX FEM SUPRACONDYL FX
W/EXTEN
OPEN TX FEM FX MED/LAT CONDYLE
CLO TX FEM EPIPHYSEAL SEPAR; WO
MAN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
CLO TX FEM EPIPHYSEAL SEP; W/MANIP
OPEN TX FEM EPIPHYS SEPAR W/WO
FIXA
CLO TX PATELLAR FX WO MANIP
No
No
No
27524
27530
27532
No
No
No
OPEN TX PATELLA FX W/FIX PATELLECT
CLO TX TIBIAL FX PROX; WO MANIP
CLO TX TIB FX; W/WO MANIP W/TRACT
No
No
No
27535
No
OPEN TX TIB FX; UNICONDYL W/WO FIXA
No
27536
27538
No
No
OPEN TX TIB FX; BICONDYLAR W/WO FIX
CLO TX FX KNEE W/WO MANIP
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27540
27550
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
27552
No
CLO TX KNEE DISLOC; REQUIRING ANES
No
27556
No
OPEN TX KNEE DISLO; WO PRI LIG REPR
No
27557
No
No
27558
27560
No
No
OPEN TX KNEE DISLO; W/PRIM LIG REPR
OPEN TX KNEE DISLO; W/LIG
REPR/AUGM
CLO TX PATELLAR DISLOC; WO ANES
27562
No
27566
27570
27580
Description
OPEN TX FX KNEE W/WO FIX
CLO TX KNEE DISLOC; WO ANES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
CLO TX PATELLAR DISLOC; REQ ANES
OPEN TX PATEL DISLO W/WO
PATELLECT
MANIP KNEE JT UNDER GEN ANES
ARTHRODESIS KNEE ANY TECH
No
No
No
27590
Yes
AMPUTA THIGH THRU FEMUR ANY LEVEL
No
27591
Yes
No
27592
Yes
AMPUTA THIGH THRU FEMUR; IMMED FIT
AMPUTA THIGH THRU FEMUR; OPEN
CIRC
27594
Yes
27596
27598
27599
Yes
Yes
Yes
AMPUTA THIGH FEMUR; 2ND CLO/REVIS
AMPUTA THIGH THRU FEMUR; REAMPUTA
DIASART AT KNEE
UNLISTED PROC FEMUR/KNEE
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
27600
Yes
Description
DECOMP FASCIOT LEG; ANT/LAT
COMPART
27601
Yes
DECOMP FASCIOT LEG; POST COMPART
No
27602
Yes
No
27603
27604
Yes
Yes
DECOMP FASCIOT LEG; ANT/LAT/POST
I&D LEG/ANK; DEEP
ABSCESS/HEMATOMA
I&D LEG/ANK; INFEC BURSA
27605
Yes
27606
27607
Yes
Yes
27610
No
No
No
No
No
Yes
TENOT PERCUT ACHILLS (SP); LOC ANES
TENOT PERCUT ACHLLES (SP); GEN
ANES
INCIS LEG/ANK
ARTHROT ANK-EXPLOR/DRAIN/REMOV
FB
27612
Yes
ARTHROT POST CAPSULAR RELASE ANK
No
27613
27614
Yes
Yes
No
No
27615
Yes
BX SOFT TISS LEG/ANK AREA; SUPERF
BX SOFT TISS LEG/ANK AREA; DEEP
RAD RESECT TUMOR SOFT TISS
LEG/ANK
27618
27619
Yes
Yes
27620
27625
Yes
Yes
EXC TUMOR LEG/ANK AREA; SUBQ TISS
EXC TUMOR LEG/ANK AREA; DEEP
ARTHROTOMY ANK W/JT EXPLOR W/WO
BX
ARTHROTOMY W/SYNOVECTOMY ANK;
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27626
Yes
27630
Yes
Description
ARTHROT W/SYNOVECT ANK;
TENOSYNOVEC
EXC LES TENDON SHEATH/CAPSULE
LEG
27635
27637
27638
27640
27641
27645
Yes
Yes
Yes
Yes
Yes
Yes
EXC/CURET BONE CYST/TUMOR TIB/FIB
EXC BONE CYST TIB/FIB; W/AUTOGFT
EXC BONE CYST TIB/FIB; W/ALLOGFT
PART EXC BONE; TIBIA
PART EXC BONE; FIBULA
RADICAL RESECT BONE TUMOR; TIBIA
No
No
No
No
No
No
27646
Yes
No
27647
27648
Yes
Yes
RADICAL RESECT BONE TUMOR; FIBULA
RAD RESECT BONE TUMOR;
TALUS/CALCAN
INJ PROC ANK ARTHROGRAPHY
No
No
27650
Yes
REPR PRIM OP/PERCUT RUPT ACHILLES
No
27652
Yes
No
27654
27656
Yes
Yes
REPR PRIM OP RUPT ACHILLES; W/GFT
REPR SECNDRY ACHILLES TEND W/WO
GFT
REPR FASCIAL DEFECT LEG
27658
Yes
27659
Yes
27664
Yes
REPR FLEX TEND LEG; PRIM WO GFT EA
REPR FLEX TEND LEG; SECND EA
TENDON
REPR EXTEN TEND LEG; PRIM WO GFT
EA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27665
Yes
27675
Yes
27676
27680
Yes
Yes
27681
Yes
27685
Yes
27686
27687
Yes
Yes
27690
Yes
27691
Yes
27692
27695
27696
Yes
Yes
Yes
27698
27700
27702
27703
27704
Description
REPR EXTEN TEND LEG; SECND EA
TEND
REPR DISLOC PERNEL TEND; WO
OSTEOT
REPR DISLOC PERONL TEND; FIB
OSTEOT
TENOLYS FLEX/EXTEN-LEG ANK; 1 EA
TENLYS FLEX/EXTEN LEG-ANK; MX TEND
LENGTH/SHORT TENDON LEG/ANK; 1
TEND
LENGTH/SHORT TEND LEG/ANK; MX
TEND
GASTROCNEMIUS RECESSION
TRANSF/TRANSPL SNGL TENDON;
SUPERF
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
Yes
TRANSF/TRANSPL SNGL TENDON; DEEP
TRANSF/TRANSPL SNGL; EA ADD
TENDON
REPR PRIM DISRUPT LIG ANK; COLLAT
REPR PRIM DISRUPT LIG ANK; BOTH
REPR SECND DISRUPT LIG ANK
COLLATER
ARTHROPLASTY ANK
No
No
No
Yes
Yes
Yes
ARTHROPLAS ANK; W/IMPLNT (TOT ANK)
ARTHROPLASTY ANK; REVIS TOT ANK
REMOV ANK IMPLNT
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27705
27707
27709
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
27712
Yes
27715
27720
Yes
Yes
27722
27724
Yes
Yes
27725
27726
Description
OSTEOTOMY; TIBIA
OSTEOTOMY; FIBULA
OSTEOTOMY; TIBIA & FIBULA
OSTEOT; MX REALIGN INTRAMEDUL ROD
OSTEOPLAS TIB-FIB
LENGTHEN/SHORTEN
REPR NON/MALUNION TIBIA; WO GFT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Yes
Yes
REPR NON/MALUNION TIBIA; W/SLID GFT
REPR NON/MALUNION TIBIA; W/GFT
REPR NONUNION TIB; SYNOSTOSIS
W/FIB
REPAIR FIBULA NONUNION
27727
Yes
REPR CONGEN PSEUDARTHROSIS TIBIA
No
27730
Yes
ARRST EPIPHYSEL ANY METHD; DIST TIB
No
27732
Yes
ARRST EPIPHYSEL ANY METHD; DIST FIB
No
27734
Yes
ARRST EPIPHYSEAL; DIST TIBIA-FIBULA
No
27740
27742
Yes
Yes
No
No
27745
27750
27752
Yes
No
No
ARRST EPIPHYSEAL PROX-DIST TIB-FIB;
ARRST EPIP PROX-DIST TIB-FIB; FEM
PROPHYLAC TX W/WO
METHYLMETHACR TIB
CLO TX TIBIAL SHAFT FX; WO MANIP
CLO TX TIB FX; W/MANIP W/WO TRACT
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
27756
No
27758
No
27759
No
27760
No
27762
No
27766
27767
27768
27769
No
No
No
No
27780
27781
No
No
27784
No
27786
27788
27792
No
No
No
27808
27810
Description
PERCUT SKELETAL FIXA TIB SHAFT FX
OPEN TX TIB SHAFT FX
W/PLATE/SCREWS
OPEN TX TIB FX-IMPLANT-W/WO
SCREWS
CLO TX MEDIAL MALLEOLUS FX; WO
MANI
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
CLO TX MED MALLEOLUS FX; W/MANIP
OPEN TX MED MALLEOLUS FX W/WO
FIXA
CLTX POST ANKLE FX
CLTX POST ANKLE FX W/MNPJ
OPTX POST ANKLE FX
No
CLO TX PROX FIB/SHAFT FX; WO MANIP
CLO TX PROX FIB/SHAFT FX; W/MANIP
OPEN TX PROX FIB/SHAFT FX W/WO
FIXA
No
No
No
No
No
No
No
No
CLO TX DISTAL FIBULAR FX; WO MANIP
CLO TX DISTAL FIBULAR FX; W/MANIP
OPEN TX DIS FIB FX W/WO INT/EXT FIX
CLO TX BIMALLEOLAR ANK FX; WO
MANIP
No
No
No
No
No
CLO TX BIMALLEOLAR ANK FX; W/MANIP
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
27814
No
27816
No
27818
No
Description
OPEN TX BIMALLEOLAR ANK FX W/WO
FIX
CLO TX TRIMALLEOLAR ANK FX; WO
MANI
CLO TX TRIMALLEOLAR ANK FX;
W/MANIP
27822
No
OPEN TX TRIMALLEOLR FX; WO FIXA LIP
No
27823
No
OPEN TX TRIMALLEOLAR FX; W/FIXA LIP
No
27824
27825
27826
27827
27828
No
No
No
No
No
CLO TX FX ARTICUL-DIST TIB; WO ANES
CLO TX FX DIST TIB; W/TRACT/ANES
OPEN TX FX DIST TIB W/FIX; FIB ONLY
OPEN TX FX DIST TIB W/FIX; TIB ONLY
OPEN TX FX DIS TIB W/FIX; TIB & FIB
No
No
No
No
No
27829
27830
27831
No
No
No
OPEN TX DIST TIBIOFIBULR JT DISRUPT
CLO TX PROX TIB-FIB JT DISL; WO ANE
CLO TX PROX TIB-FIB JT DISL; W/ANES
No
No
No
27832
27840
No
No
OPEN TX PROX TIB-FIB JT DISLO W/EXC
CLO TX ANK DISLOC; WO ANES
No
No
27842
No
No
27846
No
27848
No
CLO TX ANK DISLOC; W/ANES W/WO FIX
OPEN TX ANK DISLO W/WO FIX; WO
REPR
OPEN TX ANK DISLOC W/WO FIX;
W/REPR
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27860
27870
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
27871
27880
27881
27882
Yes
Yes
Yes
Yes
ARTHRODESIS TIB-FIB JT PROX/DISTAL
AMPUTA LEG THRU TIBIA & FIBULA
AMPUT LEG-TIB & FIB; W/FIT & CAST
AMPUTA LEG-TIBIA & FIB; OPEN CIRC
No
No
No
No
27884
27886
27888
27889
Yes
Yes
Yes
Yes
No
No
No
No
27892
Yes
AMPUTA LEG-TIB & FIB; 2ND CLO/REVIS
AMPUTA LEG-TIB & FIB; RE-AMPUTA
AMPUT ANK-MALLEOLI PLAS CLO
ANK DIASART
DECOMP FASCIOT LEG; ANT/LAT
COMPRT
27893
Yes
DECOMP FASCIOT LEG; POST COMPRT
No
27894
27899
28001
Yes
Yes
Yes
DECOMP FASCI LEG; A-P/LAT W/DEBRID
UNLISTED PROC LEG/ANK
I&D BURSA FT
No
No
No
28002
28003
28005
28008
28010
28011
28020
Yes
Yes
Yes
Yes
Yes
Yes
Yes
I&D BELOW FASCIA FT; 1 BURSAL SPACE
I&D BELOW FASCIA FT; MX AREAS
INCIS BONE CORTEX FT
FASCIOTOMY FT &/OR TOE
TENOT PERCUT TOE; SINGL TENDON
TENOT PERCUT TOE; MX TENDON
ARTHROT EXPLOR; INTERTARSAL JT
No
No
No
No
No
No
No
Description
MANIP ANK UNDER GEN ANES
ARTHRODESIS ANK ANY METHD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
28022
28024
28030
28035
28043
28045
Yes
Yes
Yes
Yes
Yes
Yes
ARTHROT EXPLOR; METATARSOPHAL JT
ARTHROT EXPLOR/DRAIN; IP JT
NEURECTOMY INTRINSIC MUSCL FT
RELEASE TARSAL TUNNEL
EXC TUMOR FT; SUBQ TISS
EXC TUMOR FT; DEEP/SUBFASCIAL/IM
No
No
No
No
No
No
28046
28050
Yes
Yes
No
No
28052
Yes
RADICAL RESECT TUMOR SOFT TISS FT
ARTHROT W/BX; INTERTARSAL JT
ARTHROT W/BX; METATARSOPHALANG
JT
28054
28055
28060
Yes
Yes
Yes
ARTHROT W/BX; INTERPHALANGEAL JT
NEURECTOMY, FOOT
FASCIECTOMY PLANTAR; PART (SP)
No
No
No
28062
28070
Yes
Yes
No
No
28072
Yes
FASCIECT PLANTAR FASCIA; RAD (SP)
SYNOVECTOMY; INTERTARSAL JT EA
SYNOVECT; METATARSOPHALANGEAL
JT EA
28080
Yes
No
28086
Yes
28088
Yes
EXC INTERDIGITAL NEUROMA SNGL EA
SYNOVECT TENDON SHEATH FT;
FLEXOR
SYNOVECT TENDON SHEATH FT;
EXTENSOR
28090
Yes
EXC LES TENDON/SHEATH/CAPSULE; FT
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28092
Yes
28100
Yes
28102
Yes
28103
Yes
28104
28106
28107
Yes
Yes
Yes
28108
Yes
28110
Yes
28111
Yes
28112
Yes
28113
Yes
28114
28116
28118
Yes
Yes
Yes
28119
28120
Yes
Yes
Description
EXC LES TEND/SHEATH/CAPSULE; TOE
EA
EXC/CURET BONE CYST/TUMOR
TALUS/CAL
EXC/CURET BONE CYST TALUS;
W/AUTOGF
EXC/CURET BONE CYST TALUS;
W/ALLOGF
EXC/CURET BONE CYST TARSAL EX
TALUS
EXC BONE CYST TARSAL/W/AUTOGFT
EXC BONE CYST TARSAL; W/ALLOGFT
EXC/CURET BONE CYST/TUMOR PHALAN
FT
OSTEOTOMY 5TH METAR HEAD (SEP
PRO)
OSTECT COMPL EXC; 1ST METATARS
HEAD
OSTECT COMPL EXC; OTHR METATAR
HEAD
OSTECT COMPL EXC; 5TH METATARS
HEAD
OSTEC; ALL METATARS HEADS-NOT 1ST
OSTECTOMY EXC TARSAL COALITION
OSTECTOMY CALCAN
OSTECTOMY CALCAN; W/WO PLANT
RELEAS
PART EXC BONE; TALUS/CALCAN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28122
28124
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
28126
28130
28140
28150
Yes
Yes
Yes
Yes
28153
Yes
28160
Yes
28171
Yes
28173
Yes
28175
28190
28192
28193
Yes
Yes
Yes
Yes
28200
Yes
28202
28208
28210
28220
28222
Description
PART EXC BONE; TARSAL EX TALUS
PART EXC BONE; PHALANX TOE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
RESECT PART/ALL PHAL BASE EA TOE
TALECTOMY
METATARSECTOMY
PHALANGECTOMY TOE EA TOE
RESECT CONDYLE DIST PHALANX EA
TOE
HEMIPHALANGECT/TOE PROX PHALANX
EA
RADICAL RESECT BONE TUMOR;
TARSAL
RADICAL RESECT BONE TUMOR;
METATARS
RAD RESECT BONE TUMOR; PHALANX
TOE
REMOV FB FT; SUBQ
REMOV FB FT; DEEP
REMOV FB FT; COMPLIC
No
No
No
No
No
Yes
REPR TEND FLEX FT; 1ST/2ND EA TEND
REPR TENDON FLEX FT; SECND W/GFT
EA
Yes
Yes
Yes
Yes
REPR TEND EXTEN FT; PRIM/SECND EA
REPR TEND EXTEN FT; SEC W/GFT EA
TENOLYSIS FLEX FT; SINGL TENDON
TENOLYSIS FLEX FT; MX TENDON
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28225
28226
28230
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
28232
28234
28238
Yes
Yes
Yes
28240
28250
Yes
Yes
28260
Yes
28261
28262
28264
28270
Yes
Yes
Yes
Yes
28272
28280
28285
Yes
Yes
Yes
28286
Yes
28288
Yes
28289
28290
Yes
Yes
Description
TENOLYSIS EXTEN FT; SINGL TENDON
TENOLYSIS EXTEN FT; MX TENDON
TENOT OP TEND FLEX; FT 1/MX (SP)
TENOT OP TEND FLEX; TOE 1 TEND (SP)
TENOT OP EXTEN FT/TOE EA TENDON
RECON POST TIBIAL TENDON
TENOT LENGTH/RELEAS ABDUCT
HALLUCIS
DIVIS PLANTAR FASCIA & MUSC (SP)
CAPSULOT MIDFT; MED RELEAS ONLY
(SP
CAPSULOT MIDFT; W/TENDON
LENTHENING
CAPSULOT MIDFT; EXTEN
CAPSULOT MIDTARSAL
CAPSULOT; MTP JT-EA JT (SP)
CAPSULOT; IP JT-EA JT (SEPART PROC)
SYNDACTYLIZATION TOES
CORRECT HAMMERTOE
CORRECT COCK-UP 5TH TOE-PLSTC
CLO
OSTECT PART EXOSTECT MTATRS HEADEA
HALLUX RIGIDIS CORRECT
W/CHEILECTMY
HALLUX VALGUS; SIMPL EXOSTECT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28292
28293
Yes
Yes
28294
Yes
28296
28297
28298
28299
28300
28302
Yes
Yes
Yes
Yes
Yes
Yes
28304
28305
Yes
Yes
28306
28307
28308
Yes
Yes
Yes
28309
Yes
28310
Yes
28312
Yes
28313
28315
Description
HALLUX VALGUS; KELLER/MAYO TYPE
PRO
HALLUX VALGUS; RESEC JT W/IMPLNT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
HALLUX VALGUS; W/TENDON TRANSPL
HALLUX VALGUS; W/METATARSAL
OSTEOT
HALLUX VALGUS; LAPIDUS TYPE PRO
HALLUX VALGUS; PHALANX OSTEOT
HALLUX VALGUS; OTH METHD
OSTEOT; CALCAN W/WO INT FIXA
OSTEOTOMY; TALUS
OSTEOT TARSL BONS NOT
CALCAN/TALUS;
OSTEOT TARSAL BONES; W/AUTOGFT
OSTEOT METATARSAL; 1ST
METATARSAL
OSTEOT METATARS; 1ST W/AUTOGFT
OSTEOT METATARSAL; NOT 1ST-EA
OSTEOT W/WO CORRECT METATARSAL;
MX
No
No
Yes
OSTEOT; PROX PHALANX 1ST TOE (SP)
OSTEOT-CORRECT; OTH PHALANG-ANY
TOE
RECON ANGULAR DEFORM TOE SOFT
TISS
Yes
SESAMOIDECTOMY 1ST TOE (SEP PRO)
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28320
28322
Yes
Yes
28340
Yes
28341
28344
Yes
Yes
28345
28360
28400
28405
Yes
Yes
No
No
28406
No
28415
No
28420
28430
28435
No
No
No
28436
28445
28446
28450
28455
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
REPR NON/MALUNION; TARSAL BONES
REPR NON/MALUNION; METATARSAL
RECON TOE MACRODACTYLY; TISS
RESECT
RECON TOE MACRODACT; REQ BONE
RESEC
RECON TOE; POLYDACTYLY
RECON TOE; SYNDAC W/WO SKIN GFT
EA
RECON CLEFT FT
CLO TX CALCAN FX; WO MANIP
CLO TX CALCAN FX; W/MANIP
No
No
PERCUT SKELE FIX CALCAN FX W/MANIP
OPEN TX CALCAN FX W/WO INT/EXT
FIXA
No
No
No
No
No
OPEN TX CALCAN FX; W/PRI AUTOG GFT
CLO TX TALUS FX; WO MANIP
CLO TX TALUS FX; W/MANIP
PERCUT SKELETL FIXA TALUS FX
W/MANI
No
No
No
No
OPEN TX TALUS FX W/WO INT/EXT FIXA
OSTEOCHONDRAL TALUS AUTOGRFT
TX TARSAL BONE FX; WO MANIP EA
TX TARSAL BONE FX; W/MANIP EA
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28456
No
PERCUT FIX TARSAL BONE FX W/MANIP
No
28465
No
OPEN TX TARSAL BONE FX W/WO FIX EA
No
28470
28475
No
No
No
No
28476
No
CLO TX METATARSAL FX; WO MANIP EA
CLO TX METATARSAL FX; W/MANIP EA
PERCUT FIX METATARSAL FX W/MANIP
EA
28485
No
28490
No
28495
No
28496
No
28505
No
28510
No
28515
No
28525
28530
No
No
CLO TX FX GRT TOE PHALANX; W/MANIP
PERCUT FIX FX GRT TOE-PHALANW/MANI
OPEN TX FX GRT TOE-PHALANX-W/WO
FIX
CLO TX FX PHALNX NOT GR TOE; WO
MAN
CLO TX FX PHALNX NOT GR TOE;
W/MANI
OPEN TX FX PHLNX EX GR TOE W/WO
FIX
CLO TX SESAMOID FX
28531
No
OPEN TX SESAMOID FX W/WO INT FIXA
Description
OPEN TX METATARSAL FX W/WO FIX EA
CLO TX FX GRT TOE PHALANX; WO
MANIP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28540
No
28545
28546
No
No
28555
Description
CLO TX TARSAL BONE DISLOC; WO
ANES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
CLO TX TARSAL BONE DISLOC; W/ANES
PERCUT FIX TARSAL DISLOC W/MANIP
OPEN TX TARSAL BONE DISLOC W/WO
FIX
28570
No
CLO TX TALOTARS JT DISLOC; WO ANES
No
28575
No
No
28576
No
28585
No
28600
No
28605
No
28606
No
28615
No
28630
No
28635
No
28636
No
CLO TX TALOTAR JT DISLOC; REQ ANES
PERCUT FIX TALOTARS JT DISLOC
W/MAN
OPEN TX TALOTARS JT DISLOC W/WO
FIX
CLO TX TARSOMETAT JT DISLOC; WO
ANE
CLO TX TARSOMETAT JT DISLOC;
W/ANES
PERCU FIX TARSOMETAT JT DISL
W/MANI
OPEN TX TARSMETAT JT DISLO W/WO
FIX
CLO TX METATARSOPHAL JT DISL;WO
ANE
CLO TX METATARSOPHAL JT DISL;
W/ANE
PERCU FIX METATARSOPHAL JT
W/MANIP
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28645
28660
No
No
OPEN TX METATARSOPHAL JT DISLOC
CLO TX IP JT DISLOC; WO ANES
No
No
28665
No
CLO TX IP JT DISLOC; REQUIRING ANES
No
28666
28675
28705
28715
28725
No
No
Yes
Yes
Yes
No
No
No
No
No
28730
Yes
PERCUT SKELET FIX IP JT DISL W/MANI
OPEN TX IP JT DISLOC W/WO FIXA
ARTHRODESIS; PANTALAR
ARTHRODESIS; TRIPLE
ARTHRODESIS; SUBTALAR
ARTHRODESIS MIDTARS/TARSOMETAT
MX
28735
Yes
No
28737
28740
Yes
Yes
28750
28755
Yes
Yes
28760
28800
28805
28810
Yes
Yes
Yes
Yes
28820
28825
Yes
Yes
ARTHRODESIS MIDTARS MX; W/OSTEOT
ARTHRODESIS TENDON LENGTH
MIDTARSAL
ARTHRODESIS MIDTARSAL SNGL JT
ARTHRODESIS GRT TOE; METATARSOPH
JT
ARTHRODESIS GREAT TOE; IP JT
ARTHRODESIS EXTEN HALLUCIS
TRANSF
AMPUTA FT; MIDTARSAL
AMPUTA FT; TRANSMETATARSAL
AMPUTA METATARSAL W/TOE SNGL
AMPUTA TOE; METATARSOPHALANGEAL
JT
AMPUTA TOE; IP JT
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
28890
28899
29000
29010
Yes
Yes
No
No
29015
No
29020
No
29025
No
29035
No
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
Description
ESWT HI NRG PFRMD PHYS W/US GDN
INVG PLNTAR FSCA
UNLISTED PROC FT/TOES
APPLIC HALO TYPE BODY CAST
APPLIC RISSER JACKET BODY; ONLY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
APPL RISSER JACKET BODY; INCL HEAD
APPLIC TURNBUCKLE JACKET BODY;
ONLY
APPLIC TURNBUCKLE JACKET BODY;
W/HD
No
No
No
No
APPLIC BODY CAST SHOULDER TO HIPS
APPLIC BODY CAST; INCL HEADMINERVA
APPLIC BODY CAST; INCL 1 THIGH
No
No
No
No
No
No
No
No
No
No
No
No
APPLIC BODY CAST; INCL BOTH THIGHS
APPLIC; PLASTER FIGURE-8
APPLIC; SHOULDER SPICA
APPLIC; PLASTER VELPEAU
APPLIC; SHOULDER TO HAND
APPLIC; ELBOW TO FINGER
APPLIC; HAND & LOWER FOREARM
APPLICATION CAST; FINGER
APPLIC LONG ARM SPLINT
APPLIC SHORT ARM SPLINT; STATIC
APPLIC SHORT ARM SPLINT; DYNAMIC
APPLIC FINGER SPLINT; STATIC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29131
29200
29220
29240
29260
29280
29305
29325
29345
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
29355
29358
29365
29405
No
No
No
No
29425
No
29435
29440
No
No
29445
No
29450
29505
29515
29520
29530
29540
29550
No
No
No
No
No
No
No
Description
APPLIC FINGER SPLINT; DYNAMIC
STRAPPING; THORAX
STRAPPING; LOW BACK
STRAPPING; SHOULDER
STRAPPING; ELBOW/WRIST
STRAPPING; HAND/FINGER
APPLIC HIP SPICA CAST; 1 LEG
APPLIC HIP SPICA CAST; 1-1/2 SPICA
APPLIC LONG LEG CAST
APPLIC LONG LEG CAST;WALKER/AMB
TYP
APPLIC LONG LEG CAST BRACE
APPLIC CYLINDER CAST
APPLIC SHORT LEG CAST
APPLIC SHORT LEG CAST;
WALKING/AMB
APPLIC PATELLAR TENDON BEARING
CAST
ADD WALKER TO PREV APPLIC CAST
APPLIC RIGID TOT CONTACT LEG CAST
APPLIC CLUBFT CAST
W/MOLDING/MANIP
APPLIC LONG LEG SPLINT
APPLIC SHORT LEG SPLINT
STRAPPING; HIP
STRAPPING; KNEE
STRAPPING; ANK
STRAPPING; TOES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29580
29590
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
29700
29705
29710
No
No
No
REMOV/BIVALV; GAUNTLET/BOOT CAST
REMOV/BIVALV; FULL ARM/LEG CAST
REMOV/BIVALV; SHOULDR/HIP SPICA
No
No
No
29715
29720
29730
29740
29750
29799
No
No
No
No
No
Yes
No
No
No
No
No
No
29800
29804
Yes
Yes
29805
Yes
REMOV/BIVALV; TURNBUCKLE JACKET
REPR SPICA BODY CAST/JACKET
WINDOWING CAST
WEDGING CAST
WEDGING CLUBFT CAST
UNLISTED PROC CASTING/STRAPPING
ARTHROSCOPY-TMJ-DX W/WO BX(SEP
PRO
ARTHROSCOPY TMJ; SURG
SCOPE SHLDR DX W/WO SYN BX SEP
PROC
29806
Yes
No
29807
Yes
29819
Yes
29820
Yes
29821
Yes
SCOPE SHOULDER SURGICAL; CPSLORR
SCOPE SHLDR SURG; REPR SLAP
LESION
ARTHROSCOPY SHOULDR SURG;
REMOV FB
ARTHROSCPY SHOULDR SURG; SYNOV
PART
ARTHROSCPY SHLDR SURG; SYNOV
COMPLT
Description
STRAPPING; UNNA BOOT
DENIS-BROWNE SPLINT STRAPPING
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
29822
Yes
29823
Yes
29824
Yes
29825
Yes
29826
Yes
29827
29828
29830
Yes
Yes
Yes
29834
Yes
29835
Yes
29836
Yes
29837
Yes
29838
29840
Yes
Yes
29843
Yes
29844
Yes
Description
ARTHROSCPY SHOULDR SURG; DEBRID
LTD
ARTHROSCP SHOULDR SURG;DEBRID
EXTEN
SCOPE SHLDR SURG;DIST CLAVICULECT
ARTHROSCPY SHLDR; W/LYSIS
ADHESIONS
ARTHROSCPY SHLDR; DECOMP
SUBACROM
SCOPE SHOULDER SURGICAL;
W/ROTATOR CUFF REPAIR
ARTHROSCOPY BICEPS TENODESIS
ARTHROSCPY ELBOW DX (SEP PRO)
ARTHROSCPY ELBOW SURG; W/REMOV
FB
ARTHROSCPY ELBOW SURG; SYNOVEC
PART
ARTHROS ELBOW SURG; SYNOVEC
COMPLT
ARTHROSCOPY ELBOW SURG; DEBRID
LTD
ARTHROSCPY ELBOW SURG; DEBRID
EXTEN
ARTHROSCPY WRIST DX (SEP PRO)
ARTHROSCPY WRIST SURG;
INFEC/DRAIN
ARTHROSCPY WRIST SURG; SYNOVEC
PART
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
29845
Yes
29846
Yes
29847
Yes
29848
Description
ARTHROS WRIST SURG; SYNOVEC
COMPLT
ARTHROS WRIST SURG; EXC/REPR
FIBROC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
ARTHROSCOPY WRIST SURG; INT FIX-FX
ENDO WRST SURG-RELEAS TRNS CARP
LIG
No
No
29850
Yes
ARTHROSCOPIC AIDED TX KNEE; WO FIX
No
29851
Yes
ARTHROSCOPIC AIDED TX KNEE; W/FIX
No
29855
Yes
ARTHROSCOPIC AIDED TX TIB FX; UNICO
No
29856
Yes
ARTHROSCOPIC AIDED TX TIB FX; BICON
No
29860
Yes
ARTHROS HIP DX W/WO BX (SEP PROC)
No
29861
Yes
No
29862
Yes
29863
Yes
29867
Yes
29868
Yes
ARTHROSCOPY HIP SURG; W/REMOV FB
ARTHROS HIP SURG; DEBRID/SHAV
CART
ARTHROSCOPY HIP SURG;
W/SYNOVECTOMY
ARTHROSCOPY KNEE SURG;
OSTEOCHONDRAL ALLOGRAFT
ARTHROSCOPY KNEE SURG; MENISCAL
TPLNT MED/LAT
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
29870
Yes
29871
Yes
29873
Yes
29874
Yes
29875
Yes
29876
Yes
29877
Yes
29879
Yes
29880
Description
ARTHROS KNEE DX W/WO BX (SEP PRO)
ARTHROSCOPY KNEE SURG;
INFEC/DRAIN
ARTHROSCOPY KNEE SURGICAL; WITH
LATERAL RELEASE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
ARTHROSCOPY KNEE SURG; REMOV FB
ARTHROS KNEE; SYNOVEC LTD (SEP
PRO)
ARTHROSCOPY KNEE; SYNOVECTOMY
MAJOR
No
No
Yes
ARTHROS KNEE; DEBRID/SHAVE CARTIL
ARTHROSCOP KNEE SURG; ABRAS
PLASTY
ARTHROS KNEE; W/MENISECT (MED &
LAT
29881
Yes
ARTHROS KNEE; W/MENISECT (MED/LAT)
No
29882
Yes
No
29883
Yes
29884
Yes
ARTHROS KNEE W/MENISCUS (MED/LAT)
ARTHROS KNEE; W/MENISCUS (MED &
LAT
ARTHROS KNEE; W/LYSIS ADH (SEP
PRO)
29885
Yes
ARTHROS KNEE; DRILL W/GFT W/WO FIX
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
29886
Yes
29887
Yes
29888
Yes
29889
Yes
29891
Yes
29892
29893
Yes
Yes
29894
Yes
29895
Yes
29897
Yes
29898
Yes
29899
Yes
29900
Yes
29901
Yes
29902
Yes
Description
ARTHROS KNEE; DRILL-OSTEOCHON
LES
ARTHROS KNEE; DRILL-OSTEOCHON
W/FIX
ARTHROSCOPIC AIDED ACL
REPAIR/RECON
ARTHROSCOPIC AIDED PCL
REPAIR/RECON
ARTHROS ANK SURG; EXC DEFEC
TAL/TIB
ARTHROS AIDED REPR OSTEO LES-TAL
FX
ENDOSCOPIC PLANTAR FASCIOTOMY
ARTHROSCOPY ANK SURG; W/REMOV
FB
ARTHROS ANK SURG; SYNOVECTOMY
PART
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
ARTHROSCOPY ANK SURG; DEBRID LTD
ARTHROSCOPY ANK SURG; DEBRID
EXTEN
ARTHROSCOPY ANKLE SURG; W/ANKLE
ARTHRODESIS
SCOPE MCP JOINT DX INCL SYNOVIAL
BX
No
SCOPE MCP JOINT SURGICAL; W/DEBRID
SCOPE MCP JNT;RDUC ULNAR COLLAT
LIG
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29904
29905
29906
29907
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
29999
Yes
UNLISTED PROCEDURE ARTHROSCOPY
No
30000
No
No
30020
30100
30110
30115
No
No
No
No
DRAIN ABSCESS/HEMATOMA-NASAL-INT
DRAIN ABSCESS/HEMATOMA NASAL
SEPTUM
BX INTRANASAL
EXC NASAL POLYP SIMPL
EXC NASAL POLYP EXTEN
30117
No
EXC INTRANASAL LES; INT APPROACH
No
30118
No
EXC INTRANASAL LES; EXT APPROACH
No
30120
No
EXC/SURG PLANING NOSE RHINOPHYMA
No
30124
30125
No
No
No
No
30130
No
30140
30150
30160
30200
No
No
No
No
EXC DERMOID CYST NOSE; SIMPL/SUBQ
EXC DERMOID CYST NOSE; COMPLX
EXC TURBINATE PART/COMPLT ANY
METHD
SMR TURBINATE PART/COMPLT ANY
METHD
RHINECTOMY; PART
RHINECTOMY; TOT
INJ INTO TURBINATE THERAP
Description
SUBTALAR ARTHRO W/FB RMVL
SUBTALAR ARTHRO W/EXC
SUBTALAR ARTHRO W/DEB
SUBTALAR ARTHRO W/FUSION
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
30210
30220
30300
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
30310
No
30320
30400
No
Not Reimbursable
30410
Not Reimbursable
30420
Not Reimbursable
30430
Not Reimbursable
30435
Not Reimbursable
30450
30460
Not Reimbursable
Yes
30462
Yes
30465
Yes
30520
Yes
30540
Yes
30545
Yes
Description
DISPLACEMENT THERAP
INSRT NASAL SEPTAL PROSTH
REMOV FB INTRANASAL; OFFIC PROC
REMOV FB INTRANASAL; REQ GEN ANES
REMOV FB INTRANASAL; LAT
RHINOTOMY
RHINOPLASTY PRIM; CARTIL/ELEV TIP
RHINOPLASTY PRIM; COMPLT-EXT
PARTS
RHINOPLASTY PRIM; INCL MAJOR
SEPTAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
RHINOPLASTY SECNDRY; MINOR REVIS
RHINOPLASTY SECNDRY; INTERMED
REVIS
Not Reimbursable
RHINOPLASTY SECNDRY; MAJOR REVIS
RHINOPLASTY-DEFORM CLEFT LIP; TIP
RHINOPLSTY-DEFORM;
TIP/SEPTUM/OSTEO
Not Reimbursable
No
REPR OF NASAL VESTIBULAR STENOSIS
SEPTOPLSTY/SMR W/WO
SCORING/REPLAC
No
REPR CHOANAL ATRESIA; INTRANASAL
REPR CHOANAL ATRESIA;
TRANSPALATINE
Not Reimbursable
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
30560
30580
30600
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
30620
30630
Yes
Yes
30801
No
30802
30901
No
No
Description
LYSIS INTRANASAL SYNECHIA
REPR FISTULA; OROMAXILLARY
REPR FISTULA; ORONASAL
SEPTAL/OTHER INTRANASL
DERMATOPLSTY
REPR NASAL SEPTAL PERFORATIONS
CAUT MUCOS TURBIN (SEP PRO);
SUPERF
CAUT MUCOS TURBIN (SEP PRO);
INTRAM
CONTRL NASAL HEMORR-ANT-SIMPL
30903
30905
No
No
CONTRL NASAL HEMORR-ANT-COMPLX
CONTRL NASAL HEMORR-POST; INIT
No
No
30906
30915
30920
30930
30999
No
Yes
Yes
No
Yes
CONTRL NASAL HEMORR-POST; SUBSQT
LIG ART; ETHMO
LIG ART; INT MAXIL ART TRANSANTRAL
FX NASAL TURBINATE THERAP
UNLISTED PROC NOSE
No
No
No
No
No
31000
Yes
No
31002
31020
Yes
Yes
31030
Yes
31032
Yes
LAVAGE BY CANNULATION; MAXIL SINUS
LAVAGE-CANNULATION; SPHENOID
SINUS
SINUSOTOMY MAXIL; INTRANASAL
SINUSOTMY MAXIL; RAD WO REMOV
POLYP
SINUSOTMY MAXIL; RAD W/REMOV
POLYPS
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31040
31050
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
31051
31070
Yes
Yes
31075
Yes
31080
Yes
31081
Yes
31084
Yes
31085
Yes
31086
Yes
31087
31090
31200
31201
31205
Yes
Yes
Yes
Yes
Yes
31225
Yes
31230
31231
Yes
No
Description
PTERYGOMAXILLARY FOSSA SURG
SINUSOTOMY SPHENOID W/WO BX
SINUSOTMY SPHENOID W/WO MUCOS
STRIP
SINUSOTOMY FRONTAL; EXT SIMPL
SINUSOTOMY FRONT; TRANSORBIT
UNILAT
SINUSOTMY FRONT; OBLIT-WO FLAPBROW
SINUSOTOMY FRONT; WO FLAPCORONAL
SINUSOTOMY FRONT; OBLIT-W/FLAPBROW
SINUSOTOMY FRONT; W/FLAP-CORONAL
SINUSOTMY FRONT; NONOBL-W/FLAPBROW
SINUSOTMY FRONT; NONBL-W/FLAPCORON
SINUSOT UNILAT 3/MORE PARANASAL
ETHMO; INTRANASAL ANT
ETHMO; INTRANASAL TOT
ETHMO; EXTRANASAL TOT
MAXILLECTOMY; WO ORBIT
EXENTERATION
MAXILLECTOMY; W/ORBIT
EXENTERATION
NASAL ENDO DX UNI/BILAT (SEP PRO)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
31233
31235
No
No
31237
No
31238
No
31239
No
31240
No
Description
NASAL/SINUS ENDO DX W/MAX
SINUSOSCP
NASAL/SINUS ENDO DX W/SPHENOID
NAS/SINUS ENDO SURG; W/BX (SEP
PRO)
NASAL/SINUS ENDO SURG; CNTRL
EPISTX HEMORRHAGE
NASAL/SINUS ENDO SURG;
DACRYOCYSTOR
NASAL/SINUS ENDO SURG; CONCHA
BULLO RESECTION
31254
No
NASAL/SINUS ENDO-OR; W/PART ETHMO
No
31255
No
No
31256
No
NASAL/SINUS ENDO-OR; W/TOT ETHMO
NAS/SINUS ENDO-OR-W/MAXIL
ANTROST;
31267
No
NAS/SINUS ENDO; W/TISS REMOV MAXIL
No
31276
No
No
31287
No
31288
No
NAS/SINUS ENDO-OR-W/FRONT EXPLOR
NASAL/SINUS ENDO SURG
W/SPHENOIDOT
NASAL ENDO W/SPHENOIDOT; REMOV
TISS
31290
No
No
31291
No
NASAL ENDO REPR CSF LEAK; ETHMOID
NASAL ENDO REPR CSF LEAK;
SPHENOID
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
31292
No
31293
No
31294
31299
No
Yes
31300
31320
Yes
Yes
31360
Yes
Description
NASAL ENDO; MED/INFER ORBIT
DECOMP
NASAL ENDO; MED & INFER ORBIT
DECOM
NASAL ENDO SURG; W/OPTIC NERV
DECOM
UNLISTED PROC ACCES SINUSES
LARYNGOTOMY; W/REMOV
TUMOR/CORDECT
LARYNGOTOMY; DX
LARYNGECT; TOT WO RAD NECK
DISSECT
31365
Yes
LARYNGECT; TOT W/RAD NECK DISSECT
No
31367
31368
31370
Yes
Yes
Yes
No
No
No
31375
Yes
31380
Yes
31382
Yes
31390
Yes
31395
31400
Yes
Yes
LARYNGECTOMY; SUBTL WO RAD NECK
LARYNGECTOMY; SUBTL W/RAD NECK
PART LARYNGECTOMY; HORIZONTAL
PART LARYNGECTOMY;
LATEROVERTICAL
PART LARYNGECTOMY;
ANTEROVERTICAL
PART LARYNGEC; ANTERO-LATVERTICAL
PHARYNGOLARYNGEC W/RAD NEC; WO
RECN
PHARYNGOLARYNGEC W/RAD NEC;
W/RECON
ARYTENOIDECTOMY EXT APPROACH
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31420
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
31500
No
31502
No
31505
31510
No
No
31511
No
31512
No
31513
No
31515
No
31520
31525
31526
No
No
No
31527
31528
31529
No
No
No
31530
No
31531
31535
No
No
Description
EPIGLOTTIDECTOMY
INTUBATION ENDOTRACHEAL EMER
PROC
TRACHEOT TUBE CHANGE BEFOR
FISTULA
LARYNGOSCOPY INDIREC; DX (SEP
PROC)
LARYNGOSCOPY INDIRECT; W/BX
LARYNGOSCOPY INDIRECT; W/REMOV
FB
LARYNGOSCOPY INDIRECT; W/REMOV
LES
LARYNGOSCOP INDIR; W/VOCAL CRD INJ
LARYNGOSCP DIR W/WO TRACHEO;
ASPIRA
LARYNGOSCP DIR W/WO TRACHEO; DX
NB
LARYNGOSCOPY DIRECT; DX EX NB
LARYNGOSCOPY DIR; DX W/OR MICRO
LARYNGOSCOPY DIR; W/INSRT
OBTURATOR
LARYNGOSCOPY DIR W/DILAT INIT
LARYNGOSCP DIR; W/DILAT SUBSQT
LARYNGOSCOPY DIRECT OR W/FB
REMOV
LARYNGOSCP DIR W/FB REMOV;
W/MICRO
LARYNGOSCOPY DIRECT OR W/BX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
31536
No
31540
No
31541
No
31545
No
31546
No
31560
No
31561
No
31570
31571
No
No
31575
No
31576
No
31577
No
31578
No
31579
No
31580
Yes
Description
LARYNGOSCPY DIRECT OR W/BX;
W/MICRO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
LARYNGOSCOPY DIR OR W/EXC TUMOR
LARYNGOSCP DIR W/EXC TUMOR;
W/MICRO
LARYN OP MIC REMV LES VC; RECNSTR
W/LOC TISS FLP
LARYN OP MIC REMV LES VOCAL CORD;
RECNSTR W/GFT
LARYNGOSCPY DIR OR
W/ARYTENOIDECTMY
LARYNGOSCP W/ARYTENOIDEC; W/OR
MICR
LARYNGOSCOPY DIR W/INJ CORDS
THERAP
LARYNGOSCP W/INJ CORDS; W/MICRO
No
LARYNGOSCOPY FLEX FIBEROPTIC; DX
LARYNGOSCOPY FLEX FIBEROPTIC;
W/BX
LARYNGOSCPY FIBEROPTIC; W/REMOV
FB
LARYNGOSCPY FIBEROPTIC; W/REMOV
LES
LARYNGOSCOPY-FLEX/RIGID
W/STROBOSCP
LARYNGOPLASTY; W/KEEL INSRT &
REMOV
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31582
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
31584
31587
31588
Yes
Yes
Yes
31590
Yes
31595
31599
Yes
Yes
31600
Yes
31601
Yes
31603
Yes
31605
Yes
31610
Yes
31611
Yes
31612
No
31613
Yes
31614
Yes
Description
LARYNGOPLASTY; STENOSIS W/GFT
LARYNGOPLASTY; W/OPEN REDUCTION
FX
LARYNGOPLASTY CRICOID SPLIT
LARYNGOPLASTY NOS
LARYNGEAL REINNERV-NEUROMUSCL
PEDIC
SECT RECUR LARYNGEAL NERV (SEP
PRO)
UNLISTED PROC LARYNX
TRACHEOSTOMY PLANNED (SEPART
PROC)
TRACH PLANNED (SEPART PROC); < 2
YR
TRACHEOSTOMY EMER PROC;
TRANSTRACH
TRACH EMER PROC; CRICOTHYROID
MEMBR
TRACH FENESTRATION PROC W/SKIN
FLAP
CONSTRUCT TRACHEOESOPHAG
FISTULA
TRACH PUNCT-PERC-W/TRNSTRAC
ASP/INJ
TRACHEOSTOMA REVIS; SIMPL WO FLAP
TRACHEOSTOMA REVIS; COMPLX
W/FLAP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
31615
No
31620
No
31622
No
31623
No
31624
No
31625
No
31628
No
31629
No
31630
No
31631
No
31632
No
31633
No
31635
No
31636
No
Description
TRACHEOBRONCHOSCOPY THRU
TRACH INCS
ENDOBRONCHIAL US DUR
BRONCHOSCOP DX/TX INTERVEN
BRONCHOSCOPY; DX W/WO CELL WASH
SEP PROC
BRONCHOSCPY W/WO FLOURO;
W/BRUSH/PROTECTED BRUSH
BRNCHSCPY W/WO FLOURO;
W/BRONCHAL ALVEOLR LAVAGE
BRONCHOSCOPY;
BRONCHIAL/ENDOBRNCHL BX 1/MX
SITES
BRNCHSCPY W/WO FLUORO;
TRANSBRNCH LUNG BX 1 LOBE
BRNCHSCPY;TRANSBRNCH NABX
TRACH STEM&/LOBR BRNCH
BRNCHSCPY; W/TRACHEAL/BRONCH
DILAT/CLOS RDUC FX
BRONCHOSCOPY RIGD/FLEX; W/PLCMT
TRACHEAL STENT
BRNCHSCPY W/WO FLUORO GUID;
W/TBLB EA ADD LOBE
BRNCHSCPY W/WO FLUORO GUID; TBNA
BX EA ADD LOBE
BRONCHOSCOPY W/WO FLOURO;
W/REMV OF FOREIGN BODY
BRNCHSCPY RIGD/FLX;PLCMT BRNCH
STNT INIT BRNCHUS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
31637
No
31638
No
31640
No
31641
No
31643
No
31645
No
31646
No
31656
31700
31708
No
No
No
31710
No
31715
31717
No
No
31720
No
31725
31730
Description
BRNCHSCPY RIGD/FLX; EA ADD MAJ
BRONCHUS STNTED
BRNCHSCPY; REV TRACH/BRNCH STNT
INSRT PREV SESS
BRONCHOSCOPY W/WO FLOURO; WITH
EXCISION OF TUMOR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
BRONCHOSCOPY; W/DESTRUC TUMOR
BRONCHOSCP; W/PLCMT CATH RAD
APPLIC
No
BRONCHOSCOPY; W/THERAP ASPIR-INIT
BRONCHOSCOPY; W/THERAP ASPIRSUBSEQ
BRONCHOSCOPY; W/ INJ CMBRONCHGRPH
CATH TRANSGLOTTIC (SEPART PROC)
INSTILL CONTRAST-LARYNGOGRAPHY
CATH BRONCHOGRAPHY W/WO
CONTRST MAT
No
No
No
No
No
No
No
No
No
No
TRANSTRACHEAL INJ BRONCHOGRAPHY
CATH W/BRONCHIAL BRUSH BX
CATH ASPIRA (SEP PRO);
NASOTRACHEAL
CATH ASPIRAT (SEP
PRO);TRACHEOBRONC
No
TRANSTRACH INTRO TUBE-O2 THERAP
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31750
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
31755
31760
31766
31770
31775
31780
Yes
Yes
Yes
Yes
Yes
Yes
31781
Yes
31785
Yes
31786
Yes
31800
Yes
31805
Yes
Description
TRACHEOPLASTY; CERV
TRACHEOPLASTY; TRACHEOPHARY
FISTULA
TRACHEOPLASTY; INTRATHORACIC
CARINAL RECON
BRONCHOPLASTY; GFT REPR
BRONCHOPLASTY; EXC STENOSIS
EXC TRACHEAL STENOSIS; CERV
EXC TRACH STENOSIS;
CERVICOTHORACIC
EXC TRACHEAL TUMOR/CARCINOMA;
CERV
EXC TRACHEAL TUMOR/CARCIN;
THORACIC
SUTURE TRACHEAL WOUND/INJURY;
CERV
SUTURE TRACH WOUND;
INTRATHORACIC
31820
Yes
SURG CLO TRACH/FISTULA; WO PLASTIC
No
31825
31830
31899
Yes
Yes
Yes
SURG CLO TRACH/FISTULA; W/PLASTIC
REVIS TRACHEOSTOMY SCAR
UNLISTED PROC TRACHEA BRONCHI
No
No
No
32000
Yes
No
32002
32005
Yes
Yes
THORACENTESIS-ASPIRAT-INIT/SUBSQT
THORACENTESIS W/INSRT TUBE (SEP
PRO
CHEM PLEURODESIS
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32019
No
32020
Yes
32035
Yes
32036
Description
INSERTION INDWELLING TUNNLED
PLEURAL CATH W/CUFF
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
TUBE THORACOSTOMY (SEPART PROC)
THORACOSTOMY; W/RIB RESECT
EMPYEMA
THORACOSTMY; W/OPEN FLAP-DRAIN
EMPY
32095
Yes
THORACOTOMY LTD BX LUNG/PLEURA
No
32100
Yes
No
32110
Yes
32120
Yes
32124
32140
Yes
Yes
32141
Yes
32150
Yes
32151
Yes
32160
Yes
32200
Yes
THORACOTOMY MAJOR; W/EXPLOR & BX
THORACOTOMY MAJOR; W/CONTRL
HEMORR
THORACOTOMY MAJOR; POSTOP
COMPLIC
THORACOTOMY MAJ;
W/PNEUMONOLYSIS
THORACOTOMY MAJ; W/CYST REMOV
THORACOTOMY MAJ; W/EXC-PLICAT
BULLA
THORACOTOMY MAJ; REMOV
INTRAPLEU FB
THORACOTOMY MAJ; REMOV
INTRAPULM FB
THORACOTOMY MAJ; W/CARDIAC
MASSAGE
PNEUMONOSTOMY W/OPEN DRAIN
ABSCESS
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32201
Yes
32215
Yes
Description
PNEUMONOSTOMY; W/PERCUT DRAIN
ABSC
PLEURAL SCARIFICATION REPEAT
PNEUMO
32220
Yes
DECORTIC PULM (SEPART PROC); TOT
No
32225
Yes
No
32310
Yes
DECORTIC PULM (SEPART PROC); PART
PLEURECTOMY, PARIETAL (SEPART
PROC)
32320
32400
32402
Yes
Yes
Yes
32405
Yes
32420
32421
32422
32440
Yes
Yes
Yes
Yes
32442
32445
Yes
Yes
32480
Yes
32482
Yes
DECORTIC & PARIETAL PLEURECTOMY
BX PLEURA; PERCUT NEEDLE
BX PLEURA; OPEN
BX LUNG/MEDIASTINUM PERCUT
NEEDLE
PNEUMONOCENTESIS-PUNCT LUNG
ASPIRAT
THORACENTESIS FOR ASPIRATION
THORACENTESIS W/TUBE INSERT
REMOV LUNG TOT PNEUMONECTOMY
REMOV LUNG; W/RESECT TRACH
W/ANASTM
REMOV LUNG; EXTRAPLEURAL
REMOV LUNG NOT TOT PNEUMON; 1
LOBE
REMOV LUNG OTHER THAN TOT; 2
LOBES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32484
Yes
32486
Yes
32488
Yes
32491
Yes
32500
Yes
32501
Yes
32503
Yes
32504
Yes
32540
32550
32551
32560
Yes
No
No
No
32601
Yes
32602
Yes
32603
Yes
32604
Yes
Description
REMOV LUNG OTHER THAN TOT; 1
SEGMT
REMOV LUNG NOT TOT; W/CIRCUM
RESECT
REMOV LUNG; AFTER PREV REMOVPORTIN
REMOV LUNG NOT TOT; LUNG VOL
REDUC
REMOV LUNG NOT TOT; WEDG RESEC
1/MX
RESECT & REPR BRONCH @ TIME
LOBEC
RESCJ APICAL LNG TUM W/O CH WALL
RCNSTJ
RESCJ APICAL LNG TUM W/CH WALL
RCNSTJ
EXTRAPLEURAL ENUCLEATION
EMPYEMA
INSERT PLEURAL CATH
INSERTION OF CHEST TUBE
TREAT LUNG LINING CHEMICALLY
THORACOSCPY DX; LUNGS/PLEURAL
WO BX
THORACOSCPY DX; LUNGS/PLEURAL
W/BX
THORACOSCPY DX; PERICARD SAC WO
BX
THORACOSCPY DX; PERICARD SAC
W/BX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32605
Yes
32606
Yes
32650
Yes
32651
Yes
32652
32653
Yes
Yes
32654
Yes
32655
Yes
32656
Yes
32657
Yes
32658
Yes
32659
Yes
32660
Yes
32661
Yes
32662
Yes
Description
THORACOSCPY DX; MEDIASTINAL WO
BX
THORACOSCPY DX; MEDIASTINAL W/BX
THORACOSCOPY SURG;
W/PLEURODESIS
THORACOSCPY SURG; W/PART PULM
DECOR
THORACOSCPY SURG; W/TOT PULM
DECORT
THORACOSCPY SURG; W/REMOV FB
THORACOSCPY SURG; CONTRL TRAUM
HEMO
THORACOSCPY SURG; W/EXC-PLICAT
BULL
THORACOSCPY SURG; W/PARIETL
PLEUREC
THORACOSCPY SURG; WEDGE RESECT
1/MX
THORACOSCPY SURG; REMOV FBPERICAR
THORACOSCPY SURG; CREAT PERICAR
WIN
THORACOSCPY SURG; W/TOT
PERICARDECT
THORACOSCPY SURG; EXC PERICARD
CYST
THORACOSCPY SURG; EXC MEDIASTN
CYST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32663
Yes
32664
Yes
32665
Yes
32800
Yes
32810
Yes
32815
32820
Yes
Yes
32850
Yes
32851
32852
32853
32854
Yes
Yes
Yes
Yes
32856
Yes
32900
Yes
32905
Yes
32906
Yes
Description
THORACOSCPY SURG; W/LOBEC
TOT/SEGMT
THORACOSCPY SURG; THORAC
SYMPATHECT
THORACOSCPY SURG;
W/ESOPHAGOMYOTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
REPR LUNG HERNIA THRU CHEST WALL
CLO CHEST WALL FOLLOWING OPEN
FLAP
No
OPEN CLO MAJOR BRONCHIAL FISTULA
MAJOR RECON CHEST WALL
DONOR PNEUMONECTOMY FROM
CADAVER DONOR
No
No
LUNG TRANSPL SNGL; WO CP BYPASS
LUNG TRANSPL SNGL; W/CP BYPASS
LUNG TRANSPL DBL; WO CP BYPASS
LUNG TRANSPL DBL; W/CP BYPASS
BACKBENCH STD PREP CADVR DONR
LUNG ALLOGFT; BIL
RESECT RIBS EXTRAPLEURAL ALL
STAGES
THORACOPLSTY SCHEDE
TYPE/EXTRAPLEUR
THORACOPLSTY; W/CLO BRONCHOPLE
FIST
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
32940
Yes
32960
32997
32998
32999
33010
33011
33015
33020
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
33025
Yes
33030
Yes
33031
33050
Yes
Yes
33120
33130
Yes
Yes
33140
Not Reimbursable
33141
Not Reimbursable
33200
Yes
Description
PNEUMOLYSIS EXTRAPERIOSTEAL
W/FILL
PNEUMOT THERAP-INTRAPLEURAL INJ
AIR
TOT LUNG LAVAGE (UNILAT)
PERQ RF ABLATE TX, PUL TUMOR
UNLISTED PROC LUNGS & PLEURA
PERICARDIOCENTESIS; INIT
PERICARDIOCENTESIS; SUBSQT
TUBE PERICARDIOSTOMY
PERICARDIOTOMY REMOV CLOT/FB
CREAT PERICARDIAL WINDOW/PART
RESEC
PERICARDIECTOMY SUBTL WO CP
BYPASS
PERICARDIECTOMY SUBTL; W/CP
BYPASS
EXC PERICARDIAL CYST/TUMOR
EXC INTRACARDIAC TUMOR W/CP
BYPASS
RESECT EXT CARDIAC TUMOR
TRANSMYOCARD LASER REVAS (SEP
PROC)
TRANSMYOCARD PERF AT THE SAME
TIME W/OTHER CARD PROC
INSRT PERM PACEMAKER; BY
THORACOTMY
33201
Yes
INSRT PERM PACEMAKER; BY XIPHOID
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33202
33203
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
33206
Yes
33207
Yes
33208
Yes
33210
Yes
33211
Yes
33212
Yes
33213
Yes
33214
Yes
33215
No
33216
Yes
33217
Yes
33218
Yes
33220
Yes
Description
INSERT EPICARD ELTRD, OPEN
INSERT EPICARD ELTRD, ENDO
INSRT/REPLAC PERM PACEMAKR;
ATRIAL
INSRT/REPLAC PERM PACEMAKR;
VENTRIC
INSRT/REPLAC PACEMKR;
ATRIL/VENTRIC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
INSRT/REPLC TEMP 1 ELECT (SEP PRO)
INSRT/REPLC TEMP ELECTROD (SEP
PRO)
No
INSRT/REPLAC PACEMKR GEN; 1 CHMBR
INSRT/REPLC PACEMKR GEN; DUAL
CHMBR
UPGRADE IMPLNT PACEMKR SYST 1DUAL
REPSTN PREV IMPL
PACEMKR/CARDIOVRT-DFIB ELEC
INSRT TRNSVEN ELECTROD; 1 CHMBPERM
INSRT TRNSVEN ELECTROD; 2 CHMBPERM
REPR ELECTRODE-1 CHMBR
PACER/DEFIB
REPR ELECTRODE-2 CHMBR
PACER/DEFIB
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33222
Yes
33223
Yes
33224
Yes
33225
Yes
33226
No
33233
Yes
33234
Yes
33235
Yes
33236
Yes
33237
Yes
33238
Yes
33240
Yes
33241
Yes
33243
Yes
Description
REVIS/RELOCAT SKIN POCKETPACEMAKER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
REVIS SKIN POCKET CARDIOVERT-DEFIB
INSRT PACE ELEC PREV PLCD
PACEMKR/CARDIOVRT-DFIB
INSRT PACE ELEC @TM INSRT
CARDIOVRT-DFIB/PACEMKR
REPSTN PREV IMPL CARDIAC VENOUS
SYS ELECTRODE
No
REMOV PERM PACEMAKER PULSE GEN
REMOV TRANSVEN PACEMKR ELEC; 1
LEAD
REMOV TRANSVEN PACEMKR ELEC; 2
LEAD
REMOV EPICARD PACEMKR-THORAC; 1
LED
REMOV EPICARD PACEMKR-THORAC;
DUAL
REMOV PERM TRANSVEN ELECTTHORACOT
No
INSRT PACING CARDIOVERT-DEFIB GEN
SUBQ REMOV CARDIOVERT-DEFIB
GENERAT
REMOV CARDIOVERT ELECTROD;
THORACOT
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33244
Yes
33245
Yes
33246
Yes
33249
Yes
33250
Yes
33251
Yes
33253
33254
33255
33256
33257
33258
33259
Yes
Yes
Yes
Yes
Yes
Yes
Yes
33261
33265
33266
Yes
Yes
Yes
33282
Yes
33284
33300
Yes
Yes
Description
REMOV CARDIOVERT ELECTROD;
TRNSVEN
INSRT EPICAR DEFIB ELECTROTHORCOT;
INSRT EPICARD DEFIB ELECTROD;
W/GEN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
INSRT/REPOS LEAD-DEFIB & INSRT GEN
OR ABLAT SUPRAVENT FOCUS; WO
BYPASS
OR ABLAT SUPRAVENT FOCUS;
W/BYPASS
No
OPER INC & RECON ATRIA-TX FIB/FLUTR
ABLATE ATRIA, LMTD
ABLATE ATRIA W/O BYPASS, EXT
ABLATE ATRIA W/BYPASS, EXTEN
ABLATE ATRIA, LMTD, ADD-ON
ABLATE ATRIA, X10SV, ADD-ON
ABLATE ATRIA W/BYPASS ADD-ON
OPER ABLAT VENT ARRHYTH FOCUS
W/BP
ABLATE ATRIA W/BYPASS, ENDO
ABLATE ATRIA W/O BYPASS ENDO
IMPLNT PT-ACTIV CARD EVENT
RECORDER
REMOV PT-ACTIV CARD EVENT
RECORDER
REPR CARDIAC WOUND; WO BYPASS
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33305
Yes
33310
Yes
33315
Yes
33320
Yes
33321
33322
Yes
Yes
33330
Yes
33332
33335
Yes
Yes
33400
Yes
33401
Yes
33403
Yes
33404
Yes
33405
Yes
33406
Yes
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
REPR CARDIAC WOUND; W/CP BYPASS
CARDIOTOMY EXPLORATORY; WITHOUT
BYPASS
CARDIOTOMY EXPLORATORY;
W/CARDIOPULMONARY BYPASS
SUT REPR AOR/GRT VESS; WO
SHNT/BYPS
SUTURE REPR AOR/GRT VESS;
W/SHUNT
SUTURE REPR AORTA; W/CP BYPASS
INSRT GFT AO/GRT VESS; WO
SHNT/BYPS
No
INSRT GFT AORTA/GRT VESS; W/SHUNT
INSRT GFT AORTA; W/CP BYPASS
VALVPLSTY AORTIC; OPEN W/CP
BYPASS
VALVPLSTY AORTIC VALV; OPEN
W/OCCL
VALVULOPLSTY AORTIC; W/DILAT-CP
BYP
CONSTRUCTION APICAL-AORTIC
CONDUIT
REPLC AORT VALVE W/BYPASS;
W/PROSTH
REPLC AORTC VALV W/CP BYP;
W/HOMOGF
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33410
Yes
33411
Yes
33412
Yes
33413
Yes
33414
Yes
33415
Yes
33416
Yes
33417
Yes
33420
Yes
33422
Description
REPLCMT AORTIC VALVE; W/TISS VALVE
REPLAC AORTIC VALV; W/AORT
ANNULUS
REPLAC AORTIC VALV; W/TRANSVEN
AORT
REPLC AORTC VALV; TRNSLOC PULM
VALV
REPR LT VENT OUTFLO OBSTRUCPATCH
RESECT/INCS SUBVALVULAR TISSSTENOS
VENTRICULOMYOTOMY-IDIOPATHIC
STENOS
AORTOPLASTY SUPRAVALVULAR
STENOSIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
VALVOTOMY MITRAL VALV; CLO HEART
VALVOT MITRAL; OPEN HEART
W/BYPASS
33425
Yes
VALVULOPLASTY-MITRAL W/CP BYPASS
No
33426
Yes
No
33427
33430
Yes
Yes
VALVULOPL-MITRAL W/BYPASS; W/RING
VALVULOPL-MITRAL W/BYPAS; RAD
RECON
REPLAC MITRAL VALV W/CP BYPASS
No
No
33460
Yes
VALVECTOMY TRICUSPID; W/CP BYPASS
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33463
Yes
33464
Yes
33465
Yes
33468
Yes
33470
Yes
33471
Yes
33472
Yes
33474
33475
Yes
Yes
33476
Yes
33478
Yes
33496
Yes
33500
Yes
33501
33502
Description
VALVULOPLSTY TRICUSPD; WO RING
INSR
VALCULOPLSTY TRICUSPD; W/RING
INSRT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Yes
REPLAC TRICUSPID VALV W/CP BYPASS
TRICUSP VALV REPOSIT-EBSTEIN
ANOMLY
VALVOTOMY PULM CLO HRT;
TRNSVENTRIC
VALVOTMY PULM CLO HRT; VIA PULM
ART
VALVOT PULM OPEN HRT; W/INFLO
OCCLU
VALVOTMY PULM OPEN HRT; W/CP
BYPASS
REPLAC PULM VALV
RT VENTRIC RESECT-INFUNDIB
STENOSIS
OUTFLOW TRACT AUGMEN W/WO
COMMISSUR
REPR PROSTH VALV DYSFUNC W/CPB
(SP)
REPR CORON AV FISTULA; W/CP
BYPASS
REPR CORON AV FISTULA; WO CP
BYPASS
No
Yes
REPR ANOMALOUS CORONARY ART; LIG
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
33503
Yes
33504
Yes
33505
Yes
33506
Yes
33507
Yes
33508
No
Description
ANOMALOUS CORON ART; GFT WO
BYPASS
ANOMALOUS CORON ART; GFT
W/BYPASS
REPR CORON ART; CONSTRUC PULM
ART
REPR CORON ART; TRNSLOC PULMAORTA
RPR ANOM AORTIC ORIGIN C ART
UNROOFING/TLCJ
ENDO SURG W/VIDEO-ASSTD HARV
VEINS COR ART BYPS
33510
Yes
CAB-VEIN ONLY; 1 CORON VENOUS GFT
No
33511
Yes
CAB-VEIN ONLY; 2 CORON VENOUS GFT
No
33512
Yes
CAB-VEIN ONLY; 3 CORON VENOUS GFT
No
33513
Yes
CAB-VEIN ONLY; 4 CORON VENOUS GFT
No
33514
33516
Yes
Yes
CAB-VEIN ONLY; 5 CORON VENOUS GFT
CAB-VEIN ONLY; 6/MORE VENOUS GFT
No
No
33517
Yes
CAB W/VENOUS & ART GFT; 1 VEIN GFT
No
33518
Yes
CAB W/VENOUS & ART GFT; 2 VEIN GFT
No
33519
Yes
CAB W/VENOUS & ART GFT; 3 VEIN GFT
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33521
Yes
CAB W/VENOUS & ART GFT; 4 VEIN GFT
No
33522
Yes
CAB W/VENOUS & ART GFT; 5 VEIN GFT
No
33523
Yes
CAB W/VENOUS & ART GFT; 6/MORE GFT
No
33530
33533
33534
33535
Yes
Yes
Yes
Yes
No
No
No
No
33536
33542
Yes
Yes
33545
Yes
33548
Yes
33572
Yes
33600
Yes
REOPERAT CAB > 1 MO AFTER ORIG OR
CAB USING ART GFT; 1 ART GFT
CAB W/ART GFT; 2 CORON ART GFT
CAB W/ART GFT; 3 CORON ART GFT
CAB W/ART GFT; 4/MORE CORON ART
GFT
MYOCARDIAL RESECT
REPR POSTINFARCT VENT SEPTAL
DEFECT
SURG VENTR RSTRJ PX W/PROSTC
PATCH PFRMD
CORON ENDARTERECT PERFMD
W/CABG-EA
CLO ATRIOVENTRIC VALVSUTURE/PATCH
33602
33606
Yes
Yes
33608
Yes
33610
Yes
Description
CLO SEMILUNAR VALV-SUTURE/PATCH
ANASTOM PULM ART TO AORTA
REPR COMPLX CARD ANOMAL NOT
ATRESIA
REPR COMPLX CARD ANOMAL-ENLARG
DEFC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33611
Yes
33612
Yes
33615
Yes
33617
Yes
33619
Yes
33641
33645
Yes
Yes
33647
Yes
33660
Yes
33665
33670
33675
33676
33677
Yes
Yes
Yes
Yes
Yes
33681
Yes
33684
Yes
33688
Yes
Description
REPR DBL OUTLET RT VENT W/TUNNL
REP
REPR DBL OUTLET RT VENT; W/REPR
OBS
REPR CARD ANOMAL-CLO DEFEC &
ANASTO
REPR CARD ANOMAL-MODIF FONTAN
PROC
REPR 1 VENT W/AORTIC OBSTRUC &
ARCH
REPR ATRIAL SEPTAL DEFECT
W/BYPASS
DIRECT/PATCH CLO-SINUS VENOSUS
REPR ATRIAL & VENT SEPTAL DEFECT
REPR INCOMPL/PART ATRIOVENT
CANAL
REPR INTERM/TRNSIT ATRIOVENT
CANAL
REPR COMPLT ATRIOVENT CANAL
CLOSE MULT VSD
CLOSE MULT VSD W/RESECTION
CL MULT VSD W/REM PUL BAND
CLO VENT SEPTAL DEFECT W/WO
PATCH;
CLO VSD W/WO PATCH; W/PULM
VALVOT
CLO VSD W/WO PATCH; W/REMOV PA
BAND
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33690
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
33692
33694
33697
Yes
Yes
Yes
33702
Yes
33710
Yes
33720
Yes
33722
33724
33726
Yes
Yes
Yes
33730
Yes
33732
Yes
33735
Yes
33736
Yes
33737
33750
33755
Description
BANDING PULM ART
COMPLT REPR TETRALOGY WO PULM
ATRES
COMPLT REPR TETRALOGY; W/PATCH
COMPLT REPR TETRALOGY FALLOT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
REPR SINUS VALSALVA FIST W/BYPASS
REPR FISTULA W/BYPASS; W/REPR
SEPTL
REPR SINUS VALSALVA ANEURY
W/BYPASS
No
CLO AORTICO-LT VENTRICULAR TUNNEL
REPAIR VENOUS ANOMALY
REPAIR PUL VENOUS STENOSIS
COMPLT REPR ANOMALOUS VENOUS
RETURN
REPR COR TRIATRIATUM/SUPRAVALV
RING
No
No
No
No
Yes
Yes
ATRIAL SEPTECT/SEPTOST; CLO HEART
ATRIAL SEPTEC/SEPTOS; OPEN HRT
W/CP
ATRIAL SEPTEC/SEPTOS; OPEN HRT
W/OC
SHUNT; SUBCLAVIAN PULM ART
No
No
Yes
SHUNT; ASCENDING AORTA PULM ART
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
33762
33764
Yes
Yes
SHUNT; DESCENDING AORTA PULM ART
SHUNT; CENTRAL W/PROSTH GFT
No
No
33766
Yes
No
33767
33768
Yes
Yes
33770
Yes
33771
Yes
33774
Yes
33775
Yes
33776
Yes
33777
Yes
33778
Yes
33779
Yes
33780
Yes
33781
33786
Yes
Yes
SHUNT; SUPER VENA CAVA-PULM ART 1
SHUNT; SUPER VENA CAVA-PULM ART
FLO
ANAST CAVOPULM 2ND SUPRIOR V/C
REPR TRNSPOSIT GRT ART; WO SURG
ENL
REPR TRNSPOSIT GRT ART; W/SURG
ENLG
REPR TRANSPOSIT GR ART W/CP
BYPASS
REPR TRANSPOSIT GR ART; W/REMOV
BND
REPR TRANSPOSIT; W/CLO SEPTAL
DEFEC
REPR TRANSPOSIT; W/REPR SUBPLUM
OBS
REPR TRANSPOSIT-AORTIC PULM
RECON
REPR TRANSPOSIT-AORTIC; W/REMOV
BND
REPR TRANSPOSIT-AORTIC; W/CLO
DEFEC
REPR TRANSPOSIT AORTIC; W/REPR
OBST
TOT REPR TRUNCUS ARTERIOSUS
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33788
Yes
33800
33802
Yes
Yes
33803
Yes
33813
Yes
33814
Yes
33820
Yes
33822
Yes
33824
Yes
33840
33845
Yes
Yes
33851
Yes
33852
Yes
33853
Yes
33860
Yes
Description
REIMPLANTATION ANOMALOUS PULM
ART
AORTIC SUSP-TRACH DECOMP (SEP
PRO)
DIVISION ABERRANT VESSEL
DIVISION ABERRANT VESS;
W/REANASTOM
OBLIT AORTOPULM DEFEC; WO CP
BYPASS
OBLIT AORTOPULM DEFECT; W/CP
BYPASS
REPR PATENT DUCTUS ARTERIOSUS;
LIG
REPR PATENT DUCT ART; DIVIS < 18 YR
REPR PATENT DUCT ART; DIVIS
18&OLDR
EXC COARCTAT AORTA; W/DIREC
ANASTOM
EXC COARCTATION AORTA; W/GFT
EXC COARCTAT AORTA; REPR W/LT
SUBCL
REPR HYPOPLST/INTER ARCH; WO CP
BYP
REPR HYPOPLASTIC AORT ARCH; W/CP
BP
ASCEND AORTA GFT W/BYPASS W/WO
VALV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33861
Yes
33863
33864
Yes
Yes
33870
Yes
33875
Yes
33877
Yes
33880
Yes
33881
Yes
33883
Yes
33884
Yes
33886
Yes
33889
33891
Yes
Yes
33910
Yes
33915
Yes
Description
ASCEND AORTA GFT W/BYPS; W/RECON
ASCEND AORTA GFT; W/AORTC ROOT
REPL
ASCENDING AORTIC GRAFT
TRANSVERSE ARCH GFT W/CP BYPASS
DESCEND THORAC AORTA GFT W/WO
BYPAS
REPR THORACOABD AORTIC ANEURY
W/GFT
EVASC RPR DTA COVERAGE ART ORIGIN
1ST ENDOPROSTH
EVASC RPR DTA EXP COVERAGE W/O
ART ORIGIN
PLMT PROX XTN PROSTH EVASC RPR
DTA 1ST XTN
PLMT PROX XTN PROSTH EVASC RPR
DTA EA PROX XTN
PLMT DSTL XTN PROSTH DLYD AFTER
EVASC RPR DTA
OPN SUBCLA CRTD ART TRPOS NCK INC
ULAT
BYP GRF W/DTA RPR NCK INC
PULM ART EMBOLECTOMY; W/CP
BYPASS
PULM ART EMBOLECTOMY; WO CP
BYPASS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
33916
Yes
33917
Yes
33920
33922
Yes
Yes
33924
Yes
33925
Yes
33926
Yes
33930
Yes
33933
33935
33940
Yes
Yes
Yes
33944
Yes
33945
Yes
33960
Yes
33961
Yes
PULM ENDARTERECTOMY W/CP BYPASS
REPR PULM ART STENOS-RECON
W/PATCH
REPR PULM ATRESIA-CONSTRUCT
CONDUIT
TRANSECT PULM ART W/CP BYPASS
LIG & TAKEDOWN SYST-PULM ART
SHUNT
RPR P-ART ARBORIZJ ANOMAL
UNIFCLIZJ W/O CARD BYP
RPR P-ART ARBORIZJ ANOMAL
UNIFCLIZJ W/CARD BYP
DONOR CARDIECTOMYPNEUMONECTOMY
BACKBENCH STD PREP CADVER DONOR
HRT/LUNG ALLOGFT
HEART-LUNG TRANSPL W/RECIPIENT
DONOR CARDIECTOMY
BACKBENCH STD PREP CADVER DONOR
HEART ALLOGFT
HEART TRANSPL W/WO RECIPIN
CARDIECT
PROLONG XTRCORPOR CIRCUL; INIT
24HR
PROLONG XTRCORPOR CIRCUL; EA ADD
24
33967
Yes
INSRT INTRA-AORTC BALLN DEVC PERQ
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
33968
Yes
33970
Yes
33971
Yes
33973
Yes
33974
Yes
Description
REMOV INTRA-AO BALLOON ASST
DEVICE
INSRT INTRA-AORTIC BALLOON-FEM
OPEN
REMOV INTRA-AORTIC DEVICE-REPR
FEM
INSRT INTRA-AORT BALOON ASSIST
DEVC
REMOV INTRA-AORT BALOON DEVIC
W/REP
33975
Yes
IMPLNT VENTRIC DEVICE; 1 VENT SUPPT
No
33976
Yes
No
33977
Yes
33978
33979
33980
33999
Yes
Yes
Yes
Yes
34001
Yes
34051
34101
34111
34151
Yes
Yes
Yes
Yes
IMPLNT VENTRIC DEVICE; BIVENT SUPPT
REMOV VENT DEVICE; 1 VENTRIC
SUPPRT
REMOV VENT DEVICE; BIVENTRIC
SUPPRT
INSRT VENT DEVC IMPL INTRACORP 1
REMV VENT DEVC IMPL INTRACORP 1
UNLISTED PROC CARDIAC SURG
EMBOLECT/THROMBEC; CAROTID ARTNECK
EMBOLECT; INNOMINATE THORACIC
INCS
EMBOLECT; AXILRY ART-ARM INCS
EMBOLECT; RADIAL ART BY ARM INCS
EMBOLECT; RENAL ART BY ABD INCS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
34201
Yes
34203
34401
34421
Yes
Yes
Yes
34451
Yes
34471
Yes
34490
34501
34502
Yes
Yes
Yes
34510
Yes
34520
34530
Yes
Yes
34800
Yes
34802
Yes
34803
Yes
34804
Yes
34805
Yes
Description
EMBOLECT; FEMPOP ART BY LEG INCS
EMBOLECT; POP-TIBIOPER ART LEG
INCS
THROMBEC; VENA CAVA BY ABD INCS
THROMBEC; VENA CAVA BY LEG INCS
THROMBEC; VENA CAVA ABD & LEG
INCS
THROMBEC; SUBCLAV VEIN NECK INCS
THROMBEC; AX & SUBCLAV BY ARM
INCS
VALVULOPLASTY FEMORAL VEIN
RECON VENA CAVA ANY METHD
VENOUS VALV TRNSPOSIT ANY VEIN
DONR
CROSS-OVER VEIN GFT TO VENOUS
SYST
SAPHENOPOPLITEAL VEIN ANASTOM
ENDOVSCLR REPR OF INFRARENAL ABD
AORTIC ANEUR OR DISSECT
ENDOVSCLR REPR USING MODULAR
BIFURCATED PROSTH
ENDOVASC REPR AAA; BIFURCAT PROS
2 DOCK LIMBS
ENDOVSCLR REPR USING UNIBODY
BIFURCATED PROSTH
ENDOVASC REP AAA; USE AORTOUNIILIAC/UNIFEM PROS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
34806
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
34808
Yes
34812
Yes
34813
Yes
34820
Yes
34825
Yes
34826
Yes
34830
34831
34832
Yes
Yes
Yes
34833
Yes
34834
No
34900
Yes
35001
Yes
35002
Yes
Description
ANEURYSM PRESS SENSOR ADD-ON
ENDOVSCLR PLACEMNT OF ILIAC
ARTERY OCCLU DEVICE
OPEN FEMORAL ARTERY EXPOSR FOR
DELIV OF AORTIC ENDOV PROSTH
PLACEMNT FEMORAL PROSTH GRAFT
DURING ENDOVSCLR REPR
OPEN ILIAC ARTERY EXPOSR FOR DEL
OF ENDOVSCLR PROSTH
PLACEMNT PROXIMAL/DISTAL EXT FOR
PROSTH ENDOVSCLR REPR
PLACEMNT PROXIMAL/DISTAL EXT-EA
ADD VESSEL
OPEN REPR OF INFRARENAL AORTIC
ANERY OR DISSECT, PLUS REPR
AORTO-BI-ILIAC PROSTHESIS
AORTO-BIFEMORAL PROSTHESIS
OPN ILIAC ART EXPS CONDUIT DEL
ENDOVSC PROS UNI
OPN BRACH ART EXPS ASST DEPLOY
ENDOVASC PROS UNI
ENDOVASCULAR GRAFT PLCMT REPAIR
ILIAC ARTERY
DIREC REPR ANEUR; CAROTID/SUBCLAV
DIREC REPR; RUPTD ANEURY-NECK
INCS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35005
Yes
35011
Yes
35013
Yes
35021
Yes
35022
Yes
35045
Yes
35081
Yes
35082
Yes
35091
Yes
35092
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
DIREC REPR; ANEURY VERTEBRAL ART
DIREC REPR; ANEURY AX-BRACH-ARM
INC
No
DIREC REPR; RUTP ANEURY AX-BRACH
DIR REPR; ANEUR INNOM/SUBCLAVTHORA
No
DIREC REPR; RUPT ANEURY INNOM ART
DIREC REPR; ANEURY RADIAL/ULNAR
ART
DIREC REPR; ANEURY/OCCLUD ABD
AORTA
No
No
Yes
DIREC REPR; RUPT ANUERY ABD AORTA
DIREC REPR; ANEURY ABD AORTA
W/VISC
DIR REPR; RUPT ANEUR ABD AORT
W/VIS
35102
Yes
DIR REPR; ANEURY ABD AORTA W/ILIAC
No
35103
35111
Yes
Yes
DIR REPR; RUPT ANEUR ABD AORT W/ILI
DIREC REPR; ANEURY SPLENIC ART
No
No
35112
Yes
DIREC REPR; RUPT ANEURY SPENIC ART
No
35121
Yes
DIREC REPR; ANEURY VISCERAL ARTS
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35122
35131
35132
Yes
Yes
Yes
35141
Yes
35142
Yes
35151
35152
Yes
Yes
35180
Yes
35182
35184
Yes
Yes
35188
Description
DIREC REPR; RUPT ANEURY HEPATIC
ART
DIREC REPR; ANEURY ILIAC ART
DIREC REPR; RUPT ANEURY ILIAC ART
DIREC REPR; ANEURY COMMON FEM
ART
DIREC REPR; RUPT ANEURY COMMON
FEM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
Yes
DIREC REPR; ANEURY/OCCLUD POP ART
DIREC REPR; RUPT ANEURY POP ART
REPR CONGEN AV FISTULA; HEAD &
NECK
REPR CONGEN AV FISTULA; THORX &
ABD
REPR CONGEN AV FISTULA; EXTREM
REPR ACQUIR AV FISTULA; HEAD &
NECK
35189
Yes
REPR ACQUIR AV FIST; THORAX & ABD
No
35190
35201
Yes
Yes
No
No
35206
Yes
35207
Yes
35211
Yes
REPR ACQUIRED AV FISTULA; EXTREM
REPR BLD VESSEL DIRECT; NECK
REPR BLD VESSEL DIRECT; UPPR
EXTREM
REPR BLD VESSEL DIRECT; HANDFINGER
REPR VESS DIR; INTRATHORAC
W/BYPASS
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35216
Yes
35221
Yes
35226
35231
Yes
Yes
35236
Yes
35241
Yes
35246
Yes
35251
Yes
35256
Yes
35261
Yes
35266
Yes
35271
Yes
35276
Yes
35281
Yes
35286
Yes
Description
REPR VESS DIR; INTRATHORAC WO
BYPAS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
REPR BLD VESSEL DIRECT; INTRA-ABD
REPR BLD VESSEL DIRECT; LOWR
EXTREM
REPR BLD VESSEL W/VEIN GFT; NECK
REPR BLD VESS W/VEIN GFT; UP
EXTREM
REPR VESS W/GFT; INTRATHORAC
W/BYPS
REPR VESS W/GFT; INTRATHOR WO
BYPAS
No
REPR BLD VESS W/VEIN GFT; INTRA-ABD
REPR VESS W/VEIN GFT; LOWER
EXTREM
No
REPR BLD VESS W/GFT NOT VEIN; NECK
REPR VESS W/GFT NOT VEIN; UP
EXTREM
REPR VESS W/GFT NOT VEIN;INTRATH
W/
REPR VESS W/GFT NOT VEIN;INTRATH
WO
REPR VESS W/GFT NOT VEIN; INTRAABD
REPR VESS W/GFT NOT VEIN; LOWR
EXTM
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35301
35302
35303
35304
35305
35306
Yes
Yes
Yes
Yes
Yes
Yes
35311
Yes
35321
Yes
35331
Yes
35341
Yes
35351
Yes
35355
Yes
35361
Yes
35363
Yes
35371
Yes
35372
Yes
35381
Yes
Description
THROMBOENDARTEREC; CAROTID-NECK
INC
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
THROMBOENDART; SUBCLAV-THORAC
INCS
THROMBOENDARTERECT; AXILRYBRACHIAL
THROMBOENDARTERECTOMY; ABD
AORTA
THROMBOENDART;
MESENTERIC/CELIAC
THROMBOENDARTERECT W/WO GFT;
ILIAC
THROMBOENDARTERECT; ILIOFEMORAL
THROMBOENDARTEREC; COMBO
AORTOILIAC
THROMBOENDARTER; COMBO
AORTOILIOFEM
THROMBOENDARTERECT; COMMON
FEMORAL
THROMBOENDARTERECT; DEEP
FEMORAL
THROMBOENDART; FEM &/OR
TIBIOPERON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35390
Yes
35400
Yes
35450
Yes
35452
Yes
35454
Yes
35456
Yes
35458
Yes
35459
Yes
35460
Yes
35470
Yes
35471
Yes
35472
Yes
35473
Yes
35474
Yes
Description
REOPER CAROTID THROMBOENDARTER
>1MO
ANGIOSCOPY DURING THERAP
INTERVENTN
TRNSLM BALOON ANGIOP OPEN; RENL
ART
TRNSLUMNL BALOON ANGIOPL OPEN;
AORT
TRNSLUMN BALOON ANGIOPL OPEN;
ILIAC
TRNSLUM BALLOON ANGPLS OPEN;
FEMPOP
TRNSLM ANGPLS-OPEN;
BRACHCEPH/BRNCH
TRNSLM BALOON ANGIPL OPEN;
TIBIOPER
TRNSLUM BALOON ANGIOPL OPEN;
VENOUS
TRNSLM ANGPLST-PERC;
TIBPERON/BRNCH
TRNSLUMNL ANGIOPL PERCUT; RENAL
ART
TRNSLUM BALOON ANGIO PERCUT;
AORTIC
TRNSLUM BALLOON ANGIOPERCUT;
ILIAC
TRNSLUMINAL ANGIOPL PERCUT; FEMPOP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35475
Yes
35476
Yes
35480
Yes
35481
Yes
35482
Yes
35483
Yes
35484
Yes
35485
Yes
35490
Yes
35491
Yes
35492
Yes
35493
Yes
35494
Yes
35495
Yes
Description
TRNSLM ANGPLST-PERC;
BRACHCEP/BRNCH
TRNSLUM BALOON ANGIO PERCUT;
VENOUS
TRNSLUM PERIPH ATHERECT OPEN;
RENAL
TRNSLUM PERIPH ATHEREC OPEN;
AORTIC
TRNSLUM PERIPH ATHERECT OPEN;
ILIAC
TRNSLUM PERIPH ATHEREC OPEN;
FEMPOP
TRNSLM ATHREC-OPEN;
BRACHCEPH/BRNCH
TRNSLM PERIPH ATHEREC OPEN; TIBPER
TRNSLUM PERIPH ATHEREC PERCU;
RENAL
TRNSLUM PERIPH ATHEREC PERQ;
AORTIC
TRNSLUM PERIPH ATHEREC PERCU;
ILIAC
TRNSLM PERIPH ATHEREC PERQ; FEMPOP
TRNSLM ATHEREC-PERC;
BRACHCEP/BRNCH
TRNSLUM PERIPH ATHEREC PERQ;
TIBPER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
35500
35501
Yes
Yes
35506
Yes
35507
Yes
Description
HARVST UP EXTREM VEIN-LEXTREM/CABG
BYPASS GFT W/VEIN; CAROTID
BYPASS GFT W/VEIN; CAROTIDSUBCLAV
BYPASS GFT W/VEIN; SUBCLAVCAROTID
35508
Yes
BYPASS GFT W/VEIN; CAROTID-VERTEB
No
35509
Yes
No
35510
Yes
35511
Yes
35512
Yes
BYPASS GFT W/VEIN; CAROTID-CAROTID
BYPASS GRAFT WITH VEIN; CAROTIDBRACHIAL
BYPASS GFT W/VEIN; SUBCLAVSUBCLAV
BYPASS GRAFT WITH VEIN; SUBCLAVIANBRACHIAL
35515
Yes
BYPASS GFT W/VEIN; SUBCLAV-VERTEB
No
35516
35518
Yes
Yes
BYPASS GFT W/VEIN; SUBCLAV-AXILRY
BYPASS GFT W/VEIN; AXILRY-AXILRY
No
No
35521
Yes
No
35522
35523
Yes
Yes
35525
Yes
BYPASS GFT W/VEIN; AXILRY-FEMORAL
BYPASS GRAFT WITH VEIN; AXILLARYBRACHIAL
ARTERY BYPASS GRAFT
BYPASS GRAFT WITH VEIN; BRACHIALBRACHIAL
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
35526
35531
Yes
Yes
Description
BYPASS GFT W/VEIN;
AORTOSUBCLAVIAN
BYPASS GFT W/VEIN; AORTOCELIAC
35533
35536
35537
35538
35539
35540
35541
Yes
Yes
Yes
Yes
Yes
Yes
Yes
BYPASS GFT W/VEIN; AXILRY-FEM-FEM
BYPASS GFT W/VEIN; SPLENORENAL
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
BYPASS GFT W/VEIN; AOILIAC/BI-ILIAC
No
No
No
No
No
No
No
35546
Yes
No
35548
Yes
BYPASS GFT W/VEIN; AORTOFEM/BIFEM
BYPASS GFT W/VEIN; AORTOILIOFEM
UNI
35549
Yes
35551
35556
Yes
Yes
35558
35560
35563
35565
35566
35571
No
No
No
Yes
Yes
Yes
Yes
BYPASS GFT W/VEIN; AORTOILIOFEM BIL
BYPASS GFT W/VEIN; AORTOFEMORALPOP
BYPASS GFT W/VEIN; FEMORAL-POP
BYPASS GFT W/VEIN; FEMORALFEMORAL
BYPASS GFT W/VEIN; AORTORENAL
BYPASS GFT W/VEIN; ILIOILIAC
BYPASS GFT W/VEIN; ILIOFEMORAL
No
No
No
No
No
Yes
Yes
BYPASS GFT W/VEIN; FEM-ANT TIB/DIST
BYPASS GFT W/VEIN; POP-TIB/DISTAL
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35572
35583
35585
Yes
Yes
Yes
35587
Yes
35600
35601
Yes
Yes
35606
Yes
35612
Yes
35616
Yes
35621
35623
Yes
Yes
IN-SITU VEIN BYPASS; POP-TIB/PERONL
HARVEST OF UPPER EXTREMITY
ARTERY FOR BYPASS PROC
BYPASS GFT NOT VEIN; CAROTID
BYPASS GFT NOT VEIN; CAROTIDSUBCLA
BYPASS GFT NOT VEIN; SUBCLAVSUBCLA
BYPASS GFT NOT VEIN; SUBCLAVAXILRY
BYPASS GFT NOT VEIN; AXILRYFEMORAL
BYPASS GFT NOT VEIN; AX-POP/-TIB
35626
Yes
BYPASS GFT NOT VEIN; AORTOSUBCLAV
No
35631
Yes
BYPASS GFT NOT VEIN; AORTOCELIAC
No
35636
35637
35638
35641
Yes
Yes
Yes
Yes
No
No
No
No
35642
Yes
BYPASS GFT NOT VEIN; SPLENORENAL
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
BYPASS GFT NOT VN; AOILIAC/BI-ILIAC
BYPASS GFT NOT VEIN; CAROTIDVERTEB
Description
HARVEST FEMPOP VEIN 1 SEGMENT
VASC RECNSTR PROC
IN-SITU VEIN BYPASS; FEMORAL-POP
IN-SITU VEIN BYPASS; FEM-ANT TIB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
35645
Yes
35646
Yes
35647
Yes
Description
BYPASS GFT NOT VEIN; SUBCLAVVERTEB
BYPASS GFT NOT VEIN;
AORTOFEB/BIFEM
BYPS GFT W/OTH THAN VEIN;
AORTOFEM
35650
Yes
BYPASS GFT NOT VEIN; AXILRY-AXILRY
No
35651
Yes
No
35654
Yes
BYPASS GFT NOT VEIN; AORTOFEM-POP
BYPASS GFT NOT VEIN; AXILRY-FEMFEM
35656
Yes
35661
35663
35665
35666
No
No
No
No
Yes
Yes
Yes
Yes
BYPASS GFT NOT VEIN; FEMORAL-POP
BYPASS GFT NOT VEIN; FEMORALFEMORL
BYPASS GFT NOT VEIN; ILIOILIAC
BYPASS GFT NOT VEIN; ILIOFEMORAL
BYPASS GFT NOT VEIN; FEM-ANT-TIB
No
No
No
No
35671
Yes
BYPASS GFT NOT VEIN; POP-TIB/-PERON
No
35681
Yes
No
35682
Yes
BYPASS GFT; COMPOSITE PROSTH VEIN
BYPASS GFT; AUTOG-2 SEGMT 2
LOCATNS
35683
Yes
35685
Yes
BYPASS GFT; AUTOG-3/> SEGMT 2/> LOC
PLCMT VEIN PATCH@DIST ANASTOM
GFT
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
35686
Yes
35691
Yes
35693
Yes
35694
Yes
35695
Yes
35697
Yes
35700
Yes
35701
Yes
35721
35741
Yes
Yes
35761
Yes
35800
Yes
35820
Yes
35840
Yes
35860
Yes
Description
CREAT DIST AV FIST DUR LW EXTRM
BYP
TRANSPOSIT/REIMPLNT; VERTEBCAROTID
TRANSPOSIT/REIMPLNT; VERTEBSUBCLAV
TRANSPOSIT/REIMPLNT; SUBCLAVCAROTD
TRANSPOSIT/REIMPLNT; CAROTIDSUBCLV
REIMPL VISCERAL ART INFRARENL
AORTC PROS EA ART
REOPER FEM-POP > 1 MO AFTER ORIG
OR
EXPLOR W/WO LYSIS ART; CAROTID ART
EXPLOR W/WO LYSIS ART; FEMORAL
ART
EXPLOR W/WO LYSIS ART; POP ART
EXPLOR W/WO LYSIS ART; OTHER
VESSEL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
EXPLOR POSTOP HEMORR/INFEC; NECK
EXPLOR POSTOP HEMORR/INFEC;
CHEST
No
EXPLOR POSTOP HEMORR/INFEC; ABD
EXPLOR POSTOP HEMORR/INFEC;
EXTREM
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35870
35875
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
35876
Yes
35879
Yes
35881
35883
35884
35901
35903
35905
35907
36000
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
36002
36005
No
No
36010
No
36011
No
36012
No
REVIS LO EXTR ART BYPASS; W/PATCH
REVIS LO EXTR ART BYPAS;
W/INTERPOS
REVISE GRAFT W/NONAUTO GRAFT
REVISE GRAFT W/VEIN
EXC INFEC GFT; NECK
EXC INFEC GFT; EXTREM
EXC INFEC GFT; THORAX
EXC INFEC GFT; ABD
INTRO NEEDLE/INTRACATHETER VEIN
INJ PROC PERQ TX EXTREM
PSEUDOANEUR
INJ PROC CONTRAST VENOGRAPHY
INTRO CATH SUPER/INFERIOR VENA
CAVA
SELECT CATH PLCMT VENOUS; 1ST
ORDER
SELECT CATH PLCMT VENOUS; 2ND
ORDER
36013
No
INTRO CATH RT HEART/MAIN PULM ART
No
36014
No
SELECT CATH PLCMT LT/RT PULM ART
No
Description
REPR GFT-ENTERIC FISTULA
THROMBECTOMY ART/VENOUS GFT;
THROMBECT ART/VENOUS GFT;
W/REVIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
36015
No
36100
No
36120
No
36140
No
36145
No
36160
36200
No
No
36215
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
SELECT CATH PLCMT SEGMT PLUM ART
INTRO NEEDLE/INTRACATH CAROTID
ART
INTRO NEEDLE; RETROGRADE
BRACHIAL
INTRO NEEDLE/INTRACATH; EXTREM
ART
INTRO NEEDLE; AV SHUNT CREATED
DIAL
No
No
No
No
INTRO NEEDLE/AORTIC TRANSLUMBAR
INTRO CATH AORTA
SELECT CATH PLCMT ART; EA 1ST
ORDER
36216
No
SELECT CATH PLCMT ART; INIT 2ND ORD
No
36217
No
No
36218
No
SELECT CATH PLCMT ART; INIT 3RD ORD
SELEC CATH PLCMT ART; ADD 2ND &
3RD
36245
No
SELECT CATH PLCMT ART; EA 1ST ABD
No
36246
No
SELECT CATH PLCMT ART; INIT 2ND ABD
No
36247
No
SELECT CATH PLCMT ART; INIT 3RD ABD
No
36248
No
SELECT CATH PLCMT; 2ND & 3RD ABD
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
36260
No
INSRT IMPLNT INTRA-ART INFUSN PUMP
No
36261
No
No
36262
36299
No
Yes
36400
No
36405
No
36406
No
36410
No
36415
No
36416
36420
36425
No
No
No
REVIS IMPLNT INTRA-ART INFUSN PUMP
REMOV IMPLNT INTRA-ART INFUSN
PUMP
UNLISTED PROC VASCULAR INJ
VENIPUNCTURE UNDER AGE 3 YEARS;
FEMORAL/JUGULAR
VENIPUNCTURE UNDER AGE 3 YEARS;
SCALP VEIN
VENIPUNCTURE UNDER AGE 3 YEARS;
OTHER VEIN
VENIPUNCT AGE 3 YR MD SKILL-SEP
PROC NOT ROUTINE
ROUTINE VENIPUNCT/FINGER/HEEL
STICK
COLLECTION OF CAPILLARY BLOOD
SPECIMAN
VENIPUNCT CUTDOWN; < 1 YR
VENIPUNCT CUTDOWN; AGE 1/OVER
36430
36440
36450
No
No
No
36455
36460
36468
No
Yes
Not reimbursable
TRANSFUSION BLD/BLD COMPONENTS
PUSH TRANSFUSION BLD 2 YR/UNDER
EXCHG TRANSFUSION BLD; NB
EXCHG TRNSFUSION BLD; OTHER THAN
NB
TRANSFUSION INTRAUTERINE FETAL
SNGL/MX INJ SCLEROS-VEINS; LIMB
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
36469
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not reimbursable
36470
36471
Not reimbursable
Not reimbursable
36475
Not reimbursable
36476
Not reimbursable
36478
Not reimbursable
36479
Not reimbursable
36481
Yes
36500
36510
No
No
36511
No
36512
No
36513
No
36514
No
36515
No
36516
No
Description
SNGL/MX INJ SCLEROS-VEINS; FACE
INJ SCLEROSING SOLUTION; SNGL VEIN
INJ SCLEROS SOLUT; MX VEINS 1 LEG
ENDOVENUS ABLAT TX INCOMPETENT
VEIN EXT RF; 1 VN
ENDOVEN ABLAT TX VEIN EXT RF;
2&>VNS 1 EXT EA
ENDOVEN ABLAT TX INCMPETNT VEIN
EXT LASR;1 VEIN
ENDOVEN ABLAT TX VEIN EXT LASR;
2&>VNS 1 EXT EA
PERCUT PORTAL VEIN CATH-ANY
METHD
VENOUS CATH SELECT ORGAN BLD
SAMPL
CATH UMBILICAL VEIN DX/THERAP NB
THERAPEUTIC APHERESIS; FOR WHITE
BLOOD CELLS
THERAPEUTIC APHERESIS; FOR RED
BLOOD CELLS
THERAPEUTIC APHERESIS; FOR
PLATELETS
THERAPEUTIC APHERESIS; FOR PLASMA
PHERESIS
TX APHERES; W/XTRACORP
IMMUOADSORPT&PLAS REINFUS
TX APHERES; W/XTRACORP
ADSORPT/FILTRAT& REINFUS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
36522
36540
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
36550
No
36555
No
36556
No
36557
No
36558
No
36560
No
36561
No
36563
Yes
36565
Yes
36566
Yes
36568
No
36569
No
36570
No
Description
PHOTOPHERESIS EXTRACORPOREAL
COLLECTION OF BLOOD SPECIMAN
DECLOT-LYTIC-IMPLNT VASC ACCESS
DEV
INSRTION NON-TUNNLD CNTRLLY INSRT
CVC; <5 YR AGE
INSRTION NON-TUNNLD CNTRLLY INSRT
CVC; AGE 5/>
INSRT TUNNLD CNTRLLY CVC NO
SUBQPORT/PUMP; <5 YR
INSRT TUNNLD CNTRLLY CVC NO
SUBQPORT/PUMP;5 YR/>
INSRT TUNNLD CNTRLLY INSRT CVAD
SUBQ PORT; <5 YR
INSRT TUNNLD CNTRLLY INSRT CVAD
SUBQ PORT;5 YR/>
INSRT TUNNLD CNTRLLY CV ACSS DEVC
W/SUBQ PUMP
INSRT TUNNL CNTRL CVAD 2 CATH-2
SITE; W/O PORT
INSRT TUNNL CNTRL CVAD 2 CATH VIA 2
SITE; W/PORT
INSERTION PICC W/O SUBQ PORT/PUMP;
< 5 YR AGE
INSERTION PICC W/O SUBQ PORT/PUMP;
AGE 5 YR/>
INSERTION PERIPHLY INSRT CVAD
W/SUBQ PORT; <5 YR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
36571
No
36575
No
36576
No
36578
No
36580
No
36581
No
36582
Yes
36583
Yes
36584
No
36585
Yes
36589
No
36590
36591
36592
36593
No
No
No
No
36595
No
Description
INSERTION PERIPHLY INSRT CVAD SUBQ
PORT; 5 YR/>
REP CV ACSS CATH NO SUBQ
PORT/PUMP CNTRL/PERIPH
REP CVAD SUBQ PORT/PUMP
CNTRL/PERIPH INSRT SITE
REPL CATH ONLY CVAD SUBQ
PORT/PUMP CNTRL/PERIPH
REPL CMPL NON-TUNNLD CNTRL CVC
NO SUBQ PORT/PUMP
REPL CMPL TUNNLD CNTRLLY CVC W/O
SUBQ PORT/PUMP
REPL CMPL TUNNLD CNTRLLY INSRT
CVAD W/SUBQ PORT
REPL CMPL TUNNLD CNTRLLY INSRT
CVAD W/SUBQ PUMP
REPL CMPL PICC NO SUBQ PORT/PUMP
THRU SAME ACSS
REPL CMPL PERIPHLY INSRT CVAD
W/SUBQ PORT
REMOVAL TUNNELED CVC WITHOUT
SUBQ PORT/PUMP
REMV TUNNLD CVAD W/SUBQ
PORT/PUMP CNTRL/PERIPH
DRAW BLOOD OFF VENOUS DEVICE
COLLECT BLOOD FROM PICC
DECLOT VASCULAR DEVICE
MECH REMV PERICATH OBST MATL CV
DEVC SEP ACSS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
36596
No
36597
No
36598
36600
36620
36625
No
No
No
No
36640
36660
No
No
36680
No
Description
MECH REMV INTRALUMNL OBST MATL
CV DEVC THRU LUMN
REPSTN PREVIOUSLY PLCD CVC UNDER
FLUORO GUID
CNTRST NJX RAD EVAL CTR VAD FLUOR
IMG&REPRT
ART PUNCT WITHDRAWAL BLD DX
ART CATH-SAMPL (SEP PRO); PERQ
ART CATH-SAMPL (SEP PRO); CUTDN
ART CATH PROLONG INFUS THERAP
CUTDN
CATH UMBILICAL ART-NB-DX/THERAP
PLCMT NEEDLE INTRAOSSEOUS
INFUSION
36800
36810
Yes
Yes
INSRT CANNULA (SEP PROC); VEIN-VEIN
INSRT CANNULA (SEP PROC); AV-EXT
No
No
36815
Yes
No
36818
Yes
36819
Yes
36820
Yes
36821
Yes
INSRT CANNULA (SEP PRO); AV-REV/CLO
AV ANASTOM OPEN; UP ARM CEPHALIC
VEIN TRNSPSTN
AV ANASTOMOSIS; BASILIC VEIN
TRNSPO
INSERTION OF CANNULA FOR
HEMODIALYSIS, OTHER PURPOSE;
ARTERI
ARTERIOVENOUS ANASTOMOSIS-OP;
DIREC
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
36822
Yes
36823
36825
Yes
Yes
36830
Yes
36831
36832
Description
INSRT CANNULA PROLNG EXTRACORP
(SP)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
Yes
INSRT ART & VEN CANNULA(S)-EXTREM
CREATE AV FISTULA (SP); AUTOG GFT
CREATE AV FISTUL (SP); NONAUTOG
GFT
THROMBECT AV FIST WO REVIS-DIAL
GFT
REVIS-AV FIST DIALYSIS GFT (SP)
36833
Yes
REVIS AV FIST; W/THROMBECT-DIAL GFT
No
36834
Yes
PLASTIC REPR AV ANEURY (SEP PROC)
No
36835
Yes
No
36838
Yes
INSRT THOMAS SHUNT (SEPART PROC)
DIST REVASC&INTRVL LIG UPPER
EXTREM HD ACSS
36860
36861
Yes
Yes
36870
37140
37145
Yes
Yes
Yes
37160
Yes
37180
Yes
EXT CANNULA DECLOT (SP); WO CATH
EXT CANNULA DECLOT (SP); W/CATH
THROMBECTOMY, PERCUTANEOUS,
ARTERIOVENOUS FISTULA
VENOUS ANASTOM; PORTOCAVAL
VENOUS ANASTOM; RENOPORTAL
VENOUS ANASTOM; CAVALMESENTERIC
VENOUS ANASTOM; SPLENORENAL
PROX
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
37181
Yes
37182
Yes
37183
Yes
37184
No
37185
37186
37187
No
No
No
37188
No
37195
37200
Yes
Yes
37201
Yes
37202
Description
VENOUS ANASTOM; SPLENORENAL
DISTAL
INSRTION TRANSVENOUS INTRAHEP
PORTOSYS SHNT-TIPS
REV TRANSVENOUS INTRAHEP
PORTOSYS SHUNT-TIPS
PRIM PRQ TRLUML MCHNL THRMBC 1ST
VSL
PRIM PRQ TRLUML MCHNL THRMBC
SBSQ VSL
SEC PRQ TRLUML THRMBC
PRQ TRLUML MCHNL THRMBC VEIN
PRQ TRLUML MCHNL THRMBC VEIN
REPEAT TX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
THROMBOLYSIS CEREBRAL BY IV INFUS
TRANSCATH BX
TRANSCATH THERAP INFUSTHROMBOLYSIS
TRANSCATH THERAP INFUS-NOT
THROMBOL
37203
Yes
TRANSCATH RETRIEVAL PERCUT-IV FB
No
37204
Yes
No
37205
Yes
37206
Yes
TRANSCATH OCCLUD-PERCUT-NON CNS
TRANSCATH PLCMT INTRAVASC STENT
PERQ; INIT VES
TRANSCATH PLCMT INTRAVASC STENT
PERQ; EA ADD VES
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
37207
Yes
37208
Yes
37209
37210
Yes
Yes
37215
Yes
37216
37250
37251
Yes
Yes
Yes
37500
Yes
37501
37565
37600
37605
Yes
Yes
Yes
Yes
37606
Yes
37607
37609
37615
37616
37617
37618
Yes
Yes
Yes
Yes
Yes
Yes
Description
TRANSCATH PLCMT IV STENT OPEN; INIT
TRNSCTH PLCMT IV STENT OPEN; EA
ADD
EXCHG PREV PLCD ART CATH DUR
THERAP
EMBOLIZATION UTERINE FIBROID
TRNSCATH PLCMT IVASC STNT; DIST
EMBOLIC PROTECT
TRNSCATH PLCMT IVASC STNT;NO DIST
EMBOLIC PROTCT
VASC US (NON-CORN) DUR DX/TX; INIT
VASC US (NON-CORN) DX/TX; EA ADD
PHLEBORRHAPHY, SUTURE OF MAJOR
VEIN, WOUND OR INJURY
UNLISTED VASCULAR ENDOSCOPY
PROCEDURE
LIG INT JUGULAR VEIN
LIG; EXT CAROTID ART
LIG; INT/COMMON CAROTID ART
LIG; INT CAROTID ART W/GRADUAL
OCCL
LIG/BANDING ANGIO ACCESS AV
FISTULA
LIG/BX TEMPORAL ART
LIG MAJOR ART; NECK
LIG MAJOR ART; CHEST
LIG MAJOR ART; ABD
LIG MAJOR ART; EXTREM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
37620
37650
37660
Yes
Yes
Yes
37700
Yes
37718
Yes
37722
Yes
Description
INTERRUPT PART/COMPLT-INFER VENA
CA
LIG FEMORAL VEIN
LIG COMMON ILIAC VEIN
LIG LONG SAPHENOUS VEIN @
SAPHENOFE
LIG DIV&STRIPPING SHORT SAPHENOUS
VEIN
LIG DIV&STRIP LONG SAPH SAPHFEM
JUNCT KNE/BELW
37735
Yes
LIG & STRIP LNG/SHRT SAPHEN W/EXC
No
37760
Yes
No
37765
Not Reimbursable
37766
Not Reimbursable
LIG PERFORATORS-RADICAL W/WO GFT
STAB PHLEBECT VARICOS VNS 1 EXT; 1020 STAB INCI
STAB PHLEBECT VARICOSE VNS 1
EXTREM; > 20 INCI
37780
Yes
37785
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Yes
LIG SHORT SAPHENOUS VEIN (SEP PRO)
LIGATION DIV &/ EXC VARICOSE VEIN
CLUSTER 1 LEG
No
No
37788
37790
37799
38100
Yes
Yes
Yes
Yes
PENILE REVASCULARIZ ART W/WO GFT
PENILE VENOUS OCCLUD PROC
UNLISTED PROC VASCULAR SURG
SPLENECTOMY; TOT (SEPART PROC)
No
No
No
No
38101
Yes
SPLENECTOMY; PART (SEPART PROC)
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
38102
No
38115
38120
38129
38200
Yes
Yes
Yes
No
38204
Bundled
38205
No
38206
No
38207
Yes
38208
Yes
38209
Yes
38210
Yes
38211
Yes
38212
38213
Yes
Yes
38214
Yes
Description
SPLENECTOMY; TOT EN BLOC W/OTH
PROC
REPR RUPT SPLEEN W/WO PART
SPLENECT
LAP SURG-SPLENECTOMY
UNLISTED LAP PROC-SPLEEN
INJ PROC SPLENOPORTOGRAPHY
MGMT RECIP HEM PROGNATOR CELLS
DONR SEARCH&ACQN
BLD-DERIV HEM PROGNATR CELL HARV
TPLNT; ALLOGNIC
BLD-DERIV HEM PROGNATOR CELL
HARV TPLNT; AUTOL
TPLNT PREP HEM PROGNATOR CELLS;
CRYOPRES&STOR
TPLNT PREP HEM PROGNTR CELL;
THAW HARV W/O WASH
TPLNT PREP HEMATOPOIET PROGNTOR
CELLS; THAW-WASH
TPLNT PREP HEM PROGNTR CELL;
DEPLET HARV T-CELL
TPLNT PREP HEM PROGNTOR CELLS;
TUMR CELL DEPLET
TPLNT PREP HEMATOPOIET PROGNTOR
CELLS; RBC REMV
PLATELET DEPLETION
TPLNT PREP HEMATOPOIET PROGNTR
CELL; PLAS DEPLET
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Bundled
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
38215
38220
Yes
No
38221
No
38230
Yes
38240
Yes
38241
Yes
38242
Yes
38300
Yes
38305
Yes
38308
Yes
38380
Yes
38381
Yes
38382
Yes
38500
No
38505
Yes
Description
TPLNT PREP HEM PROGNATOR CELLS;
CELL CONC PLAS
BONE MARROW ASPIRATION
BONE MARROW BIOPSY NEEDLE OR
TROCAR
BONE MARROW HARVESTING TRANSPL
BONE MARROW/STEM CELL TRANSPL;
ALLO
BONE MARROW/STEM CELL TRANSPL;
AUTO
BN MARROW/BLD-DERIV STEM CELL
TPLNT; ALLOGN DONR
DRAINAGE LYMPH NODE ABSCESS;
SIMPL
DRAINAGE LYMPH NODE ABSCESS;
EXTEN
LYMPHANGIOTOMY ON LYMPHATIC
CHANNEL
SUTURE THORACIC DUCT; CERV
APPROACH
SUTURE THORACIC DUCT; THORACIC
APPR
SUTURE THORACIC DUCT; ABD
APPROACH
BX/EXC LYMPH NODE; SUPERF (SEP
PRO)
BX/EXC LYMPH NODE; BY NEEDLE
SUPERF
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
38510
Yes
38520
Yes
38525
Yes
38530
38542
Yes
Yes
38550
Yes
38555
Yes
38562
Yes
38564
Yes
38570
Yes
38571
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
BX/EXC LYMPH NODE; DEEP CERV NODE
BX/EXC LYMPH NODE; DEEP CERV
W/EXC
BX/EXC LYMPH NODE; DEEP AXILRY
NODE
BX LYMPH NODE; INT MAMMARY (SEP
PRO
DISSECTION DEEP JUGULAR NODE
EXC CYST HYGROMA AX/CERV; WO
DISSEC
EXC CYST HYGROMA AX/CERV;
W/DISSEC
No
No
Yes
LTD LYMPHADENECT (SEP PRO); PELVIC
LTD LYMPHADENEC (SEP PRO);
RETROPER
LAP SURG; W/RETRO LYMPH NODE
SAMP
LAP SURG; W/BIL TOT PELV
LYMPHECTMY
No
38572
Yes
LAP SURG; PELV LYMPHEC-NODE SAMP
No
38589
38700
Yes
Yes
UNLISTED LAP PROC-LYMPHATIC SYST
SUPRAHYOID LYMPHADENECTOMY
No
No
38720
Yes
CERV LYMPHADENECTOMY (COMPLETE)
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
38724
38740
Yes
Yes
38745
Yes
38746
38747
Yes
Yes
38760
Yes
38765
Yes
38770
Yes
38780
38790
38792
38794
Yes
No
No
No
38999
Yes
39000
Yes
39010
39200
39220
39400
39499
Yes
Yes
Yes
Yes
Yes
Description
CERV LYMPHADENECTOMY (MOD RAD
NECK)
AXILRY LYMPHADENECTOMY; SUPERF
AXILRY LYMPHADENECTOMY; COMPLT
THORACIC LYMPHADENECTOMY
REGIONAL
ABD LYMPHADENECTOMY REGIONAL
INGUINOFEM LYMPHADENECT (SEP
PRO)
INGUINFEM/PELV LYMPHADNEC (SEP
PRO)
PELVIC LYMPHADNECT W/ILIAC (SEP
PRO
RETROPERIT TRANSABD LYMPH (SEP
PRO)
INJ PROC; LYMPHANGIOGRAPHY
INJ PROC; ID SENTINEL NODE
CANNULATION THORACIC DUCT
UNLISTED PROC HEMIC/LYMPHATIC
SYST
MEDIASTINOT W/EXPLOR/DRAIN/BX;
CERV
MEDIASTINOT W/EXPLOR/BX;
TRANSTHORA
EXC MEDIASTINAL CYST
EXC MEDIASTINAL TUMOR
MEDIASTINOSCOPY W/WO BX
UNLISTED PROC MEDIASTINUM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
39501
Yes
39502
Yes
39503
Yes
39520
Yes
39530
Yes
39531
Yes
39540
Yes
39541
Description
REPR LACERAT DIAPHRAGM ANY
APPROACH
REPR PARAESOPHAGEAL HIATUS
HERNIA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
REPR NEONAT DIAPHRAGMATIC HERNIA
REPR DIAPHRAGM HERNIA;
TRANSTHORAC
REPR DIAPHRAGM HERNIA;
THORACOABD
REPR DIAPHRAGM HERNIA; THORA-ABD
W/
REPR DIAPHRAGM HERNIA-TRAUMA;
ACUTE
REPR DIAPHRAGM HERNIA-TRAUMA;
CHRON
39545
39560
Yes
Yes
IMBRICAT DIAPHRAGM; PARALYTIC/NON
RESECT DIAPHRAGM; W/SIMP REPR
No
No
39561
39599
40490
Yes
Yes
Yes
No
No
No
40500
Yes
40510
40520
40525
Yes
Yes
Yes
RESECT DIAPHRAGM; W/COMPLX REPR
UNLISTED PROC DIAPHRAGM
BX LIP
VERMILIONECTOMY W/MUCOS
ADVANCEMENT
EXC LIP; TRANSVERSE WEDGE EXC
W/CLO
EXC LIP; V-EXC W/PRIM LINEAR CLO
EXC LIP; FULL THICK RECON W/FLAP
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
40527
40530
Yes
Yes
EXC LIP; FULL THICK RECON W/LIP FLP
RESECT LIP > 1/4 WO RECON
No
No
40650
Yes
REPR LIP FULL THICK; VERMILION ONLY
No
40652
40654
Yes
Yes
REPR LIP FULL THICK; TO HALF VERTIC
REPR LIP FULL THICK; > 1/2 VERTICAL
No
No
40700
Yes
PLASTIC REPR CLEFT LIP; PRIM UNILAT
No
40701
40702
40720
40761
40799
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
40800
Yes
40801
40804
Yes
Yes
40805
40806
40808
Yes
No
Yes
PLASTIC REPR CLEFT LIP; BILAT-1 STG
PLASTIC REPR CLEFT LIP; 1 OF 2 STG
PLASTIC REPR CLEFT LIP; SECNDRY
PLASTIC REPR CLEFT LIP; W/PEDICLE
UNLISTED PROC LIPS
DRAIN ABSCESS VESTIBULE MOUTH;
SIMP
DRAIN ABSCESS VESTIBULE MOUTH;
COMP
REMOV EMBEDDED FB MOUTH; SIMPL
REMOV EMBEDDED FB MOUTH;
COMPLIC
INCS LABIAL FRENUM
BX VESTIBULE MOUTH
No
No
No
40810
40812
40814
Yes
Yes
Yes
EXC LES-VESTIBULE MOUTH; WO REPR
EXC LES-MOUTH; W/SIMPL REPR
EXC LES-MOUTH; W/COMPLX REPR
No
No
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
40816
Yes
40818
40819
Yes
Yes
40820
Yes
Description
EXC LES-MOUTH; COMPLX W/EXC
MUSCL
EXC MUCOS VESTIBULE MOUTH-DONOR
GFT
EXC FRENUM LABIAL/BUCCAL
DESTRCT LES VESTIBULE MOUTHPHYSICL
40830
Yes
CLO LACERATION MOUTH; 2.5 CM/LESS
No
40831
40840
40842
40843
40844
40845
40899
41000
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
CLO LACERATION MOUTH; > 2.5/COMPLX
VESTIBULOPLASTY; ANT
VESTIBULOPLASTY; POST UNILAT
VESTIBULOPLASTY; POST BILAT
VESTIBULOPLASTY; ENTIRE ARCH
VESTIBULOPLASTY; COMPLX
UNLISTED PROC VESTIBULE MOUTH
INTRAORAL I&D ABSCESS; LINGUAL
No
No
No
No
No
No
No
No
41005
41006
No
Yes
INTRAORAL I&D ABSCESS; SUBLINGUAL
INTRAORAL I&D; SUPRAMYLOHYOID
No
No
41007
Yes
No
41008
41009
41010
Yes
Yes
Yes
INTRAORAL I&D ABSCESS; SUBMENTAL
INTRAORAL I&D; SUBMANDIBULAR
SPACE
INTRAORAL I&D; MASTICATOR SPACE
INCS LINGUAL FRENUM
No
No
No
41015
Yes
EXTRAORAL I&D ABSCESS; SUBLINGUAL
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
41016
41017
Yes
Yes
EXTRAORAL I&D ABSCESS; SUBMENTAL
EXTRAORAL I&D; SUBMANDIBULAR
No
No
41018
41019
41100
41105
41108
41110
Yes
Yes
Yes
Yes
Yes
Yes
EXTRAORAL I&D; MASTICATOR SPACE
PLACE NEEDLES H&N FOR RT
BX TONGUE; ANT TWO-THIRDS
BX TONGUE; POST ONE-THIRD
BX FLOOR MOUTH
EXC LES TONGUE WO CLO
No
No
No
No
No
No
41112
Yes
EXC LES TONGUE W/CLO; ANT 2-THIRDS
No
41113
Yes
No
41114
41115
41116
41120
41130
Yes
Yes
Yes
Yes
Yes
41135
Yes
EXC LES TONGUE W/CLO; POST 1-THIRD
EXC LES TONGUE W/CLO; W/TONGUE
FLAP
EXC LINGUAL FRENUM
EXC LES FLOOR MOUTH
GLOSSECTOMY; < ONE-HALF TONGUE
GLOSSECTOMY; HEMIGLOSSECTOMY
GLOSSECTOMY; PART W/UNILAT RAD
NECK
41140
Yes
41145
Yes
41150
Yes
GLOSSECTOMY; COMPLT WO RAD NECK
GLOSSECTOMY; TOT W/UNILAT RAD
NECK
GLOSSECTOMY; COMPOSITE WO RAD
NECK
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
41153
Yes
41155
Yes
41250
No
41251
No
41252
Yes
41500
Yes
41510
41520
Yes
No
41599
Yes
41800
Yes
41805
Yes
41806
41820
Yes
Yes
41821
Yes
41822
Yes
Description
GLOSSECTOMY; W/SUPRAHYOID
DISSECT
GLOSSECTOMY; COMPOSITE & RAD
NECK
REPR LACERAT 2.5CM/LESS; ANT
TONGUE
REPR LACERAT 2.5CM/LESS; POST
TONGU
REPR LACERAT TONGUE > 2.6
CM/COMPLX
FIXA TONGUE MECH OTHER THAN
SUTURE
SUTURE TONGUE TO LIP
MICROGNATHIA
FRENOPLASTY
UNLISTED PROC TONGUE FLOOR
MOUTH
DRAIN ABSCESS DENTOALVEOLAR
STRUCT
REMOV FB-DENTOALVEOLAR; SOFT TISS
REMOV EMBED FB-DENTOALVEOLAR;
BONE
GINGIVECTOMY EA QUADRANT
OPERCULECTOMY EXC PERICORONAL
TISS
EXC FIBROUS TUBEROSITIES
DENTOALVEO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
41823
Yes
41825
Yes
41826
Yes
41827
Description
EXC OSSEOUS TUBEROSITIES
DENTOALVEO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
EXC LES DENTOALVEOLAR; WO REPR
EXC LES DENTOALVEOLAR; W/SIMPL
REPR
EXC LES DENTOALVEOLAR; W/COMPLX
REP
41828
Yes
EXC HYPERPLASTIC ALVEOLAR MUCOS
No
41830
Yes
No
41850
41870
41872
41874
Yes
Yes
Yes
Yes
41899
42000
42100
42104
42106
Yes
Yes
Yes
Yes
Yes
ALVEOLECTOMY INCL CURET OSTEITIS
DESTRCT LES DENTOALVEOLAR
STRUCT
PERIODONTAL MUCOS GFT
GINGIVOPLASTY EA QUADRANT
ALVEOLOPLASTY EA QUADRANT
UNLISTED PROC DENTOALVEOLAR
STRUCT
DRAINAGE ABSCESS PALATE UVULA
BX PALATE UVULA
EXC LES PALATE UVULA; WO CLO
EXC LES PALATE UVULA; W/PRIM CLO
No
No
No
No
No
42107
42120
42140
42145
42160
Yes
Yes
Yes
Yes
Yes
EXC LES PALATE UVULA; W/FLAP CLO
RESECT PALATE/EXTEN RESECT LES
UVULECTOMY EXC UVULA
PALATOPHARYNGOPLASTY
DESTRCT LES PALATE/UVULA
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
42180
42182
Yes
Yes
42200
Yes
42205
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
REPR LACERATION PALATE; UP TO 2 CM
REPR LACERATION PALATE; > 2 CM
PALATOPLASTY-CLEFT PALATE
SOFT/HARD
PALATOPLASTY-CLEFT PALATE; SOFT
TIS
42210
Yes
PALATOPLASTY CLEFT PALATE; W/GFT
No
42215
Yes
No
42220
Yes
42225
Yes
42226
Yes
PALATOPLASTY CLEFT PALATE; REVIS
PALATOPLASTY; SECNDRY
LENGTHENING
PALATOPLASTY; ATTACH PHARYNGEAL
FLP
LENGTHENING PALATE & PHARYNGEAL
FLP
42227
42235
42260
42280
Yes
Yes
Yes
Yes
LENGTHENING PALATE W/ISLAND FLAP
REPR ANT PALATE INCL VOMER FLAP
REPR NASOLABIAL FISTULA
MAXIL IMPRESSION PALATAL PROSTH
No
No
No
No
42281
42299
42300
Yes
Yes
Yes
INSRT PIN-RETAINED PALATAL PROSTH
UNLISTED PROC PALATE UVULA
DRAINAGE ABSCESS; PAROTID SIMPL
No
No
No
42305
Yes
DRAINAGE ABSCESS; PAROTID COMPLIC
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
42310
Yes
42320
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
DRAIN ABSCESS; SUBMAXIL INTRAORAL
DRAINAGE ABSCESS; SUBMAXILLARY
EXT
42330
Yes
SIALOLITHOTOMY; UNCOMP INTRAORAL
No
42335
42340
42400
42405
42408
Yes
Yes
Yes
Yes
Yes
SIALOLITHOTOMY; SUBMANDIB COMPLIC
SIALOLITHOTOMY; PAROTID COMPLIC
BX SALIVARY GLAND; NEEDLE
BX SALIVARY GLAND; INCS
EXC SUBLINGUAL SALIVARY CYST
No
No
No
No
No
42409
42410
Yes
Yes
No
No
42415
Yes
MARSUPIALIZATION SUBLINGUAL CYST
EXC PAROTID TUMOR; LAT LOBE
EXC PAROTID TUMOR; LAT
W/DISSECTION
42420
42425
Yes
Yes
EXC PAROTID TUMOR; TOT W/DISSECT
EXC PAROTID TUMOR; TOT W/NERVE
No
No
42426
42440
42450
Yes
Yes
Yes
EXC PAROTID TUMOR; TOT W/RAD NECK
EXC SUBMANDIBULAR GLAND
EXC SUBLINGUAL GLAND
No
No
No
42500
Yes
PLASTIC REPR SALIV DUCT; PRIM/SIMPL
No
42505
42507
Yes
Yes
PLASTIC REPR SALIV DUCT; SECNDRY
PAROTID DUCT DIVERSION BILAT
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
42508
Yes
PAROTID DIVERS BILAT; W/EXC 1 GLAND
No
42509
42510
42550
42600
42650
Yes
Yes
No
Yes
No
PAROTID DIVERS BILAT; W/EXC GLANDS
PAROTID DIVERS BILAT; W/LIG DUCTS
INJ PROC SIALOGRAPHY
CLO SALIVARY FISTULA
DILAT SALIVARY DUCT
No
No
No
No
No
42660
42665
No
Yes
No
No
42699
42700
Yes
No
42720
No
DILAT & CATH SALIVARY DUCT W/WO INJ
LIG SALIVARY DUCT INTRAORAL
UNLISTED PROC SALIVARY
GLANDS/DUCTS
I&D ABSCESS; PERITONSILLAR
I&D ABSCESS; RETROPHARYNG
INTRAORAL
42725
42800
42802
No
No
No
I&D ABSCESS; RETROPHARYNGEAL EXT
BX; OROPHARYNX
BX; HYPOPHARYNX
No
No
No
42804
No
No
42806
No
42808
42809
No
No
42810
No
BX; NASOPHARYNX VISIBLE LES SIMPL
BX; NASOPHARYNX SURVEY-UKN PRIM
LES
EXC/DESTRCT LES PHARYNX ANY
METHD
REMOV FB FROM PHARYNX
EXC BRANCHIAL CLEFT CYSTSKIN/SUBQ
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
42815
42820
42821
No
No
No
42825
No
42826
No
42830
42831
No
No
42835
No
42836
42842
No
No
42844
No
42845
42860
No
Yes
42870
42890
Yes
Yes
42892
42894
42900
Description
EXC BRANCH CLEFT CYST-BENEATH
SUBQ
T & A; UNDER AGE 12
T & A; AGE 12/OVER
TONSILLECTMY PRIM/SECNDRY; < AGE
12
TONSILLECTOMY PRIM/SECNDRY;
12/OVER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
ADENOIDECTOMY PRIM; UNDER AGE 12
ADENOIDECTOMY PRIM; AGE 12/OVER
ADENOIDECTOMY SECNDRY; UNDER
AGE 12
ADENOIDECTOMY SECNDRY; AGE
12/OVER
RADICAL RESECT TONSIL; WO CLO
RAD RESECT TONSIL; CLO W/LOCAL
FLAP
RAD RESECT TONSIL; CLO W/OTHER
FLAP
EXC TONSIL TAGS
No
No
No
No
Yes
EXC/DESTRCT LING TONSIL (SEP PRO)
LTD PHARYNGECTOMY
RESECT LAT PHARYNGEAL WALL
DIRECT
Yes
No
RESECT PHARYNG WALL W/CLO W/FLAP
SUTURE PHARYNX WOUND/INJURY
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
42950
42953
42955
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
42960
No
42961
No
42962
No
42970
No
42971
No
42972
Yes
42999
43020
43030
Yes
Yes
Yes
43045
Yes
43100
Yes
43101
Yes
43107
Yes
43108
Yes
Description
PHARYNGOPLASTY
PHARYNGOESOPHAGEAL REPR
PHARYNGOSTOMY
CONTRL OROPHARYNG HEMORR; SIMPL
CONTRL OROPHARYNG HEMORR;
COMPLIC
CONTRL OROPHARYNG HEMORR;
W/SURG
CONTRL NASOPHARYNG HEMORR;
SIMPL
CONTRL NASOPHARYNG HEMORR;
COMPLIC
CONTRL NASOPHARYNG HEMORR;
W/SURG
UNLISTED PROC
PHARYNX/ADENOID/TONSI
ESOPHAGOTOMY CERV; W/REMOV FB
CRICOPHARYNGEAL MYOTOMY
ESOPHAGOTOMY THORACIC, W/REMOV
FB
EXC LES ESOPHAGUS W/PRIM REPR;
CERV
EXC LES ESOPHAG W/REPR;
THORAC/ABD
ESOPHAGECT WO THORCTMY;
W/GASTROST
ESOPHAGECT WO THORCTMY; W/SB
RECON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43112
Yes
43113
Yes
43116
Yes
43117
Yes
43118
Yes
43121
Yes
43122
Yes
43123
43124
Yes
Yes
43130
Yes
43135
Yes
43200
No
43201
No
43202
No
43204
No
Description
ESOPHAGECT W/THORCTMY;
W/GASTROST
ESOPHAGECT W/THORCTMY; W/SB
RECON
PART ESOPHAGECT-CERVW/GFT/ANASTOM
PART ESOPHAGECT;
W/ESOPHGASTROST
PART ESOPHAGECT; W/INTRPOS/SB
RECON
PART ESOPHAGECT W/THORCTMY,
W/GASTR
PART ESOPHAGECT THORABD;
W/ESOGASTR
PART ESOPHAGECT THORABD; W/SB
RECON
TOT/PART ESOPHAGECT WO RECON
DIVERTICULECTOMY HYPOPHARYNX;
CERV
DIVERTICULECTOMY HYPOPHARYNX;
THORA
ESOPHAGOSCOPY; DX (SEPART PROC)
ESOPHGSCPY RIGD/FLXIBLE; DIR
SUBMUCOS INJ SBSTNC
ESOPHAGOSCOPY RIGID/FLEX; W/BX
1/MX
ESOPHAGOSCOPY; W/INJ-SCLEROS
VARICE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
43205
43215
No
No
43216
No
43217
No
Description
ESOPHAGOSCPY RIGID/FLEX; W/BAND
LIG
ESOPHAGOSCOPY; W/REMOV FB
ESOPHAGOSCPY RIGID/FLEX; REMOV
TUMR
ESOPHAGOSCOPY; W/REMOV LESSNARE
43219
No
ESOPHAGOSCOPY; INSRT TUBE/STENT
No
43220
No
No
43226
No
43227
No
43228
No
43231
No
43232
No
ESOPHAGOSCOPY; W/BALLOON DILAT
ESOPHAGOSCOPY; W/INSRT GUIDE
WIRE
ESOPHAGOSCOPY; W/CONTRL
BLEEDING
ESOPHAGOSCOPY; W/ABLAT TUMR-NOT
AMN
ESOPHAGOSCOPY; W/ENDOSCOPIC
ULTRASOUND
ESOPHAGOSCOPY;
W/TRANSENDOSCOPIC ULTRASOUND
43234
No
UGI ENDO SIMPL PRIM EXAM (SEP PRO)
No
43235
No
No
43236
No
43237
No
UGI ENDO; DX W/WO COLLEC SPECMN
UP GI ENDO ESOPH STOMACH; W/DIR
SUBMUCOS INJ ANY
UPPER GI ENDO; W/ENDO US EXAM LTD
ESOPHAGUS
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43238
43239
No
No
43240
No
43241
No
43242
43243
43244
No
No
No
43245
No
43246
43247
43248
No
No
No
43249
No
43250
No
43251
No
43255
No
43256
No
43257
No
Description
UP GI ENDO;TRANSENDO US FINE NDLE
ASPIR/BX ESOPH
UGI ENDO; W/BX 1/MX
ESOPHAGOSCOPY; W/TRANSMURAL
DRAINAGE OF PSEUDOCYST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
UGI ENDO; W/TRANSENDOSCOPIC TUBE
UGI ENDO; W/US GUID FINE NEEDLE
ASPIR/BX
UGI ENDO; W/INJ SCLEROSIS-VARICES
UGI ENDO; W/BAND LIG VARICES
No
UGI ENDO; W/DILAT OUTLET-ANY METHD
UGI ENDO; W/PLCMT GASTROSTOMY
TUBE
UGI ENDO; W/REMOV FB
UGI ENDO; W/INSRT GUIDE WIRE
UGI ENDO; W/BALLOON DILAT
ESOPHAGUS
No
UGI ENDO; W/REMOV TUMOR/POLYP/LES
UGI ENDO; W/REMOV TUMOR/LESSNARE
UGI ENDO; W/CONTRL BLEED ANY
METHD
UGI ENDO; W/TRANSENDOSCOPIC
STENT PLACEMNT
UP GI ENDO;DEL THRML ENRGY MUSC
LW ESOPH SPHNCTR
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
43258
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
43259
43260
43261
No
No
No
43262
No
43263
Description
UGI ENDO; W/ABLAT LES NOT SNARE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
UGI ENDO; W/ENDO ULTRASOUND EXAM
ERCP; DX W/WO SPECMN (SEP PRO)
ERCP; W/BX 1/MX
ERCP;
W/SPHINCTEROTOMY/PAPILLOTOMY
ERCP; W/PRESS MEASUR-SPHINCTER
ODDI
43264
No
ERCP; W/ENDO RETRO REMOV STONE
No
43265
No
No
43267
No
43268
No
43269
No
43271
No
ERCP; W/ENDO RETRO DESTRCT-STONE
ERCP; W/ENDO RETRO INSRT DRAIN
TUBE
ERCP; W/ENDO RETRO INSRT
TUBE/STENT
ERCP; W/ENDO RETRO REMOV
FB/CHANGE
ERCP; W/ENDO RETRO BALOON DILATDUC
43272
No
No
43280
43289
Yes
Yes
43300
Yes
ERCP; W/ABLAT TUMOR/LES NOT SNARE
LAP SURG-ESOPHAGOGASTRIC
FUNDOPLSTY
UNLISTED LAP PROC-ESOPHAGUS
ESOPHAGOPLASTY CERV; WO REPR
FIST
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43305
Yes
43310
Yes
43312
Yes
43313
Yes
43314
Yes
43320
43324
Yes
Yes
43325
Yes
43326
Yes
43330
Yes
43331
Yes
43340
43341
43350
Yes
Yes
Yes
43351
Yes
ESOPHAGOMYOTOMY; ABD APPROACH
ESOPHAGOMYOTOMY; THORACIC
APPROACH
ESOPHAGOJEJUNOSTOMY; ABD
APPROACH
ESOPHAGOJEJUNOSTOMY; THORACIC
ESOPHAGOSTOMY FISTULIZ-EXT; ABD
ESOPHAGOSTOMY FISTULIZ-EXT;
THORACI
43352
Yes
ESOPHAGOSTOMY FISTULIZ-EXT; CERV
Description
ESOPHAGOPLASTY CERV; W/REPR FIST
ESOPHAGOPLASTY THORACIC; WO
FISTULA
ESOPHAGOPLASTY THORACIC; W
FISTULA
ESOPHGPLSTY CONGN DEFEC;NO REP
FIST
ESOPHGPLSTY CONGN DEFEC; W/REP
FIST
ESOPHAGOGASTROST THOR/ABD
APPROACH
ESOPHAGOGASTRIC FUNDOPLASTY
ESOPHAGOGASTRIC FUNDOPLSTY;
W/PATCH
ESOPHAGOGASTRIC FUNDOPLSTY;
W/GASTR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43360
Yes
43361
43400
Yes
Yes
43401
Yes
43405
Yes
43410
Yes
43415
Yes
43420
Yes
43425
Yes
43450
43453
43456
No
No
No
43458
No
43460
No
43496
43499
43500
Yes
Yes
Yes
Description
GI RECON-PREV ESOPHAGECT;
W/STOMACH
GI RECON-PREV ESOPHGEC; W/BOWEL
REC
LIG DIRECT ESOPH VARICES
TRANSECT ESOPHAGUS W/REPR
VARICES
LIG/STAPLE GE JNCTN-EXIST ESO PERF
SUTURE ESOPH WOUND; CERV
APPROACH
SUTURE ESOPH WOUND; THOR/ABD
APPROA
CLO ESOPHAGOSTOMY/FISTULA; CERV
CLO ESOPHAGOSTOMY/FISTULA;
THOR/ABD
DILAT ESOPH-SOUND/BOUGIE-1/MX
PASS
DILAT ESOPH OVER GUIDE WIRE
DILAT ESOPH BALLOON/DILAT RETRO
DILAT ESOPHAGUS W/BALLOONACHALASIA
ESOPHAGOGASTRIC TAMPONADE
W/BALLOON
FREE JEJUNUM TRANS W/MICROVAS
ANAST
UNLISTED PROC ESOPHAGUS
GASTROTOMY; W/EXPLOR/FB REMOV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43501
Yes
43502
Yes
43510
Yes
43520
Yes
43600
43605
Yes
Yes
43610
43611
Yes
Yes
43620
Yes
43621
Yes
43622
Yes
43631
Yes
43632
Yes
43633
Yes
43634
Yes
Description
GASTROTOMY; W/SUTURE BLEED
ULCER
GASTROTOMY; W/SUTURE EXIST EG
LACER
GASTROT; W/ESO DIL, INSRT PERM
TUBE
PYLOROMYOTOMY CUTTING PYLORIC
MUSCL
BX STOMACH; BY
CAPSULE/TUBE/PERORAL
BX STOMACH; BY LAPAROTOMY
EXC LOCAL; ULCER/BEN TUMORSTOMACH
EXC LOCAL; MALIG TUMOR STOMACH
GASTRECTOMY TOT;
W/ESOPHAGOENTEROST
GASTRECTOMY TOT; W/ROUX-EN-Y
RECON
GASTRECT TOT; W/FORMAT INTEST
POUCH
GASTRECT PART DIST;
W/GASTRODUODEN
GASTRECT PART DIST;
W/GASTROJEJUNOS
GASTRECT PART DIST; ROUX-EN-Y
RECON
GASTRECTOMY PART DIST; W/FORM
POUCH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43635
Yes
43640
Yes
43641
Yes
43644
Yes
43645
43647
43648
Yes
Yes
Yes
43651
Yes
43652
Yes
43653
43659
43750
Yes
Yes
Yes
43752
43760
Bundled
Yes
43761
43770
43771
43772
Yes
Yes
Yes
Yes
Description
VAGOTOMY PERFORM W/PART DIS
GASTRCT
VAGOTOMY INCL PYLOROPLASTY;
TRUNCAL
VAGOTOMY W/PYLOROPLASTY;
PARIETAL
LAP GASTR RSTRCIV PROC; GASTR
BYPS & ROUX-EN-Y
LAP GASTR RSTRCIV PROC;GASTR
BYPS&SM INTST RECON
LAP IMPL ELECTRODE, ANTRUM
LAP REVISE/REMV ELTRD ANTRUM
LAP SURG; TRANSEC VAGUS NRVTRUNCAL
LAP SURG; TRANSECT VAGUS NERVESSEL
LAP SURG; GASTROS WO TUBE (SEP
PRO)
UNLISTED LAP PROC-STOMACH
PERCUT PLCMT GASTROSTOMY TUBE
NASO/ORO-GASTRC TUBE PLCMT RQR
PHYS SKILL&FLOURO
CHANGE GASTROSTOMY TUBE
REPOSIT GASTRIC FEED TUBE THRU
DUOD
LAPS GSTR RSTCV PX PLMT BAND
LAPS GSTR RSTCV PX REVJ BAND
LAPS GSTR RSTCV PX RMVL BAND
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Yes
Yes
No
No
No
No
No
Bundled
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
43773
Yes
43774
43800
43810
Yes
Yes
Yes
Description
LAPS GSTR RSTCV PX RMVL&RPLCMT
BAND
LAPS GSTR RSTCV PX RMVL
BAND&PORT
PYLOROPLASTY
GASTRODUODENOSTOMY
43820
Yes
GASTROJEJUNOSTOMY; WO VAGOTOMY
No
43825
Yes
No
43830
Yes
43831
Yes
43832
Yes
43840
Yes
43842
Not Reimbursable
43843
Not Reimbursable
43845
Yes
43846
Not Reimbursable
43847
Not Reimbursable
GASTROJEJUNOSTOMY; W/VAGOTOMY
GASTROSTMY; WO GAST TUBE (SEP
PRO)
GASTROSTOMY-OP; NEONATAL
FEEDING
GASTROSTOMY; W/CONSTRUC GAST
TUBE
GASTRORRHAPHY SUTUREULCER/WOUND
GASTRIC RESTRIC WO BYP; VERTCL
BAND
GAST RESTRIC WO BYP; NOT VERT
BAND
GASTRIC RESTRICTIVE PROC PARTIAL
GASTRECTOMY
GASTR RSTRC PROC W/GASTR
BYPS;SHRT LMB ROUX-EN-Y
GAST RESTRC W/BYP; W/SM BOWEL
RECON
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
43848
Not Reimbursable
43850
Yes
43855
Yes
43860
Yes
43865
43870
43880
43881
43882
Yes
Yes
Yes
Yes
Yes
43886
Yes
43887
Yes
43888
43999
44005
Yes
Yes
Yes
44010
Yes
44015
Yes
44020
44021
Yes
Yes
Description
REVIS GASTR RESTRICT PROC (SEP
PRO)
REVIS GASTRODUOD ANASTOM; WO
VAGOT
REVIS GASTRODUOD ANASTOM;
W/VAGOTMY
REVIS GASTROJEJUN ANASTOM; WO
VAGOT
REVIS GASTROJEJUN ANASTOM;
W/VAGOT
CLO GASTROSTOMY SURG
CLO GASTROCOLIC FISTULA
IMPL/REDO ELECTRD, ANTRUM
REVISE/REMOVE ELECTRD ANTRUM
GSTR RSTCV PX OPN REVJ SUBQ PORT
COMPONENT ONLY
GSTR RSTCV PX OPN RMVL SUBQ PORT
COMPONENT ONLY
GSTR RSTCV OPN RMVL&RPLCMT SUBQ
PORT
UNLISTED PROC STOMACH
ENTEROLYSIS (SEPART PROC)
DUODENOTOMY-EXPLOR/BX/FB REMOV
TUBE/NEEDLE CATH JEJUNOSTMYINTRAOP
ENTEROT-SM BOWEL; EXPLO/BX/FB
REMOV
ENTEROTOMY-SM BOWEL; DECOMP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
44025
44050
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
44055
Yes
44100
No
44110
Yes
44111
Yes
44120
Yes
44121
Yes
44125
Yes
44126
Description
COLOTOMY EXPLOR BX/FB REMOV
REDUCT VOLVULUS BY LAPAROTOMY
CORRECT MALROTATION BY LYSIS
BANDS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
BX INTESTINE-CAPSULE/TUBE/PERORAL
EXC 1/MORE LES-BOWEL; 1
ENTEROTOMY
EXC 1/MORE LES-BOWEL; MX
ENTEROTOMS
No
No
Yes
ENTERECT SM INTES; 1 RESECT & ANAS
ENTERECTOMY SM INTES; EA ADD
RESECT
ENTERECTOMY SM INTES;
W/ENTEROSTOMY
ENTERECT RES SM INTST;W/O
TAPERING
44127
Yes
ENTERECT RES SM INTST; W/TAPERING
No
44128
44130
Yes
Yes
No
No
44132
Yes
44133
Yes
44135
Not Reimbursable
ENTERECT RES SM INTST; EA ADD RES
ENTEROENTEROSTOMY (SEP PROC)
DONOR ENTERECT INCL COLD PRES
OPEN; CADVR DONOR
DONOR ENTERECT W/PREP ALLOGFT;
PART- LIVE DONOR
INTESTINAL ALLOTRANSPLANTATION,
FROM CADAVER DONOR
No
No
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
44136
Not Reimbursable
44137
Yes
44139
44140
44141
Yes
Yes
Yes
44143
Yes
44144
Yes
44145
Yes
44146
Yes
44147
Yes
44150
Yes
44151
Yes
44152
Yes
44153
Yes
44155
Yes
Description
INTESTINAL ALLTRANSPLANTATION
FROM LIVING DONOR
REMOVAL TRANSPLANTED INTESTINAL
ALLOGFT COMPETE
MOBILIZA SPLENIC FLEX DUR
COLECTOMY
COLECTOMY PART; W/ANASTOM
COLECTOMY PART; W/CECOSTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
COLECTOMY PART; W/END COLOSTOMY
COLECTOMY PART; W/RESECT &
MUCOFIST
COLECTOMY PART;
W/COLOPROCTOSTOMY
COLECTMY PART; W/COLOPROCTO
W/COLOS
No
COLECTOMY PART; ABD & TRANSANAL
COLECTOMY WO PROCTECT;
W/ILEOSTOMY
COLECTOMY WO PROCTECT;
W/CONTINENT
COLECTOMY WO PROCTECT; W/RECTAL
MUC
COLECTOMY WO PROCTECT;
W/RESERVOIR
COLECTOMY W/PROCTECT;
W/ILEOSTOMY
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
44156
44157
44158
44160
Yes
Yes
Yes
Yes
44180
44186
Yes
Yes
44187
44188
Yes
Yes
44202
Yes
44203
Yes
44204
Yes
44205
Yes
44206
Yes
44207
Yes
44208
Yes
44210
Yes
44211
Yes
Description
COLECTOMY W/PROCTECT;
W/CONTINENT
COLECTOMY W/ILEOANAL ANAST
COLECTOMY W/NEO-RECTUM POUCH
COLECTOMY W/REMOV TERM ILEUM
LAPS ENTEROLSS FRING INTSTINAL
ADHESION SPX
LAPS JEJUNOSTOMY
LAPS ILEOST/JEJUNOSTOMY NON-TUBE
LAPS CLST/SKN LVL CECOSTOMY
LAP SURG; INTESTNL RESECT
W/ANASTOM
LAPARSCPY SURG; EA ADD SM INTST
RES
LAPARSCPY SURG; COLECT PART
W/ANAST
LAP SURG; COLECT W/REMV TERM
ILEUM
LAP SURG; COLECT PART W/END
COLOST&CLOS DIST SEG
LAP SURG; COLECT PART W/ANASTOM
W/COLOPROCTOST
LAP SURG;COLECT PART W/ANAST
COLOPROCTOST&COLOST
LAP;COLECT TOT ABD NO PROCTECT
W/ILEOST/PROCTOST
LAP; COLECT TOT ABD W/PROCTECT
RESRVOR W/ILEOST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
44212
Yes
44213
Yes
44227
Yes
44238
44300
Yes
Yes
Description
LAP SURG; COLECT TOTAL ABD
W/PROCTECT W/ILEOST
LAPS MOBLJ SPLENIC FLXR PFRMD
W/PRTL COLCT
LAPS CLSR NTRSTM LG/SM INT
W/RESCJ&ANAST
UNLISTED LAPAROSCOPY PROC
INTESTINE NO RECTUM
ENTEROSTOMY TUBE (SEPART PROC)
44310
44312
Yes
Yes
ILEOSTOMY NON-TUBE (SEPART PROC)
REVIS ILEOSTOMY; SIMPL (SEP PRO)
No
No
44314
Yes
REVIS ILEOSTOMY; COMPLIC (SEP PRO)
No
44316
Yes
No
44320
Yes
CONTINENT ILEOSTOMY (SEPART PROC)
COLOSTOMY/CECOSTOMY (SEPART
PROC)
44322
44340
Yes
Yes
COLOSTOMY; W/MX BX (SEPART PROC)
REVIS COLOSTOMY; SIMPL (SEP PRO)
No
No
44345
Yes
No
44346
44360
Yes
No
REVIS COLOSTOMY; COMPLIC (SEP PRO)
REVIS COLOSTOMY; W/HERNIA (SEP
PRO)
SM INTEST ENDO NOT ILEUM; DX (SP)
44361
No
SM INTEST ENDO NOT ILEUM; W/BX 1/MX
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
44363
No
44364
No
44365
No
44366
44369
No
No
44370
No
44372
No
44373
44376
44377
No
No
No
44378
No
44379
44380
44382
No
No
No
44383
No
SM INTEST ENDO W/TRANSENDOSCOPIC
STENT PLACEMNT
SM INTEST ENDO; W/PLCMT JEJUNO
TUBE
SM INTEST ENDO; W/GASTRO TO
JEJUNO
SM INTEST ENDO W;ILEUM; DX (SP)
SM INTEST ENDO W/ILEUM; W/BX 1/MX
SM INTEST ENDO W/ILEM; CONTRL
BLEED
SM INTEST ENDO W/TRANSENDO STENT
PLACEMNT
ILEOSCPY-STOMA; DX W/WO SPECMN
ILEOSCOPY-STOMA; W/BX 1/MX
ILEOSCOPY W/TRANSENDO STENT
PLACEMNT
44385
No
ENDO EVAL SM INTEST POUCH; DX (SP)
Description
SM INTEST ENDO NOT ILEUM;W/REMOV
FB
SM INTEST ENDO NOT ILEUM; REMOV
LES
SM INTEST ENDO WO ILEUM; REMOV
TUMR
SM INTEST ENDO NOT ILEUM; CONTR
BLD
SM INTEST ENDO; W/ABLAT TUMOR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
44386
No
44388
44389
44390
No
No
No
44391
No
44392
No
44393
No
44394
No
44397
44500
No
No
Description
ENDO EVAL SM INTEST POUC; W/BX
1/MX
COLONOSCOPY-STOMA; DX (SEPART
PROC)
COLONOSCOPY-STOMA; W/BX 1/MX
COLONOSCOPY-STOMA; W/REMOV FB
COLONOSCOPY-STOMA; W/CONTRL
BLEED
COLONOSCPY-STOMA; W/REMOV
TUMOR/LES
COLONOSCOPY-STOMA; W/ABLAT
TUMOR
COLONSCPY-STMOA; REMOV
TUMOR/POLYP
COLONOSCOPY W/TRANSENDO STENT
PLACEMNT
INTRO LONG GI TUBE (SEPART PROC)
44602
Yes
SUTURE SM INTESTINE; 1 PERFORATION
No
44603
Yes
No
44604
Yes
SUTURE SM INTEST; MX PERFORATIONS
SUTURE LG INTESTINE; WO
COLOSTOMY
44605
Yes
SUTURE LG INTESTINE; W/COLOSTOMY
No
44615
44620
Yes
Yes
INTEST STRICTUROPLASTY W/WO DILAT
CLO ENTEROSTOMY LG/SM INTEST
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
44625
Yes
44626
44640
44650
Yes
Yes
Yes
44660
Yes
44661
Yes
44680
Yes
44700
44701
Yes
Yes
44715
Yes
44720
Yes
44721
44799
44800
44820
44850
44899
44900
44901
Description
CLO ENTEROSTMY; W/RESEC NOT
COLOREC
CLO ENTEROSTOMY; W/RESECT
COLORECTL
CLO INTESTINAL CUT FISTULA
CLO ENTEROENTERIC FISTULA
CLO ENTEROVESICAL FISTULA; WO
RESEC
CLO ENTEROVESICAL FISTULA;
W/RESECT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
Yes
Yes
INTESTINAL PLICATION (SEPART PROC)
EXCLUS SM BOWEL FROM PELVMESH/TISS
INTRAOPERATIVE COLONIC LAVAGE
BACKBENCH STD PREP CD/LD
INTESTINE ALLOGFT
BCKBNCH RECNSTR CD/LD INTST
ALLOGFT;VEN ANAST EA
BCKBNCH RECNSTR CD/LD INTST
ALLOGFT;ART ANAST EA
UNLISTED PROC INTESTINE
EXC MECKEL'S DIVERTIC
No
No
No
No
Yes
Yes
Yes
Yes
Yes
EXC LES MESENTERY (SEPART PROC)
SUTURE MESENTERY (SEPART PROC)
UNLISTED PROC MECKEL'S DIVERTIC
I&D APPENDICEAL ABSC; OPEN
I&D APPENDICEAL ABSC; PERCUT
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
44950
44955
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
44960
44970
44979
No
No
No
45000
45005
45020
Yes
No
Yes
45100
45108
Yes
Yes
45110
Yes
45111
Yes
45112
Yes
45113
Yes
45114
Yes
45116
Yes
45119
Yes
45120
Yes
Description
APPENDECTOMY
APPY; DONE @ TIME OF OTH PROC
APPY; RUPT W/ABSCESS/GEN
PERITONITS
LAP SURG-APPENDECTOMY
UNLISTED LAP PROC-APPENDIX
TRANSRECTAL DRAINAGE PELVIC
ABSCESS
I&D SUBMUCOSAL ABSCESS RECTUM
I&D DEEP SUPRALEVATOR ABSCESS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
BX ANORECTAL WALL ANAL APPROACH
ANORECTAL MYOMECTOMY
PROCTECTOMY; COMPLT-ABDPERI
W/COLOS
No
No
PROCTECTOMY; PART RESECT RECTUM
PROCTECTOMY ABDOMPERINEAL PULLTHRU
PROCTECT PART W/RECTAL MUCOSECANAS
No
PROCTECTOMY PART W/ANASTOM; ABD
PROCTECTMY PART W/ANASTOM;
TRANSACR
PROCTECTOMY-COLON RESVOIR W/WO
OST
PROCTECT COMPLT; W/PULL-THRU &
ANAS
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
45121
45123
Yes
Yes
Description
PROCTECT COMP; W/SUBTL/TOT
COLECTMY
PROCTECTOMY PART WO ANASTOM
45126
Yes
PELV EXENTERATION-COLOREC MALIG
No
45130
Yes
No
45135
Yes
45136
45150
Yes
Yes
45160
Yes
45170
Yes
EXC RECTAL PROCIDENTIA; PERIANAL
EXC RECTAL PROCIDENT; ABD &
PERINEL
EXCISION ILEOANAL RESRVOR
W/ILEOST
DIVISION STRICT RECTUM
EXC RECTAL TUMOR-PROCTOTOMY
APPROCH
EXC RECTAL TUMOR TRANSANAL
APPROACH
45190
Yes
No
45300
No
45303
No
45305
No
45307
No
45308
No
DESTRCT RECTAL TUMOR ANY METHD
PROCSIGMOSCOPY RIGID; DX (SEP
PROC)
PROCTOSIGMOIDOSCOPY RIGID;
W/DILAT
PROCTOSIGMOIDOSCPY RIGID; W/BX
1/MX
PROCTOSIGMOIDOSCPY
RIGID;W/REMOV FB
PROCTOSIGMOID RIGID; REMOV LESFORC
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
45309
No
45315
No
45317
No
45320
No
45321
No
45327
No
45330
45331
45332
No
No
No
45333
No
45334
No
45335
No
45337
No
45338
No
45339
No
Description
PROCTOSIGMOID RIGID; REMOV LESSNAR
PROCTOSIGMOIDOS RIGID; W/REMOV
LES
PROCTOSIGMOIDOS RIGID; W/CONTRL
BLD
PROCTOSIGMOIDOS RIDIG; W/ABLAT
LES
PROCTOSIGMOIDOS RIGID; W/DECOMP
VOL
PROCTOSIGMOIDOSCOPY
W/TRANSENDO STENT PLACEMNT
SIGMOIDOSCOPY FLEX; DX (SEP PROC)
SIGMOIDOSCOPY FLEX; W/BX 1/MX
SIGMOIDOSCOPY FLEX; W/REMOV FB
SIGMOIDOSCPY FLEX; W/REMOV LESCAUT
SIGMOIDOSCOPY FLEX; W/CONTRL
BLEED
SIGMOIDSCPY FLXIBLE; W/DIR
SUBMUCOS INJ SBSTNC
SIGMOIDOSCOPY FLEX; W/DECOMP
VOLVUL
SIGMOIDOSCOPY FLEX; REMOV LESSNARE
SIGMOIDOS FLEX; ABLAT LES-NOT
AMENA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
45340
No
45341
No
45342
No
45345
45355
45378
45379
45380
No
No
No
No
No
45381
No
45382
45383
No
No
45384
No
45385
No
45386
No
45387
No
45391
No
Description
SIGMOIDSCPY FLXIBLE; W/DILAT BALLN
1/MORE STRICT
SIGMOIDOSCOPY W/ENDO
ULTRASOUND EXAM
SIGMOIDOSCOPY W/TRANSENDO
ULTRASOUND
SIGMOIDOSCOPY W/TRANSENDO STENT
PLACEMNT
COLONOSCPY RIGID/FLEX 1/MX
COLONOSCOPY FLEX; DX (SEP PRO)
COLONOSCOPY FLEX; W/REMOV FB
COLONOSCOPY FLEX; W/BX 1/MX
COLNSCPY FLX PROX SPLENIC FLXR;
DIR SUBMUCOS INJ
COLONOSCOPY FLEX; W/CONTRL BLEED
COLONOSCOPY FLEX; W/ABLAT LES
COLONOSOCPY FLEX; REMOV LESFORCEPS
COLONOSCOPY FLEX; W/REMOV LESSNARE
COLNSPY FIBRPTC BEYND SPLNC;
W/RETRGRDE LAVAGE
COLONOSCOPY W/TRANSENDO STENT
PLACEMNT
COLONSCPY FLEX PROX SPLENIC
FLXURE; W/ENDO US EX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
45392
No
45395
Yes
45397
45400
Yes
Yes
45402
45499
45500
Yes
Yes
Yes
45505
Yes
45520
No
45540
45541
Yes
Yes
COLONSCPY
FLEX;INTRAMURAL/TRANSMURAL
FNA/BXS
LAPS PRCTECT COMPL CMBN
ABDOMINOPRNL W/CLST
LAPS PRCTECT CMBN PULL-THRU CRTJ
RSVR
LAPS PROCTOPEXY FOR PROLAPSE
LAPS PROCTOPEXY FOR PROLAPSE
SIGMOID RESCJ
UNLIS LAPS PX RECTUM
PROCTOPLASTY; STENOSIS
PROCTOPLASTY; PROLAPSE MUCOS
MEMBRN
PERIRECTAL INJ SCLEROSING
SOLUTION
PROCTOPEXY PROLAPSE; ABD
APPROACH
PROCTOPEXY PROLAPSE; PERINEAL
45550
45560
Yes
Yes
PROCTOPEXY COMBO W/RESECT-ABD
REPR RECTOCELE (SEPART PROC)
No
No
45562
Yes
No
45563
45800
Yes
Yes
45805
Yes
EXPLOR, REPR & DRAIN-RECTAL INJURY;
EXPLOR-REPR-DRAIN RECTAL;
W/COLOST
CLO RECTOVESICAL FISTULA
CLO RECTOVESICAL FIST;
W/COLOSTOMY
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
45820
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
45825
Yes
45900
Yes
Description
CLO RECTOURETHRAL FISTULA
CLO RECTOURETHRAL FIST;
W/COLOSTOMY
REDUCT PROCIDENTIA (SEP PRO)
W/ANES
45905
Yes
DILAT ANAL SPHINCT (SEP PRO) W/ANES
No
45910
Yes
No
45915
Yes
45990
45999
46020
46030
No
Yes
Yes
No
DILAT RECTAL STRICT (SEP PRO) W/ANE
REMOV FECAL IMPACT (SEP PRO)
W/ANES
ANRCT XM SURG REQ ANES GENERAL
SPI/EDRL DX
UNLISTED PROC RECTUM
PLACEMENT OF SETON
REMOV ANAL SETON OTHER MARKER
No
No
No
No
46040
Yes
I&D ISCHIORECTAL ABSCESS (SEP PRO)
No
46045
46050
Yes
No
No
No
46060
46070
46080
Yes
Yes
Yes
I&D INTRAMURAL ABSCESS TRANSANAL
I&D PERIANAL ABSCESS SUPERF
I&D ISCHIORECTAL/INTRAMURAL
ABSCESS
INCS ANAL SEPTUM (INFANT)
SPHINCTEROTOMY ANAL (SEP PRO)
46083
No
No
46200
Yes
INCS THROMBOSED HEMORRHOID EXT
FISSURECTOMY W/WO
SPHINCTEROTOMY
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
46210
46211
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
46220
46221
No
No
46230
46250
No
Yes
46255
Yes
46257
Yes
46258
Yes
46260
Yes
46261
Yes
46262
46270
Description
CRYPTECTOMY; SNGL
CRYPTECTOMY; MX (SEPART PROC)
PAPILLECTOMY ANUS (SEPART PROC)
HEMORRHOIDECTOMY BY SIMPL LIG
EXC EXT HEMORRHOID TAGS/MX
PAPILLAE
HEMORRHOIDECTOMY EXT COMPLT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
HEMORRHOIDECTOMY INT & EXT SIMPL
HEMORRHOIDECTOMY SIMPL;
W/FISSURECT
HEMORRHOIDECTOMY SIMPL;
W/FISTULECT
No
No
Yes
Yes
HEMORRHOIDECTOMY COMPLX/EXTEN
HEMORRHOIDECT COMPLX;
W/FISSURECTMY
HEMORRHOIDECT COMPLX;
W/FISTULECTMY
SURG TX ANAL FISTULA; SUBQ
46275
46280
46285
Yes
Yes
Yes
SURG TX ANAL FISTULA; SUBMUSCULAR
SURG TX ANAL FISTULA; COMPLX/MX
SURG TX ANAL FISTULA; 2ND STAGE
No
No
No
46288
Yes
No
46320
No
CLO ANAL FIST W/RECTAL ADVANC FLAP
ENUCLEATION EXT THROMBOTIC
HEMORRHO
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
46500
46505
No
Yes
46600
46604
46606
46608
No
No
No
No
46610
No
46611
No
46612
No
46614
No
46615
No
46700
Yes
46705
Yes
46706
No
46710
Yes
46712
Yes
Description
INJ SCLEROSING SOLUTION
HEMORRHOIDS
CHEMODNRVTJ INT ANAL SPHNCTR
ANOSCOPY; DX W/WO SPECMN (SEP
PRO)
ANOSCOPY; DILAT ANY METHD
ANOSCOPY; W/BX 1/MX
ANOSCOPY; W/REMOV FB
ANOSCOPY; W/REMOV 1 LESFORCEP/CAUT
ANOSCOPY; W/REMOV 1 TUMOR/LESSNARE
ANOSCOPY; W/REMOV MX LESCAUT/SNARE
ANOSCOPY; W/CONTRL BLEED ANY
METHD
ANOSCPY; ABLAT LES NOT AMENABFORCP
ANOPLASTY PLASTIC OR STRICT; ADULT
ANOPLASTY PLASTIC OR STRICT;
INFANT
REPAIR OF ANAL FISTULA WITH FIBRIN
GLUE
RPR ILEOANAL POUCH FSTL/POUCH
ADVMNT TPRNL APPR
RPR ILEOANAL POUCH FSTL/POUCH
ADVMNT CMBN APPR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
46715
Yes
46716
Yes
46730
Yes
46735
Yes
46740
Yes
46742
Yes
46744
Yes
46746
Yes
46748
Yes
46750
Yes
46751
46753
46754
Yes
Yes
No
46760
Yes
46761
Yes
Description
REPR LO IMPERFORAT ANUS;
W/FISTULA
REPR LO IMPERFORAT ANUS;
W/TRNSPOST
REPR HI IMPERFORAT ANUS;
PERINL/SAC
REPR HIGH IMPERFORATE ANUS;
COMBO
REPR HI IMPERFOR ANUS W/FIST; PERIN
REPR HI IMPERFOR ANUS; COMBO
APPROC
REPR CLOACAL ANOMALYSACROPERINEAL
REPR CLOACAL ANOMALY-COMBO
APPROACH
REPR CLOACAL ANOMALY; W/VAG
LENGTH
SPHINCTEROPLASTY-ANAL-INCONT;
ADULT
SPHINCTEROPLASTY-ANAL-INCONT;
CHILD
GFT RECTAL INCONT &/OR PROLAPSE
REMOV THIERSCH WIRE ANAL CANAL
SPHINCTEROPLSTY-ANAL; MUSCL
TRANSPL
SPHINCTEROPLSTY-ANAL; LEVATOR
MUSCL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
46762
46900
Yes
No
46910
No
46916
No
46917
No
Description
SPHINCTEROPLSTY-ANAL; IMPLNT
SPHINC
DESTRCT LES ANUS SIMPL; CHEM
DESTRCT LES ANUS SIMP;
ELECTRODESIC
DESTRCT LES ANUS SIMPL;
CRYOSURGERY
DESTRCT LES ANUS SIMPL; LASER
SURG
46922
No
DESTRCT LES ANUS SIMPL; SURG EXC
No
46924
No
No
46934
No
46935
46936
46937
No
No
No
DESTRCT LES ANUS EXTEN ANY METHD
DESTRCT HEMORRHOIDS ANY METHD;
INT
DESTRCT HEMORRHOIDS ANY METHD;
EXT
DESTRCT HEMORRHOIDS; INT & EXT
CRYOSURGERY RECTAL TUMOR; BEN
46938
46940
No
No
46942
46945
46946
46947
46999
47000
No
No
No
No
Yes
No
CRYOSURGERY RECTAL TUMOR; MALIG
CURET ANAL FISSURE (SEP PRO); INIT
CURET ANAL FISSURE (SEP PRO);
SUBSQ
LIG INT HEMORRHOIDS; SNGL PROC
LIG INT HEMORRHOIDS; MX PROC
HEMORRHOIDOPEXY BY STAPLING
UNLISTED PROC ANUS
BX LIVER NEEDLE; PERCUT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
47001
Yes
47010
Yes
47011
Yes
47015
47100
Yes
Yes
47120
47122
47125
47130
Yes
Yes
Yes
Yes
47133
Yes
47135
47136
Yes
Yes
47140
Yes
47141
Yes
47142
Yes
47143
Yes
47144
Yes
Description
BX LIVER NEEDLE; DONE W/OTH MAJ
PRO
HEPATOT; OPEN DRAIN ABSC 1/2
STAGES
HEPATOT; PERC DRAIN ABSC 1/2
STAGES
LAPAROT W/ASP/INJ HEPATIC
CYST/ABSC
BX LIVER WEDGE
HEPATECTOMY RESEC LIVER; PART
LOBEC
HEPATECTOMY; TRISEGMENTECTOMY
HEPATECTOMY; TOT LT LOBEC
HEPATECTOMY; TOT RT LOBEC
DONOR HEPATECTOMY FROM CADAVER
DONOR
LIVER ALLOTRANSPL; ORTHOTOPPRT/ALL
LIVER ALLOTRANSPL; HETEROTOPIC
DONOR HEPATECTOMY LIVING DONOR;
LT LAT SEG ONLY
DONOR HEPATECTOMY LIVING DONOR;
TOT LT LOBECTOMY
DONOR HEPATECTOMY LIVING DONOR;
TOT RT LOBECTOMY
BCKBNCH STD PREP CD WHOLE LG;NO
TRISEG/LOBE SPLT
BCKBNCH STD PREP CD WHOLE LIVR
GFT; TRISEG SPLIT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
47145
Yes
47146
Yes
47147
Yes
47300
Yes
47350
47360
Yes
Yes
47361
Yes
47362
Yes
Description
BCKBNCH STD PREP CD WHOLE LIVR
GFT; W/LOBE SPLIT
BACKBENCH RECONSTR CD/LD LG;
VENUS ANASTOM EA
BACKBENCH RECONSTR CD/LD LIVR
GFT;ART ANASTOM EA
MARSUPIALIZATION CYST/ABSCESS
LIVER
MGMT LIVER HEMORR; SIMPL SUT
WOUND
MGMT LIVER HEMORR; COMPLX
MGMT LIVER HEMORR; EXTEN
DEBRID/SUT
MGMT LIVER HEMORR; RE-EXPLOR
WOUND
47370
47371
Yes
Yes
LAP ABLAT 1/> LIVR TUMR; RADIOFREQ
LAP ABLAT 1/> LIVR TUMR; CRYOSURG
No
No
47379
Yes
UNLISTED LAPAROSCOPIC PROC, LIVER
No
47380
Yes
ABLAT OPN 1/> LIVR TUMR; RADIOFREQ
No
47381
Yes
ABLAT OPN 1/> LIVR TUMR; CRYOSURG
No
47382
47399
Yes
Yes
No
No
47400
Yes
ABLAT 1/> LIVR TUMR PERQ RADIOFREQ
UNLISTED PROC LIVER
HEPATICOTOMY W/EXPLOR/REMOV
CALCU
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
47420
Yes
47425
Yes
47460
Yes
47480
47490
Yes
Yes
47500
Yes
47505
Yes
Description
CHOLEDOCH W/EXPLR/DRAIN; WO
SPHINCT
CHOLEDOCHOTOMY; W/SPHINC
TEROTOMY
TRANSDUODEN SPHINCTEROTOM (SEP
PRO)
CHOLECYSTOTOMY W/EXPLOR (SEP
PRO)
PERCUT CHOLECYSTOSTOMY
INJ PROC TRANSHEPATIC
CHOLANGIOGRAP
INJ PROC CHOLANGIOGRAPHY THRU
CATH
47510
Yes
INTRO TRANSHEPATIC CATH BILI DRAIN
No
47511
Yes
INTRO TRANSHEPATIC STENT BILI DRAIN
No
47525
Yes
CHANGE PERCUT BILI DRAINAGE CATH
No
47530
47550
47552
47553
Yes
No
No
No
REVIS/REINSERT TRANSHEPATIC TUBE
BILI ENDO INTRAOPERATIVE
BILI ENDO VIA T-TUBE; DX (SEP PROC)
BILI ENDO VIA T-TUBE; W/BX 1/MX
No
No
No
No
47554
47555
47556
No
No
No
BILI ENDO VIA T-TUBE; W/REMOV STONE
BILI ENDO; W/DILAT DUCT WO STENT
BILI ENDO; W/DILAT DUCT W/STENT
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
47560
Yes
47561
47562
Yes
Yes
47563
Yes
47564
Yes
47570
47579
47600
47605
47610
Yes
Yes
Yes
Yes
Yes
47612
Yes
47620
Yes
Description
LAP SURG; W/TRNSHEP CHOLANGIO WO
BX
LAP SURG; W/TRNSHEP CHOLANGIOG
W/BX
LAP SURG; CHOLECYSTECTOMY
LAP SURG; CHOLECYSTECTOMY
W/CHOLANG
LAP SURG; CHOLE W/EXPLR COMMON
DUCT
LAP SURG;
CHOLECYSTOENTEROSTOMY
UNLISTED LAP PROC-BILIARY TRACT
CHOLEY
CHOLEY; W/CHOLANGIOGRAPHY
CHOLEY W/EXPLOR COMMON DUCT
CHOLEY W/EXPLOR DUCT;
CHOLEDOCHEONT
CHOLEY; W/TRANSDUODEN
SPHINCTEROTMY
47630
Yes
BILI DUCT STONE EXTRACT VIA T-TUBE
No
47700
47701
Yes
Yes
EXPLOR ATRESIA BILE DUCTS WO REPR
PORTOENTEROSTOMY
No
No
47711
Yes
EXC BILE DUCT TUMOR; EXTRAHEPATIC
No
47712
47715
Yes
Yes
EXC BILE DUCT TUMOR; INTRAHEPATIC
EXC CHOLEDOCHAL CYST
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
47716
47719
47720
Yes
Yes
Yes
47721
Yes
47740
Yes
47741
Yes
47760
Yes
47765
Yes
47780
Yes
47785
47800
47801
47802
Yes
Yes
Yes
Yes
47900
47999
48000
Yes
Yes
Yes
48001
Yes
48005
Yes
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
ANASTOM CHOLEDOCHAL CYST WO EXC
FUSION OF BILE DUCT CYST
CHOLECYSTOENTEROSTOMY; DIRECT
CHOLECYSTOENTEROS;
W/GASTROENTEROST
CHOLECYSTOENTEROSTOMY; ROUX-ENY
CHOLECYSTOENTEROS; ROUX-EN-Y
W/GAST
No
No
No
ANAS EXTRAHEP BIL DUCTS & GI TRACT
ANASTOM INTRAHEPAT DUCTS & GI
TRACT
ANASTOM ROUX-EN-Y EXTRAHEPATIC
DUCT
No
ANAS ROUX-EN-Y INTRAHEP DUCTS & GI
RECON PLASTIC EXTRAHEPATIC BILI
PLCMT CHOLEDOCHAL STENT
U-TUBE HEPATICOENTEROSTOMY
SUTURE EXTRAHEP BIL DUCT (SEP
PROC)
UNLISTED PROC BILI TRACT
PLCMT DRAINS PERIPANCREATIC
PLCMT DRAINS; W/CHOLECYSTOS
GASTROS
RESECT/DEBRID PANCREAS &
PERIPANCRE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
48020
48100
48102
48105
48120
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
Yes
48140
Yes
48145
Yes
48146
48148
Yes
Yes
48150
Yes
48152
Yes
48153
Yes
48154
48155
Yes
Yes
48160
Yes
48180
Yes
48400
48500
Yes
Yes
Description
REMOV PANCREATIC CALCU
BX PANCREAS OPEN ANY METHD
BX PANCREAS PERCUT NEEDLE
RESECT/DEBRIDE PANCREAS
EXC LES PANCREAS
PANCREATECTMY; WO
PANCREATICOJEJUNO
PANCREATECTOMY;
W/PANCREATICOJEJUNO
PANCREATECTMY DIST NEAR-TOT
PRESERV
EXC AMPULLA VATER
PANCREATECTMY
W/PANCREATICODUODENEC
PANCREATEC TOT DUODEN; WO
PANCREATO
PANCREATEC W/NEAR-TOT;
W/PANCREATOJ
PANCREATEC W/NEAR-TOT; WO
PANCREATJ
PANCREATECTOMY TOT
PANCREATECT TOT/SUBTOT
W/TRANSPL
PANCREATICOJEJUNOST SIDE-SIDE
ANAST
INJ PROC INTRAOPERAT
PANCREATOGRPH
MARSUPIALIZATION CYST PANCREAS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
48510
Yes
48511
Yes
Description
EXT DRAIN PSEUDOCYST PANCREAS;
OPEN
EXT DRAIN PSEUDOCYST PANCREAS;
PERC
48520
Yes
INT ANAST PANCREATIC CYST-GI; DIREC
No
48540
48545
Yes
Yes
INT ANAST PANCREAT CYST; ROUX-EN-Y
PANCREATORRHAPHY TRAUMA
No
No
48547
48548
Yes
Yes
No
No
48550
Yes
48551
48554
Yes
Yes
DUODENAL EXCLUS W/GASTROJEJUNOS
FUSE PANCREAS AND BOWEL
DONOR PANCREATECTOMY W/WO
DUODENAL SEGMENT TPLNT
BACKBENCH STD PREP CADVR DONR
PANC ALLOGFT
TRANSPC PANCREATIC ALLOGFT
48556
48999
Yes
Yes
No
No
49000
49002
Yes
Yes
REMOV TRANSPL PANCREATIC ALLOGFT
UNLISTED PROC PANCREAS
EXPLOR LAPAROTOMY W/WO BX (SEP
PRO)
REOPENING RECENT LAPAROTOMY
49010
49020
49021
Yes
Yes
Yes
EXPLOR RETROPERITONEAL (SEP PRO)
DRAIN PERITONEAL ABSC; OPEN
DRAIN PERITONEAL ABSC; PERCUT
No
No
No
49040
Yes
DRAIN SUBDIAPHRAGMATIC ABSC; OPEN
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
49041
Yes
49060
Yes
49061
Yes
49062
49080
49081
49085
Yes
Yes
Yes
Yes
49180
Yes
49200
49201
49203
49204
49205
Description
DRAIN SUBDIAPHRAGMATIC ABSC;
PERCUT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
DRAIN RETROPERITONEAL ABSC; OPEN
DRAIN RETROPERITONEAL ABSC;
PERCUT
DRAIN EXTRAPERITON LYMPHOCELE,
OPEN
PERITONEOCENTESIS; INIT
PERITONEOCENTESIS; SUBSQT
REMOV PERITONEAL FB FROM CAVITY
BX ABD/RETROPERITONEAL MASS
PERCUT
EXC INTRA-ABD/RETROPERITONEAL
TUMOR
Yes
Yes
Yes
Yes
EXC INTRA-ABD TUMORS/CYSTS; EXTEN
EXC ABD TUM 5 CM OR LESS
EXC ABD TUM OVER 5 CM
EXC ABD TUM OVER 10 CM
No
No
No
No
49215
Yes
49220
Yes
49250
Yes
49255
Yes
EXC PRESACRAL/SACROCOCCYGEAL
TUMOR
STAGING CELIOTOMY-HODGKIN'S
DISEASE
UMBILECTOMY/OMPHALECTOMY (SEP
PRO)
OMENTECTOMY/EPIPLOECTOMY (SEP
PRO)
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
49320
Yes
49321
49322
Yes
Yes
49323
49324
49325
49326
Yes
Yes
Yes
Yes
49329
Yes
49400
49402
No
Yes
49419
Yes
49420
No
49421
Yes
49422
Yes
49423
49424
49425
49426
Description
LAP SURG-ABD; DX-W/WO SPECMN (SP)
LAP SURG-ABD PERITNM & OMENTM;
W/BX
LAP SURG-ABD PERITNM; W/ASPIR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
LAP SURG-ABD; W/DRAIN LYMPHOCELE
LAP INSERTION PERM IP CATH
LAP REVISION PERM IP CATH
LAP W/OMENTOPEXY ADD-ON
UNLIST LAP PROCABD/PERITONM/OMENTM
No
No
No
No
No
Yes
No
INJ AIR/CONTRAST-PERITONEAL CAVITY
REMOVE FOREIGN BODY, ADBOMEN
INSRT INTRAPER CANNULA/CATH
W/SUBQ RESRVOR PERM
INSRT INTRAPERITONEAL CANNULA;
TEMP
INSRT INTRAPERITONEAL CANNULA;
PERM
REMOV PERM INTRAPERITONEAL
CANNULA
EXCHG ABSC/CYST CATH-RAD GUIDE
(SP)
No
Yes
Yes
CONTRST INJ-ABSC/CYST VIA CATH (SP)
INSRT PERITONEAL-VENOUS SHUNT
REVIS PERITONEAL-VENOUS SHUNT
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
49427
49428
49429
49435
49436
49440
49441
49442
49446
49450
49451
49452
49460
49465
49491
49492
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Description
INJ PROC-EVAL PERITON-VENOUS
SHUNT
LIG PERITONEAL-VENOUS SHUNT
REMOV PERITONEAL-VENOUS SHUNT
INSERT SUBQ EXTEN TO IP CATH
EMBEDDED IP CATH EXIT-SITE
PLACE GASTROSTOMY TUBE PERC
PLACE DUOD/JEJ TUBE PERC
PLACE CECOSTOMY TUBE PERC
CHANGE G-TUBE TO G-J PERC
REPLACE G/C TUBE PERC
REPLACE DUOD/JEJ TUBE PERC
REPLACE G-J TUBE PERC
FIX G/COLON TUBE W/DEVICE
FLUORO EXAM OF G/COLON TUBE
REP ING HERN PRTERM INFNT; REDUC
REP ING HERN PRTERM INFNT; INCAR
49495
No
REPR INIT ING HERNIA <6 MO; REDUCIB
No
49496
No
REPR INIT ING HERNIA <6MO; INCARCER
No
49500
No
No
49501
No
REPR INIT ING HERNIA 6MO-<5YR; REDU
REPR ING HERNIA 6MO<5YR;INCAR/STRN
49505
49507
49520
No
No
No
REPR INIT ING HERNIA 5YR/MORE; REDU
REPR INIT ING HERNIA > 5YR; INCARC
REPR RECUR ING HERNIA; REDUCIBLE
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
49521
49525
49540
No
No
No
49550
No
49553
No
49555
No
49557
Description
REPR RECUR ING HERNIA;
INCARC/STRAN
REPR ING HERNIA SLIDING ANY AGE
REPR LUMBAR HERNIA
REPR INIT FEM HERNIA ANY AGE;
REDUC
REPR INIT FEM HERNIA;
INCARC/STRANG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
REPR RECUR FEM HERNIA; REDUCIBLE
REPR RECUR FEM HERNIA;
INCARC/STRAN
49560
No
REPR INIT INCS/VENT HERNIA; REDUCIB
No
49561
No
No
49565
No
49566
No
49568
No
REPR INIT INCS/VENT HERN; INCARCER
REPR RECUR INCS/VENT HERNIA;
REDUCI
REPR RECUR INCS/VENT HERNIA;
INCARC
IMPLNT MESH/OTH-INCS/VENT HERN
REPR
49570
No
No
49572
No
49580
No
REPR EPIGASTRIC HERNIA; REDUCIBLE
REPR EPIGAST HERNIA;
INCARC/STRANG
REPR UMBILIC HERNIA <5YR;
REDUCIBLE
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
49582
No
49585
No
49587
49590
No
No
49600
No
49605
No
49606
49610
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
REPR UMBILIC HERNIA <5YR; INCAR/STR
REPR UMBIL HERNIA 5YR/OVER;
REDUCIB
REPR UMBIL HERNIA 5YR/OVER;
INCARCR
REPR SPIGELIAN HERNIA
No
No
No
No
REPR SM OMPHALOCELE W/PRIM CLO
REPR LG OMPHALOCELE; W/WO
PROSTH
REPR LG OMPHALOCELE; W/REMOV
PROSTH
REPR OMPHALOCELE; FIRST STAGE
49611
No
REPR OMPHALOCELE; SECOND STAGE
No
49650
No
LAP SURG; REPR INIT INGUINAL HERNIA
No
49651
No
No
49659
Yes
LAP SURG; REPR RECUR INGUIN HERNIA
UNLISTED LAP PROCHERNIOPLSTY/OTOMY
49900
49904
49905
Yes
Yes
No
No
No
No
49906
Yes
SUTURE 2ND ABD WALL EVISCERATION
OMENTL FLAP EXTRA-ABDOMINAL
OMENTAL FLAP
FREE OMENTAL FLAP W/MICROVASC
ANAST
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
49999
Yes
50010
Yes
50020
Yes
50021
Yes
50040
50045
50060
Yes
Yes
Yes
50065
Yes
50070
Yes
50075
Yes
50080
Yes
50081
Yes
50100
50120
Yes
Yes
50125
50130
50135
Yes
Yes
Yes
Description
UNLIST PROC ABD
PERITONEUM/OMENTUM
RENAL EXPLOR WO OTHER SPECIFIC
PROC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
DRAIN PERIRENAL/RENAL ABSC; OPEN
DRAIN PERIRENAL/RENAL ABSC;
PERCUT
NEPHROSTOMY NEPHROTOMY
W/DRAINAGE
NEPHROTOMY W/EXPLOR
NEPHROLITHOTOMY; REMOV CALCU
NEPHROLITHOTOMY; 2ND SURG FOR
CALCU
NEPHROLITHOTOMY; CONGEN KIDNEY
ABN
No
NEPHROLITHOTOMY; REMOV LG CALCU
PERQ NEPHROSTOLITHOTOMY; UP TO 2
CM
PERQ NEPHROSTOLITHOTOMY; OVER 2
CM
TRANSEC ABERRNT RENAL VESS (SEP
PRO
PYELOTOMY; W/EXPLOR
PYELOTOMY; W/DRAINAGE
PYELOSTOMY
PYELOTOMY; W/REMOV CALCU
PYELOTOMY; COMPLIC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50200
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
50205
Yes
50220
Yes
50225
Yes
50230
Yes
50234
Yes
50236
50240
Yes
Yes
50250
50280
50290
Yes
Yes
Yes
50300
Yes
50320
Yes
50323
Yes
50325
Yes
50327
Yes
Description
RENAL BX; PERCUT-TROCAR/NEEDLE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
RENAL BX; BY SURG EXPOSURE KIDNEY
NEPHRECTOMY W/PART
URETERECTOMY
No
NEPHRECT; PREV SURG SAME KIDNEY
NEPHREC; RAD W/REGION
LYMPHADENECT
NEPHRECT W/TOT URETERECT; SAME
INCS
NEPHRECT W/URETERECT; SEPART
INCS
NEPHRECTOMY PART
ABLTJ OPN 1+ RNL LES CRYOSURG
W/INTRAOP US
EXC/UNROOFING CYST KIDNEY
EXC PERINEPHRIC CYST
DONOR NEPHRECTOMY CADAVER
DONOR UNI/BIL
DONOR NEPRECTOMY; OPEN LIVING
DONOR
BACKBENCH STD PREP CADVER DONOR
RENL ALLOGFT
BACKBENCH STD PREP L/D RENAL
ALLOGFT OPEN/LAP
BCKBNCH RECONSTR CD/LD RENL
ALLOGFT;VEN ANAST EA
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
50328
Yes
50329
Yes
50340
Yes
50360
Yes
50365
50370
Yes
Yes
50380
Yes
50382
50384
50385
50386
No
No
No
No
50387
50389
Yes
Yes
50390
Yes
50391
No
50392
Yes
50393
Yes
Description
BCKBNCH RECONSTR CD/LD RENL
ALLOGFT;ART ANAST EA
BCKBNCH RECNSTR CD/LD RENL
ALLOGFT;URET ANAST EA
RECIPIENT NEPHRECTOMY (SEPART
PROC)
RENAL ALLOTPLNT IMPLNT GRAFT; W/O
RECIP NEPHRECT
RENAL ALLOTRANSPL; W/RECIP
NEPHRECT
REMOV TRANSPL RENAL ALLOGFT
RENAL AUTOTRANSPL; REIMPLNT
KIDNEY
RMVL&RPLCMT INTLY DWELLING URTRL
STENT
RMVL INTLY DWELLING URTRL STENT
CHANGE STENT VIA TRANSURETH
REMOVE STENT VIA TRANSURETH
RMVL&RPLCMT XTRNLLY ACCESSIBLE
URTRL STENT
RMVL NFROS TUBE REQ FLUOR GID
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
ASPIRAT &/OR INJ RENAL CYST-NEEDLE
INSTL TX AGT RENL PELV&/URETR THRU
EST NEPHROST
No
INTRO INTRACATH-RENAL PELVIS-DRAIN
INTRO URETERAL CATH THRU RENAL
PELV
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
50394
50395
Yes
Yes
50396
Yes
50398
50400
50405
Yes
Yes
Yes
50500
50520
50525
Yes
Yes
Yes
50526
50540
50541
Yes
Yes
Yes
50542
Yes
50543
50544
50545
50546
Yes
Yes
Yes
Yes
50547
Yes
CLO NEPHROVISCERAL FIST; THORACIC
SYMPHYSIOTOMY UNILAT/BILAT
LAP SURG; ABLATION RENAL CYSTS
LAPAROSCOPY SURGICAL; ABLAT
RENAL MASS LESION
LAPAROSCOPY SURGICAL; PARTIAL
NEPHRECTOMY
LAP SURG; PYELOPLASTY
LAP SURG; RADICAL NEPHRECTOMY
LAP SURG; NEPHRECTOMY
LAPARSCPY SURG; DONOR NEPHRECT
FROM LIVING DONOR
50548
50549
Yes
Yes
LAP ASSISTED NEPHROURETERECTOMY
UNLISTED LAP PROC-RENAL
Description
INJ PROC PYELOGRAPHY-NEPHROST
TUBE
INTRO-GUIDE-RENAL PELVIS W/DILAT
MANOMETRIC STUDIES-NEPHROSTOMY
TUBE
CHANGE NEPHROSTOMY/PYELOSTOMY
TUBE
PYELOPLASTY; SIMPL
PYELOPLASTY; COMPLIC
NEPHRORRHAPHY SUTURE KIDNEY
WOUND
CLO NEPHROCUT/PYELOCUT FISTULA
CLO NEPHROVISCERAL FISTULA; ABD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50551
50553
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
50555
Yes
50557
50561
Yes
Yes
50562
Yes
50570
Yes
50572
50574
Yes
Yes
50575
50576
Yes
Yes
Description
RENAL ENDO-ESTAB NEPHROSTOMY
RENAL ENDO; W/URETHERAL CATH
RENAL ENDO-ESTAB NEPHROSTOMY;
W/BX
RENAL ENDO-ESTAB NEPHROST;
W/FULG
RENAL ENDO; W/REMOV FB/CALCU
RENL ENDO THRU EST
NEPHROST/PYELOST; W/RES TUMR
RENAL ENDO-NEPHROTOMY; W/WO
IRRIGA
RENAL ENDO-NEPHROTMY; W/URETER
CATH
RENAL ENDO-NEPHROTOMY; W/BX
RENAL ENDO-NEPHROT;
W/ENDOPYELOTOMY
RENAL ENDO-NEPHROTOMY; W/FULG
50580
Yes
RENAL ENDO-NEPHROTOMY; REMOV FB
No
50590
50592
50593
Yes
Not Reimbursable
Yes
No
No
No
50600
Yes
50605
Yes
50610
Yes
LITH EXTRACORPOREAL SHOCK WAVE
ABLTJ 1+ RNL TUM PRQ UNI RF
PERC CRYO ABLATE RENAL TUM
URETEROTOMY W/EXPLOR (SEPART
PROC)
URETEROTOMY INSRT STENT ALL
TYPES
URETEROLITHOTOMY; UPPER 1/3
URETER
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50620
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
50630
Yes
50650
Yes
Description
URETEROLITHOTOMY; MID 1/3 URETER
URETEROLITHOTOMY; LOWER 1/3
URETER
URETERECTMY W/BLADDER CUFF(SEP
PRO)
50660
Yes
URETERECTOMY TOT-COMBO ABD/VAG
No
50684
Yes
No
50686
50688
50690
Yes
Yes
Yes
INJ PROC-URETEROGRAPHY THRU CATH
MANOMETRIC STUDIES THRU
URETEROSTMY
CHANGE URETEROSTOMY TUBE
INJ PROC-VISUALIZ ILEAL CONDUIT
50700
Yes
URETEROPLASTY PLASTIC OR URETER
No
50715
Yes
No
50722
Yes
50725
50727
Yes
Yes
50728
50740
50750
50760
50770
Yes
Yes
Yes
Yes
Yes
URETEROLYSIS W/WO REPOSIT URETER
URETEROLYSIS OVARIAN VEIN
SYNDROME
URETEROLYSIS W/REANASTOM URIN
TRACT
REVIS URIN-CUT ANASTOM
REVIS URIN-CUT ANASTOM; REPR
DEFECT
URETEROPYELOSTOMY ANASTOM
URETEROCALYCOSTOMY ANASTOM
URETEROURETEROSTOMY
TRANSURETEROURETEROSTOMY
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
50780
Yes
50782
Yes
50783
50785
Yes
Yes
50800
Yes
50810
Yes
50815
Yes
50820
Yes
50825
50830
Yes
Yes
50840
50845
Yes
Yes
50860
50900
50920
50930
50940
50945
Yes
Yes
Yes
Yes
Yes
Yes
Description
URETERONEOCYSTOSTOMY; SNGL
URETER
URETERONEOCYSTOSTOMY; DUPLIC
URETER
URETERONEOCYSTOSTOMY;
W/TAILORING
URETERONEOCYSTOSTOMY; W/HITCH
URETEROENTEROSTOMY DIRECT
ANASTOM
URETEROSIGMOIDOSTOMY W/CREAT
BLADDR
URETEROCOLON CONDUIT INCL
ANASTOM
URETEROILEAL CONDUIT INCL
ANASTOM
CONTINENT DIVERSION W/BOWEL
ANASTOM
URIN UNDIVERSION
REPL ALL/PART URETER BY BOWEL
SEGMT
CUT APPENDICO-VESICOSTOMY
URETEROSTOMY TRANSPL URETER TO
SKIN
URETERORRHAPHY (SEPART PROC)
CLO URETEROCUTANEOUS FISTULA
CLO URETEROVISCERAL FISTULA
DELIGATION URETER
LAP SURG-URETEROLITHOTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
50947
Yes
LAP SURG; URETERONEOCYSTOSTOMY
W/CYSTOSCOPY
No
50948
Yes
50949
50951
Yes
Yes
50953
Yes
50955
Yes
50957
Yes
50961
50970
Yes
Yes
50972
Yes
50974
Yes
50976
Yes
50980
51000
51005
Code
LAP SURG; URETERONEOCYSTOSTOMY
W/OUT CYSTOSCOPY
LAP SURG; UNLISTED LAPAROSCOPY
PROC, URETER
URETERAL ENDO-URETEROSTOMY
URETERAL ENDO-URETEROSTOMY;
W/CATH
URETERAL ENDO-URETEROSTOMY;
W/BX
URETERAL ENDO-URETEROSTOMY;
W/FULG
URETERAL ENDO-URETEROSTMY;
REMOV FB
URETERAL ENDO-URETEROTOMY
URETERAL ENDO-URETEROTOMY;
W/CATH
No
No
No
No
No
No
No
No
No
Yes
No
URETERAL ENDO-URETEROTOMY; W/BX
URETERAL ENDO-URETEROTOMY;
W/FULG
URETERAL ENDO-URETEROTOMY;
REMOV FB
ASPIRAT BLADDER BY NEEDLE
No
No
No
No
ASPIRAT BLADDER; TROCAR/INTRACATH
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
51010
No
51020
Yes
51030
Yes
51040
Yes
51045
Yes
51050
51060
Yes
Yes
51065
Yes
51080
51100
51101
51102
Yes
No
No
No
51500
Yes
51520
Yes
51525
51530
Yes
Yes
51535
Yes
Description
ASPIRAT BLADDER; W/SUPRAPUBIC
CATH
CYSTOTOMY; W/FULG &/OR INSRT
RADIOA
CYSTOTOMY; W/CRYOSURG DESTRCT
LES
CYSTOSTOMY CYSTOTOMY
W/DRAINAGE
CYSTOTOMY W/INSRT CATH (SEP PRO)
CYSTOLITHOTMY WO VESICL NECK
RESECT
TRANSVESICAL URETEROLITHOTOMY
CYSTOTOMY W/STONE BSKT EXTRACT
CALC
DRAINAGE PERIVESICAL SPACE
ABSCESS
DRAIN BLADDER BY NEEDLE
DRAIN BLADDER BY TROCAR/CATH
DRAIN BL W/CATH INSERTION
EXC URACHAL CYST W/WO HERNIA
REPR
CYSTOTOMY; EXC VESIC NECK (SEP
PRO)
CYSTOTOMY; EXC DIVERTIC (SEP PRO)
CYSTOTOMY; EXC BLADDER TUMOR
CYSTOTOMY EXC INCS/REPR
URETEROCELE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
51550
51555
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
51565
Yes
51570
Yes
51575
Yes
51580
Yes
51585
Yes
51590
Yes
51595
Yes
51596
Yes
51597
51600
Yes
No
51605
No
51610
51700
No
No
51701
No
Description
CYSTECTOMY PART; SIMPL
CYSTECTOMY PART; COMPLIC
CYSTECTOMY PART W/REIMPLNT
URETER
CYSTECTOMY COMPLT; (SEPART PROC)
CYSTECTOMY COMPLT; W/BILAT
LUMPHADN
CYSTECTMY COMPLT
W/URETEROSIGMOIDOS
CYSTECTOMY W/URETERSIGMOID;
W/LYMPH
CYSTECTOMY COMPLT
W/URETEROILEAL
CYSTECTOMY W/SIGMOID BLAD;
W/LYMPH
CYSTECTOMY COMPLT W/CONTINENT
DIVER
PELVIC EXENTERATION-URETHRAL
MALIG
INJ PROC-CYSTOGRAPHY
INJ PROC-CONTRAST
URETHROCYSTOGRAPY
INJ PRO RETROGRD
URETHROCYSTOGRAPHY
BLADDER IRRIGA SIMPL LAVAGE
INSERT OF NON-INDWELLING BLADDER
CATHETER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
51702
No
51703
51705
No
No
51710
No
51715
No
51720
51725
51726
51736
51741
51772
No
No
No
No
No
No
51784
No
51785
51792
No
No
51795
51797
No
No
51798
No
CHANGE CYSTOSTOMY TUBE; COMPLIC
ENDO INJ IMPLNT MAT-URETH/BLAD
NECK
BLADDER INSTILL ANTICARCOGENIC
AGNT
SIMPL CYSTOMETROGRAM
COMPLX CYSTOMETROGRAM
SIMPL UROFLOWMETRY
COMPLX UROFLOWMETRY
URETHRAL PRESS PROFILE STUDIES
EMG ANAL/URETH SPHINCTER-NOT
NEEDLE
NEEDLE EMG STDY ANAL/URETHRAL
SPHIN
STIMULUS EVOKED RESPONSE
VOIDING PRESS STUDIES; BLADDER
VOID
VOIDING PRESS STUDIES; INTRA-ABD
MEASUREMENT PVR URIN&/BLADD
CAPACTY US NON-IMAG
51800
Yes
CYSTOPLASTY/CYSTOURETHROPLASTY
Description
INSERT OF TEMP INDWELLING BLADDER
CATHETER
INSERT OF NON-INDWELLING BLADDER
CATHETER COMPL
CHANGE CYSTOSTOMY TUBE; SIMPL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
51820
51840
51841
Yes
Yes
Yes
51845
51860
Yes
Yes
51865
51880
Yes
Yes
51900
51920
Yes
Yes
51925
51940
Yes
Yes
51960
51980
51990
Yes
Yes
Yes
51992
51999
Yes
Yes
52000
No
52001
No
52005
No
Description
CYSTOURETHROPLASTY
W/URETERONEOCYST
ANT VESICOURETHROPEXY; SIMPL
ANT VESICOURETHROPEXY; COMPLIC
ABD-VAG VESICAL NECK SUSP W/WO
ENDO
CYSTORRHAPHY WOUND/RUPT; SIMPL
CYSTORRHAPHY WOUND/RUPT;
COMPLIC
CLO CYSTOSTOMY (SEPART PROC)
CLO VESICOVAG FISTULA ABD
APPROACH
CLO VESICOUTERINE FISTULA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
CLO VESICOUTERINE FISTULA; W/HYST
CLO BLADDER EXSTROPHY
ENTEROCYSTOPLASTY INCL BOWEL
ANASTO
CUT VESICOSTOMY
LAP SURG; URETHRAL SUSPENSION
LAP SURG; SLING OPER-STRESS
INCONTI
UNLIS LAPS PX BLDR
No
No
CYSTOURETHROSCOPY (SEPART PROC)
CYSTURETHRSCPY W/IRRIG&EVAC
CLOTS
CYSTOURETHROSCOPY W/URETERAL
CATH
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
52007
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
52010
52204
No
No
52214
No
52224
No
52234
No
52235
No
52240
No
52250
No
52260
No
52265
No
52270
No
52275
No
52276
No
52277
52281
No
No
Description
CYSTOURETHROSCOPY; W/BRUSH BX
CYSTOURETHROSCOPY W/EJACULAT
DUCT
CYSTOURETHROSCOPY W/BX
CYSTOURETHROSCOPY W/FULG
TRIGONE
CYSTOURETHROSCOPY W/TX MINOR
LES
CYSTOURETHROSCOPY W/FULG &/ RES;
SM BLADDER TUMR
CYSTOURETHROSCOPY W/FULG; MED
TUMOR
CYSTOURETHROSCOPY W/FULG; LG
TUMOR
CYSTOURETHROSCOPY W/INSRT
RADIOACT
CYSTOURETHROSCPY W/DILAT; GEN
ANES
CYSTOURETHROSCOPY W/DIL; LOCAL
ANES
CYSTOURETHROSCOPY
W/URETHROTOMY; FE
CYSTOURETHROSCPY W/URETHROTMY;
MALE
CYSTOURETHROSCOPY W/INT
URETHROTOMY
CYSTOURETHROSCOPY W/RESECT
SPHINCT
CYSTOURETHROSCOPY W/CALIBRAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
52282
No
52283
No
52285
No
52290
No
52300
No
52301
No
52305
No
52310
No
52315
No
52317
52318
No
No
52320
No
52325
No
52327
No
52330
No
Description
CYSTOURETHSCPY W/INSRT URETH
STENT
CYSTOURETHROSCOPY W/STEROID INJ
CYSTOURETHROSCPY TX FE URETHRL
SYND
CYSTOURETHROSCOPY; W/URETERL
MEATOT
CYSTURETHROSCPY; W/RESECT
URETERCEL
CYSTURETHSCPY; RESEC ECTOP
URETOCEL
CYSTOURETHROSCOPY; W/INCS
DIVERTIC
CYSTOURETHROSCOPY (SEP PRO);
SIMPL
CYSTOURETHROSCPY (SEP PRO);
COMPLIC
LITH: CRUSH CALCU-BLADDER;
SIMPL/SM
LITH: CRUSH CALCU-BLADDER; LG
CYSTOURETHROSCOPY; W/REMOV
CALCU
CYSTOURETHROSCOPY; W/FRAGMNT
CALCU
CYSTOURETHROSCOPY; W/INJ IMPLNT
MAT
CYSTOURETHROSCOPY; W/MANIP WO
REMOV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
52332
No
52334
No
52341
No
52342
No
52343
No
52344
No
52345
No
52346
No
52351
No
52352
No
52353
No
52354
No
52355
No
Description
CYSTOURETHROSCOPY W/INSRT STENT
CYSTOURETHROSCPY W/INSRT GUIDE
WIRE
CYSTOURETHROSCOPY; W/TREATMNT
OF URETERAL STRICTURE
CYSTOURETHROSCOPY;
W/URETERPELVIC JUNCT STRICT
TRTMNT
CYSTOURETHROSCOPY; W/INTRARENAL STRICT TRTMNT
CYSTOURETHROSCOPY
W/URETEROSCOPY
CYSTOURETHROSCOPY W TRTMNT OF
INTRA RENAL STRICTURE
CYSTOURETHROSCOPY W/INTRA RENAL
STRICT TRTMNT
CYSTOURETHROSCOPY,
W/URETEROSCOPY AND/OR
PYELOSCOPY
CYSTOURETHROSCOPY W/REMOVE OR
MANIPUL OF CALCULUS
CYSTOURETHROSCOPY;
W/LITHOTRIPSY
CYSTOURETHROSCOPY; W/BX AND/OR
FULGURTION OF LESION
CYSTOURETHROSCOPY; W/RESECTION
OF TUMOR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
52400
No
52402
52450
No
No
52500
No
52510
No
52601
52606
52612
52614
No
No
No
No
52620
No
52630
No
52640
No
52647
No
52648
52649
No
Yes
52700
53000
Description
CYSTOURETHROSCOPY W/INCISION,
FULG, RESECT
CYSTURETHRSCPY TRNSURETH
RES/INCI EJACULAT DUCTS
TRANSURETHRAL INCS PROSTATE
T U R BLADDER NECK (SEPART PROC)
TRANSURETH BALOON DIL PROSTAT
URETH
T U R P INCL CONTRL POSTOP
BLEEDING
TRANSURETH FULG BLEED AFTER F/U
T U R P; 1ST STAGE OF 2
T U R P; 2ND STAGE OF 2
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
T U R; RESIDUAL OBSTRUC AFTER 90 DA
T U R; REGROWTH OBSTRUC >1YR
POSTOP
T U R; POSTOP BLADDR NECK
CONTRACTU
NON-CONTACT LASER COAGULA
PROSTATE
No
No
No
No
CONTACT LASER VAPORIZA W/WO TURP
PROSTATE LASER ENUCLEATION
TRANSURETH DRAIN PROSTATIC
ABSCESS
No
Yes
URETHROT EXT (SEP PRO); PENDULOUS
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
53010
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
53020
Yes
53025
Yes
53040
Yes
53060
Yes
53080
Yes
53085
53200
Yes
Yes
53210
Yes
53215
53220
Yes
Yes
Description
URETHROT EXT (SEP PRO); PERINEAL
MEATOTOMY (SEPART PROC); EX
INFANT
MEATOTOMY CUTTING MEATUS (SEP
PRO)
DRAINAGE DEEP PERIURETHRAL
ABSCESS
DRAINAGE SKENE'S GLAND
ABSCESS/CYST
DRAIN EXTRAVASAT; UNCOMP (SEP
PRO)
DRAIN PERINEAL EXTRAVASAT;
COMPLIC
BX URETHRA
URETHRECTMY TOT INCL CYSTOSTOMY;
FE
URETHRECTOMY TOT W/CYSTOSTOMY;
MALE
EXC/FULG CARCINOMA URETHRA
53230
Yes
EXC URETHRAL DIVERTIC (SEP PRO); FE
No
53235
Yes
No
53240
53250
Yes
Yes
53260
53265
Yes
Yes
EXC URETH DIVERTIC (SEP PRO); MALE
MARSUPIALIZ URETH DIVERTIC;
MALE/FE
EXC BULBOURETHRAL GLAND
EXC; URETHRAL POLYP/DISTAL
URETHRA
EXC/FULG; URETHRAL CARUNCLE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
53270
53275
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
53400
Yes
53405
Yes
53410
Yes
53415
Yes
53420
Yes
53425
Yes
53430
Yes
53431
Yes
53440
Yes
53442
53444
Yes
Yes
53445
53446
Yes
Yes
53447
Yes
Description
EXC/FULG; SKENE'S GLANDS
EXC/FULG; URETHRAL PROLAPSE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
URETHROPLASTY; 1ST STAGE-FISTULA
URETHROPLASTY; 2ND STAGE
W/DIVERS
No
URETHROPLSTY 1-STAGE RECON MALE
URETHROPLASTY 1 STAGE RECON
URETHRA
URETHROPLSTY 2-STAGE RECON; 1ST
STG
URETHROPLSTY 2-STAGE RECON; 2ND
STG
No
URETHROPLASTY RECON FE URETHRA
URETHRPLSTY W/TUBULARIZ PST
URETHRA
OR CORRECT MALE INCONT W/WO
PROSTH
REMOV PERINEAL PROSTH FOR
CONTINENC
INSERTION OF TANDEM CUFF
OR-CORRECT URIN INCONT
W/SPHINCTER
REMV INFLATABLE SPHNCTR W/PUMP
REMOV/REPR/REPLAC INFLATBL
SPHINCTR
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
53448
Yes
53449
Yes
53450
Yes
53460
Yes
53500
Yes
53502
Yes
53505
Yes
53510
Yes
53515
Yes
53520
53600
Yes
No
53601
No
53605
Yes
53620
No
53621
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
REMV&REPL INFLAT SPHNCTR INF FLD
SURG CORRECT ABNL INFLATBL
SPHINCTR
URETHROMEATOPLASTY W/MUCOS
ADVANCMT
URETHROMEATOPLSTY W/EXC
URETHRL SEG
URETHROLYSIS TRANSVAG SEC OPN
W/CYSTOURETHROSCPY
URETHRORRHAPHY SUTURE WOUND;
FE
URETHRORRHAPHY SUTURE WOUND;
PENILE
No
URETHRORRHAPHY WOUND; PERINEAL
URETHRORRHAPHY;
PROSTATOMEMBRANOUS
CLO URETHROSTMY FIST MALE (SEP
PRO)
DILAT URETHRAL STRICT-MALE; INIT
No
DILAT URETHRAL STRICT-MALE; SUBSQT
DILAT URETHRAL STRICT-MALE-GEN
ANES
No
DILAT URETHRAL-FILLIFORM-MALE; INIT
DILAT URETHRAL FILLIFRM-MALE;
SUBSQ
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
53660
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
53661
No
53665
Yes
53850
Yes
53852
Yes
53853
53899
Yes
Yes
Description
DILAT FE URETHRA W/SUPPOSIT; INIT
DILAT FE URETHRA W/SUPPOSIT;
SUBSQT
DILAT FE URETHRA GEN/CONDUCT
ANES
TRNSURETH DESTRUC PROSTATE;
MICWAVE
TRNSURETH DESTRUC PROSTAT;
RADIOFRQ
TU DESTRUC PROS TISS; WATRTHERMOTX
UNLISTED PROC URIN SYST
54000
No
SLIT PREPUCE DORSAL (SEP PRO); NB
No
54001
54015
54050
Yes
Yes
Yes
No
No
No
54055
Yes
SLIT PREPUCE DORSL (SEP PRO); EX NB
I&D PENIS DEEP
DESTRCT LES PENIS SIMPL; CHEM
DESTRCT LES PENIS SIMPL;
ELECTRODES
54056
Yes
No
54057
Yes
DESTRCT LES PENIS SIMPL; CRYOSURG
DESTRCT LES PENIS SIMPL; LASER
SURG
54060
Yes
DESTRCT LES PENIS SIMPL; SURG EXC
No
54065
54100
Yes
Yes
DESTRCT LES PENIS EXTEN ANY METHD
BX PENIS; (SEP PROC)
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
54105
54110
54111
54112
54115
54120
54125
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
Yes
Yes
Yes
54130
Yes
54135
54150
54152
Yes
Yes
Yes
54160
54161
54162
54163
54164
54200
Yes
Yes
Yes
Yes
Yes
No
54205
Yes
54220
No
54230
No
54231
No
Description
BX PENIS; DEEP STRUCT
EXC PENILE PLAQUE
EXC PENILE PLAQUE; W/GFT TO 5 CM
EXC PENILE PLAQUE; W/GFT > 5 CM
REMOV FB FROM DEEP PENILE TISS
AMPUTA PENIS; PART
AMPUTA PENIS; COMPLT
AMPUTA PENIS RAD; W/INGUINOFEM
LYMP
AMPUTA PENIS RAD; W/PELVIC
LYMPHADN
CIRCUMCISION USING CLAMP; NB
CIRCUMCISION USING CLAMP; EX NB
CIRCUMCISION SURG EXC NOT CLAMP;
NB
CIRCUMCISION SURG EXC; EX NB
LYSIS/EXC PENILE POST-CIRC ADHES
REPAIR INCOMPLETE CIRCUMCISION
FRENULOTOMY OF PENIS
INJ PROC PEYRONIE DISEASE
INJ PROC PEYRONIE DISEAS;
W/EXPOSUR
IRRIGA CORPORA CAVERNOSA
PRIAPISM
INJ PROC CORPORA
CAVERNOSOGRAPHY
DYNAMIC CAVERNOSOMETRY W/INJ
DRUGS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
54235
54240
No
No
54250
54300
Not Reimbursable
Yes
54304
Yes
54308
Yes
54312
Yes
54316
Yes
54318
Yes
54322
Yes
54324
Yes
54326
Yes
54328
Yes
54332
54336
Description
INJ CORPORA CAVERNOSA W/PHARM
AGENT
PENILE PLETHYSMOGRAPHY
NOCTURNAL PENILE TUMESCENCE
TEST
PLASTIC OPERAT PENIS-CHORDEE
PLASTIC OPERAT PENIS W/WO TRANSPL
URETHROPLSTY 2ND STAGE REPR; < 3
CM
URETHROPLSTY 2ND STAGE REPR; > 3
CM
URETHROPLSTY 2ND STAGE REPR;
W/GFT
URETHROPLSTY RELEAS PENIS FRM
SCROT
1 STAGE DISTAL REPR; W/SIMPL
ADVANC
1 STAGE DISTAL REPR;
W/URETHROPLSTY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
Yes
1 STAGE DISTAL REPR; MOBILIZ URETHR
1 STAGE DISTAL REPR; W/EXTEN
DISSEC
1 STAGE PENILE REPR W/EXTEN
DISSECT
No
Yes
1 STAGE PERINEAL HYPOSPADIAS REPR
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
54340
Yes
54344
Yes
54348
Yes
54352
Yes
54360
54380
Yes
Yes
Description
REPR HYPOSPADIAS COMPLIC; CLO
SIMPL
REPR HYPOSPADIAS COMPLIC; REQ
FLAPS
REPR HYPOSPADIAS COMPLIC;
W/DISSECT
REPR HYPOSPADIAS CRIPPLE
W/DISSECT
PLASTIC OR PENIS CORRECT
ANGULATION
PLASTIC OR PENIS EPISPADIAS
54385
Yes
PLASTIC-PENIS EPISPADIAS; W/INCONT
No
54390
Yes
No
54400
54401
Yes
Not Reimbursable
PLASTIC-PENIS EPISPAD; W/EXSTROPHY
INSRT PENILE PROSTH; NONINFLATABLE
INSRT PENILE PROSTH; INFLATABLE
54405
Not Reimbursable
54406
Yes
54408
Not Reimbursable
54410
Not Reimbursable
54411
Not Reimbursable
No
No
No
No
No
No
No
Not Reimbursable
INSRT PENILE PROSTH W/PLCMT PUMP
REMV INFLATABL PENIL PROSTH NO
REPL
REP CMPNT INFLATABLE PENILE
PROSTH
Not Reimbursable
REMV&REPL INFLAT PENIL PRSTH-ID OP
REMV&REPL INFLAT PNIL PRSTH-INF
FLD
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
54415
Yes
Description
REMV PENILE PROSTH NO
REPLACEMENT
54416
Yes
REMV&REPL PENILE PROSTH-SAME OP
No
54417
Yes
No
54420
Yes
54430
Yes
54435
54440
Yes
Yes
54450
54500
54505
No
Yes
Yes
54512
54520
54522
54530
Yes
Yes
Yes
Yes
54535
54550
Yes
Yes
54560
54600
Yes
Yes
REMV&REPL PENILE PROSTH-INF FIELD
CORPORA CAVERNOSA-SAPHENOUS
SHUNT
CORPORA CAVERNOSA-CORPUS
SPONGIOSUM
CORPORA CAVERNOSA-GLANS PENIS
FIST
PLASTIC OR PENIS INJURY
FORESKIN MANIP INCL LYSIS
ADHESIONS
BX TESTIS NEEDLE (SEPART PROC)
BX TESTIS INCS (SEPART PROC)
EXC OF EXTRAPARENCHYMAL LES
TESTIS
ORCHIECTOMY SIMPL W/WO PROSTH
ORCHIECTOMY, PARTIAL
ORCHIECTOMY RADICAL-TUMOR; ING
ORCHIECTOMY RADICAL; W/ABD
EXPLOR
EXPLOR UNDESCENDED TESTIS
EXPLOR UNDESCEND TESTIS W/ABD
EXPLO
REDUCTION TORSION TESTIS-SURG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
54620
54640
54650
Yes
Yes
Yes
Description
FIXA CONTRALAT TESTIS (SEPART
PROC)
ORCHIOPEXY-ING-W/WO HERNIA REPR
ORCHIOPEXY ABD APPROACH
54660
54670
54680
54690
54692
54699
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
INSRT TESTICULAR PROSTH (SEP PRO)
SUTURE/REPR TESTICULAR INJURY
TRANSPL TESTIS TO THIGH
LAP SURG; ORCHIECTOMY
LAP SURG; ORCHIOPEXY ABD TESTIS
UNLISTED LAP PROC-TESTIS
Not Reimbursable
No
No
No
No
No
54700
54800
54820
54830
Yes
Yes
Yes
Yes
No
No
No
No
54840
54860
54861
54865
54900
54901
Yes
Yes
Yes
Yes
Yes
Yes
55000
55040
55041
55060
55100
Yes
Yes
Yes
Yes
Yes
I&D EPIDIDYMIS/TESTIS &/OR SCROTAL
BX EPIDIDYMIS NEEDLE
EXPLOR EPIDIDYMIS W/WO BX
EXC LOCAL LES EPIDIDYMIS
EXC SPERMATOCELE W/WO
EPIDIDYMECTMY
EPIDIDYMECTOMY; UNILAT
EPIDIDYMECTOMY; BILAT
EXPLORE EPIDIDYMIS
EPIDIDYMOVASOSTOMY; UNILAT
EPIDIDYMOVASOSTOMY; BILAT
PUNCT ASPIRAT HYDROCELE W/WO
MEDS
EXC HYDROCELE; UNILAT
EXC HYDROCELE; BILAT
REPR TUNICA VAG HYDROCELE
DRAINAGE SCROTAL WALL ABSCESS
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
55110
55120
55150
55175
55180
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
Yes
55200
No
55250
55300
No
No
55400
55450
Not Reimbursable
No
55500
Yes
VASOVASOSTOMY VASOVASORRHAPHY
LIG VAS DEFER UNI/BILAT (SEP PRO)
EXC HYDROCELE SPERM CORD (SEP
PRO)
55520
55530
55535
55540
55550
Yes
Yes
Yes
Yes
Yes
EXC LES SPERMATIC CORD (SEP PRO)
EXC VARICOCELE; (SEPART PROC)
EXC VARICOCELE; ABD APPROACH
EXC VARICOCELE; W/HERNIA REPR
LAP SURG-W/LIG SPERMATIC VEINS
No
No
No
No
No
55559
55600
55605
55650
55680
Yes
Yes
Yes
Yes
Yes
UNLISTED LAP PROC-SPERMATIC CORD
VESICULOTOMY
VESICULOTOMY; COMPLIC
VESICULECTOMY ANY APPROACH
EXC MULLERIAN DUCT CYST
No
No
No
No
No
55700
Yes
BX PROSTATE; NEEDLE/PUNCH SNGL/MX
No
Description
SCROTAL EXPLOR
REMOV FB SCROTUM
RESECT SCROTUM
SCROTOPLASTY; SIMPL
SCROTOPLASTY; COMPLIC
VASOTOMY CANNULIZ (SEPART PROC)
VASECTOMY (SEP PRO) W/POSTOP
SEMEN
VASOTOMY-VASOGMS UNI/BILAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
55705
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
55720
Yes
55725
55801
55810
55812
Yes
Yes
Yes
Yes
55815
Yes
55821
Yes
55831
Yes
55840
Yes
55842
Yes
55845
Yes
55859
Yes
55860
Yes
55862
Yes
55865
Yes
Description
BX PROSTATE; INCS ANY APPROACH
PROSTATOMY EXT DRAIN ABSCESS;
SIMPL
PROSTATOMY DRAIN ABSCESS;
COMPLIC
PROSTATECTOMY PERINEAL SUBTL
PROSTATECTOMY PERINEAL RADICAL
PROSTATECT PERINEAL; W/NODE BX
PROSTATECT PERINEAL; W/BILAT
LYMPH
PROSTATECTOMY; SUPRAPUBIC
SUBTOT
PROSTATECTOMY; RETROPUBIC SUBTL
PROSTATECT RETROPUB RAD W/WO
NERV
PROSTATECTOMY RETROPUBIC;
W/NODE BX
PROSTATECT RETROPUBIC; W/BILAT
LYMP
PLC NDLE/CATH PROSTAT-RADELMNT
APPL
EXPOSURE PROSTATE-INSRT
RADIOACTIVE
EXPOS PROSTATE-INSRT RADIOACT;
W/BX
EXPOSURE PROSTATE-RADIOACT;
W/LYMPH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
55866
55870
55873
55875
55876
55899
55920
55970
55980
56405
56420
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
No
Not Reimbursable
Not Reimbursable
No
No
56440
56441
56442
No
No
No
56501
No
56515
No
Description
LAP SURG PROSCTOMY RETROPUB
RADL INCL NERVE SPAR
ELECTROEJACULATION
CRYOSURGICAL ABLATION PROSTATE
TRANSPERI NEEDLE PLACE, PROS
PLACE RT DEVICE/MARKER, PROS
UNLISTED PROC MALE GENIT SYST
PLACE NEEDLES PELVIC FOR RT
INTERSEX SURG; MALE TO FE
INTERSEX SURG; FE TO MALE
I&D VULVA/PERINEAL ABSCESS
I&D BARTHOLIN'S GLAND ABSCESS
MARSUPIALIZ BARTHOLIN'S GLAND
CYST
LYSIS LABIAL ADHESIONS
HYMENOTOMY
DESTRCT LES VULVA; SIMPL ANY
METHD
DESTRCT LES VULVA; EXTEN ANY
METHD
56605
No
BX VULVA/PERINEUM (SEP PRO); 1 LES
No
56606
56620
56625
56630
No
Yes
Yes
Yes
No
No
No
No
56631
Yes
BX VULVA (SEP PRO); EA SEP ADD LES
VULVECTOMY SIMPL; PART
VULVECTOMY SIMPL; COMPLT
VULVECTOMY RADICAL PART
VULVECTOMY PART; W/INGUINOFEM
LYMPH
No
Not Reimbursable
No
Yes
Yes
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
56632
56633
Yes
Yes
56634
Yes
56637
Yes
56640
Yes
56700
56720
56740
56800
56805
No
No
No
Yes
Yes
56810
56820
Yes
No
56821
57000
No
Yes
57010
57020
Yes
No
57022
No
57023
Yes
Description
VULVECT RAD PART; W/INGUINOFEM
LYMP
VULVECTOMY RADICAL COMPLT
VULVECT COMPLT; W/INGUINOFEM
LYMPH
VULVECT COMPLT; W/BILAT
INGUINOFEM
VULVECT COMPLT W/INGUINOFEM/ILIAC
PART HYMENECTOMY/REVIS HYMENAL
RING
HYMENOTOMY SIMPL INCS
EXC BARTHOLIN'S GLAND/CYST
PLASTIC REPR INTROITUS
CLITOROPLASTY INTERSEX STATE
PERINEOPLASTY NON-OB (SEPART
PROC)
COLPOSCOPY OF THE VULVA;
COLPOSCOPY OF THE VULVA; WITH
BIOPSY
COLPOTOMY; W/EXPLOR
COLPOTOMY; W/DRAIN PELVIC ABSCESS
COLPOCENTESIS (SEPART PROC)
INCISION DRAINAGE VAG HEMATOMA;
POST O/B
INCISION DRAINAGE VAG HEMATOMA;
NON O/B
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
57061
No
DESTRCT VAG LES; SIMPL ANY METHD
No
57065
No
DESTRCT VAG LES; EXTEN ANY METHD
No
57100
57105
No
Yes
BX VAG MUCOS; SIMPL (SEPART PROC)
BX VAG MUCOS; EXTEN REQ SUTURE
No
No
57106
Yes
No
57107
Yes
57109
Yes
VAGINECTOMY PART REMOV VAG WALL;
VAGINECT REMOV WALL; REMOV
PARAVAG
VAGINECT REMOV WALL;
W/LYMPHADENECT
57110
Yes
57111
Yes
57112
57120
57130
57135
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
Yes
No
No
VAGINECT COMPLT REMOV VAG WALL;
VAGINECT COMPLT REMOV WALL;
PARAVAG
VAGINECT COMPLT REMOV;
W/LYMPHADEN
COLPOCLEISIS
EXC VAG SEPTUM
EXC VAG CYST/TUMOR
No
No
No
No
No
57150
No
IRRIGA VAG &/OR APPLIC MEDICAMENT
No
57155
Yes
No
57160
57170
No
No
INSRT UTERN TANDEMS &/ VAG OVOIDS
FIT/INSRT PESSARY-OTH SUPPORT
DEVIC
DIAPHRAGM/CERVICAL CAP FITTING
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
57180
57200
Yes
Yes
57210
Yes
57220
57230
Yes
Yes
57240
Yes
57250
Yes
57260
Yes
57265
Yes
57267
No
57268
Yes
57270
57280
Yes
Yes
57282
Yes
57283
57284
57285
Yes
Yes
Yes
Description
INTRO HEMOSTATC AGENT VAG (SEP
PRO)
COLPORRHAPHY SUTURE INJURY VAG
COLPOPERINEORRHAPHY SUTURE
INJURY
PLASTIC OR URETHRAL SPHINCTVAGINAL
PLASTIC REPR URETHROCELE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
ANT COLPORRHAPHY REPR CYSTOCELE
POST COLPORRHAPHY REPR
RECTOCELE
COMBO ANTEROPOSTERIOR
COLPORRHAPHY
COMBO A-P COLPORRHAPHY;
W/ENTEROCEL
INSRT MESH/OTH REPR PELV FLR EA
SITE VAG APPRCH
No
REPR ENTEROCELE-VAGINAL (SEP PRO)
REPR ENTEROCELE-ABD (SEPART
PROC)
COLPOPEXY ABD APPROACH
COLPOPEXY VAGNIAL; EXTRAPERITONEAL APPROACH
COLPOPEXY VAGNIAL; INTRAPERITONEAL APPROACH
PARAVAGINAL DEFEC REPR
REPAIR PARAVAG DEFECT, VAG
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
57287
Yes
REMOV & REVIS SLING STRESS INCONT
No
57288
Yes
No
57289
Yes
57291
Not Reimbursable
SLING OPERATION FOR STRESS INCONT
PEREYRA PROC INCL ANT
COLPORRHAPHY
CONSTRUCTION ARTIFICIAL VAG; WO
GFT
57292
Not Reimbursable
57295
57296
Yes
Yes
57300
Yes
57305
Yes
57307
Yes
57308
57310
Yes
Yes
57311
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Not Reimbursable
CONSTRUCTION ARTIFICIAL VAG; W/GFT
REVJ RMVL PROSTC VAG GRF VAG
APPR
REVISE VAG GRAFT, OPEN ABD
CLO RECTOVAG FISTULA;
VAG/TRANSANAL
CLO RECTOVAG FISTULA; ABD
APPROACH
CLO RECTOVAG FIST; ABD
W/COLOSTOMY
Not Reimbursable
No
No
Yes
CLO RECTOVAG FIST; TRNSPERITONEAL
CLO URETHROVAGINAL FISTULA
CLO URETHROVAG FIST;
W/BULBOCAVERN
57320
Yes
CLO VESICOVAG FIST; VAG APPROACH
No
57330
57335
Yes
Yes
CLO VESICOVAG FIST; TRANSVESICAL
VAGINOPLASTY INTERSEX STATE
No
No
No
Yes
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
57400
57410
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
57415
Yes
57420
No
57421
57423
No
No
57425
57452
Yes
No
57454
No
57455
No
57456
No
57460
No
57461
No
57500
57505
57510
No
No
No
57511
57513
No
No
Description
DILAT VAG UNDER ANES
PELVIC EXAM UNDER ANES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
REMOV VAG FB (SEP PRO) UNDER ANES
COLPOSCOPY ENTIRE VAGINA
W/CERVIX IF PRESENT;
COLPOSCOPY ENTIRE VAG W/CERV IF
PRESENT; W/BX
REPAIR PARAVAG DEFECT, LAP
No
LAPAROSCOPY SURGICAL COLPOPEXY
COLPOSCOPY; (SEPART PROC)
COLPOSCOPY; W/BX-CERV &/OR
ENDOCERV
COLPOSCOPY CERV INCL UP/ADJ
VAGINA; W/BX CERVIX
COLPSCPY CERV INCL UP/ADJ VAG;
W/ENDOCERV CURET
COLPOSCOPY; W/LOOP ELECTRD EXCCERV
COLPSCPY CERV W/UP VAG; W/LOOP
ELEC CONIZAT CERV
No
No
BX 1/MX LOCAL EXC LES (SEPART PROC)
ENDOCERVICAL CURET
CAUT CERV; ELEC/THERMAL
CAUT CERV; CRYOCAUTERY
INIT/REPEAT
CAUT CERV; LASER ABLATION
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
57520
No
57522
No
57530
Yes
57531
57540
Yes
Yes
57545
57550
57555
Yes
Yes
Yes
57556
57558
57700
Yes
Yes
Yes
57720
Yes
57800
57820
Yes
No
58100
No
58110
58120
58140
Description
CONIZATION CERV W/WO D&C;
KNIF/LASR
CONIZA CERV W/WO D&C; LOOP ELEC
EXC
TRACHELECTOMY AMPUTA CERV (SEP
PRO)
RAD TRACHELECTMY W/PELV
LYMPHADENEC
EXC CERV STUMP ABD APPROACH
EXC CERV STUMP ABD; W/PELVIC
FLOOR
EXC CERV STUMP VAG APPROACH
EXC CERV STUMP VAG; W/ANT REPR
EXC CERV STUMP VAG; W/REPR
ENTEROCE
D&C OF CERVICAL STUMP
CERCLAGE UTERINE CERV NON-OB
TRACHELORRHAPHY REPR CERV-VAG
APPRO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Yes
DILAT CERV CANAL INSTRUM (SEP PRO)
DILAT & CURET CERV STUMP
ENDOMET BX W/WO ENDOCERV BX
(SEPAR)
ENDOMETRIAL BX CONJUNCT
W/COLPOSCOPY
D&C DX &/OR THERAP (NON OB)
Yes
MYOMECTOMY SNGL/MX (SEP PRO); ABD
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
58145
Yes
58146
Yes
58150
Yes
58152
Yes
58180
Yes
58200
Yes
58210
Yes
58240
58260
Yes
Yes
58262
Yes
58263
Yes
58267
58270
58275
Yes
Yes
Yes
58280
58285
Yes
Yes
Description
MYOMECTOMY SNGL/MX (SEP PRO);
VAG
MYOMECT 5/>MYOMAS&/MYOMAS W/TOT
WT>250 GMS ABD
TAH W/WO REMOV TUBE(S) - OVARY(S)
TOT HYST; W/COLPOURETHROCYSTOPEXY
SUPRACERV ABD HYST W/WO REMOV
TUBE
TAH W/PART VAGINECT W/LYMPH NODE
RAD ABD HYST W/TOT PELVIC
LYMPHADEN
PELVIC EXENTERATION-GYN MALIG
W/TAH
VAG HYST
VAG HYST; W/REMOV TUBE &/OR OVARY
VAG HYST; TUBE/OVARY W/REPR
ENTEROC
VAG HYST; W/COLPOURETHROCYSTOPEXY
VAG HYST; W/REPR ENTEROCELE
VAG HYST W/TOT/PART COLPECTOMY
VAG HYST W/COLPECT; W/REPR
ENTEROCE
VAG HYST RADICAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
58290
Yes
58291
Yes
58292
Yes
58293
Yes
58294
58300
58301
Yes
No
No
Description
VAG HYST FOR UTERUS GREATER THAN
250 GRAMS;
VAG HYST UTRUS >250 GMS; W/REMV
TUBE &/ OVARY
VAG HYST UTRUS>250 GMS; REMV T&/O
REP ENTEROCL
VAG HYST UTRUS > 250 GMS; W/COLPOURETHROCYSTPXY
VAG HYST UTERUS > 250 GRAMS;
W/REPAIR ENTEROCELE
INSRT INTRAUTERINE DEVICE
REMOV INTRAUTERINE DEVICE
58321
58322
Not Reimbursable
Not Reimbursable
ARTIFICIAL INSEMINATION; INTRA-CERV
ARTIFICIAL INSEMINAT; INTRA-UTERINE
Not Reimbursable
Not Reimbursable
58323
Not Reimbursable
Not Reimbursable
58340
Yes
58345
Not Reimbursable
58346
Yes
SPERM WASH-ARTIFICIAL INSEMINATION
CATH & INTRO SALINE/CONTRAST MATL
SIS/HSG
TRANSCERV INTRO FALLOPIAN TUBE
CATH
INSERTION HEYMAN CAPS CLIN
BRACHYTX
58350
Not Reimbursable
Not Reimbursable
58353
Yes
58356
Yes
CHROMOTUBATION OVIDUCT INCL MAT
ENDOMETR ABLATION, THERM, W/OUT
HYSTEROSCOPIC
ENDOMET CRYOABLAT W/US GUID INCL
ENDOMETRL CURET
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
58400
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
58410
Yes
58520
Yes
58540
58541
58542
58543
58544
Yes
Yes
Yes
Yes
Yes
58545
Yes
58546
58548
Yes
Yes
58550
Yes
58552
Yes
58553
Yes
58554
58555
Yes
Yes
58558
Yes
Description
UTERINE SUSPEN; (SEP PRO)
UTERINE SUSPEN; W/PRESACRAL
SYMPATH
HYSTERORRHAPHY REPR UTERUS (NONOB)
HYSTEROPLASTY REPR UTERINE
ANOMALY
LSH, UTERUS 250 G OR LESS
LSH W/T/O UT 250 G OR LESS
LSH UTERUS ABOVE 250 G
LSH W/T/O UTERUS ABOVE 250 G
LAP MYOMECT; 1-4 MYOM TOT 250
GMS/<&/SURFCE MYOM
LAP MYOMECT
EXC;5/>MYOMAS&/MYOMAS TOT WT>250
GMS
LAP RADICAL HYST
LAP SURG; W/VAG HYST W/WO REMOV
OVA
LAP VAG HYST UTRUS 250 GMS/<;
W/REMV TUBE&/OVRY
LAPARSCPY SURGICAL W/VAG HYST
UTERUS > 250 GMS;
LAP W/VAG HYST UTRUS >250 GMS;
W/REMV TUBE&/OVRY
HYSTEROSCOPY DX (SEPART PROC)
HYSTEROSCPY SURG;
W/SAMP/POLYPECT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
58559
Yes
58560
Yes
58561
58562
Yes
Yes
58563
Yes
58565
58570
58571
58572
58573
58578
Yes
Yes
Yes
Yes
Yes
Yes
58579
Yes
58600
No
HYSTEROSCOPY SURG; W/LYSIS ADHES
HYSTEROSCPY SURG; W/RESECT
SEPTUM
HYSTEROSCOPY SURG; W/REMOV
LEIOMYOM
HYSTEROSCOPY SURG; W/REMOV FB
HYSTEROSCOPY SURG; W/ENDO
ABLATION
HYSTEROSC;BIL FALLP TUBE CANNULAT
PLCMT PRM IMPL
TLH, UTERUS 250 G OR LESS
TLH W/T/O 250 G OR LESS
TLH, UTERUS OVER 250 G
TLH W/T/O UTERUS OVER 250 G
UNLISTED LAP PROC-UTERUS
UNLISTED HYSTEROSCOPY PROCUTERUS
LIG/TRANSECT FALLOPIAN TUBE
ABD/VAG
58605
58611
No
No
LIG FALLOPIAN-SAME HOSP (SEP PRO)
LIG FALLOPIAN-W/C-SECT/INTRA-ABD
No
No
58615
No
OCCLUD FALLOPIAN TUBE-DEVICE VAG
No
58660
Yes
LAP SURG; W/LYSIS ADHES (SEP PROC)
No
58661
Yes
LAP SURG; W/REMOV ADNEXAL STRUCT
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
58662
58670
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
No
58671
58672
58673
58679
No
Not Reimbursable
Yes
Yes
58700
Yes
58720
58740
58750
58752
58760
58770
58800
58805
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
58820
Yes
58822
Yes
58823
58825
Yes
Yes
Description
LAP SURG; W/FULG/EXCIS LES-OVARY
LAP SURG; W/FULG OVIDUCTS
LAP SURG; W/OCCLUS OVIDUCTSDEVICE
LAP SURG; W/FIMBRIOPLASTY
LAP SURG; W/SALPINGOSTOMY
UNLISTED LAP PROC-OVIDUCT/OVARY
SALPINGECTOMY COMPLT/PART (SEP
PRO)
SALPINGO-OOPHORECTOMY (SEPART
PROC)
LYSIS ADHESIONS
TUBOTUBAL ANASTOM
TUBOUTERINE IMPLNT
FIMBRIOPLASTY
SALPINGOSTOMY
DRAIN OVARIAN CYST (SEP PRO); VAG
DRAIN OVARIAN CYST (SEP PRO); ABD
DRAIN OVARIAN ABSC; VAG APPRCH
OPEN
DRAIN OVARIAN ABSCESS; ABD
APPROACH
DRAIN PELV ABSC TRNSVAG/RECTPERCUT
TRANSPOSITION OVARY
58900
58920
58925
Yes
Yes
Yes
BX OVARY UNILAT/BILAT (SEPART PROC)
WEDGE RESECT OVARY UNILAT/BILAT
OVARIAN CYSTECTOMY UNILAT/BILAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
58940
Yes
58943
Yes
58950
Yes
58951
Yes
58952
Yes
58953
Yes
58954
Yes
58956
58957
58958
Yes
Yes
Yes
58960
58970
58974
Yes
Not Reimbursable
Not Reimbursable
58976
58999
59000
Not Reimbursable
Yes
No
59001
59012
No
No
Description
OOPHORECTOMY PART/TOT
UNILAT/BILAT
OOPHORECTOMY; OVARIAN MALIG W/BX
RESECT OVARIAN MALIG W/SALPINGOOOP
RESECT OVARIAN MALIG; W/TAHLYMPHAD
RESECT OVARIAN MALIG; W/RAD
DISSECT
BIL S-O W/OMENTECT TAH&RADL
DEBULK;
BIL S-O OMENTECT TAH; PELV
LYMPHECT
BIL SALPINGOOOPHORECT W/TOT
OMENTECT TAH MALIG
RESECT RECURRENT GYN MAL
RESECT RECUR GYN MAL W/LYM
LAPAROTOMY STAGING OVARIAN MALIG
FOLLICLE PUNCT OOCYTE RETRIEVAL
EMBRYO TRANSF, INTRAUTERINE
GAMETE/ZYGOTE/EMBRYO INFALLOP
TRNSF
UNLISTED PROC FE GENIT SYST
AMNIOCENTESIS ANY METHD
AMNIO; THERAPEUTIC AMNIOTIC FL
RDUC
CORDOCENTESIS ANY METHD
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
59015
59020
59025
59030
No
No
No
No
CHORIONIC VILLUS SAMPL ANY METHD
FETAL CONTRACTION STRESS TEST
FETAL NON-STRESS TEST
FETAL SCLP BLD SAMPL
No
No
No
No
59050
No
No
59051
No
59070
Yes
59072
Yes
59074
Yes
59076
59100
Yes
Yes
59120
No
FETAL MONITOR-LABOR-CONS MD; S&I
FETAL MONITOR-LABOR-CONS MD;
INTERP
TRANSABD AMNIOINFUS INCLUDING
ULTRASOUND GUID
FETAL UMBILICAL CORD OCCLUSION
INCL US GUID
FETAL FLUID DRAIN INCLUDING
ULTRASOUND GUIDANCE
FETAL SHUNT PLACEMENT INCLUDING
ULTRASOUND GUID
HYSTEROTOMY ABD
SURG TX ECTOPIC PG; REQ
SALPINGECT
59121
59130
59135
No
No
No
SURG TX ECTOPIC PG; WO SALPINGECT
SURG TX ECTOPIC PG; ABD PG
SURG TX ECTOPIC PG; REQ TOT HYST
No
No
No
59136
No
No
59140
59150
No
No
SURG TX ECTOPIC PG; RESEC UTERUS
SURG TX ECTOPIC PG; CERV
W/EVACUAT
LAP TX ECTOPIC PG; WO SALPINGECT
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
59151
59160
59200
59300
59320
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
59410
No
No
Prior Authorization for Basic Health
Plan only
Prior Authorization for Basic Health
Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
59412
59414
59425
No
No
No
59325
59350
59400
59409
59426
59430
59510
Description
LAP TX ECTOPIC PG; W/SALPINGECT
CURET PP
INSRT CERV DILAT (SEPART PROC)
EPISIOTOMY-BY OTHER THAN ATTEND
MD
CERCLAGE CERV DURING PG; VAG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
CERCLAGE CERV DURING PG; ABD
No
HYSTERORRHAPHY RUPT UTERUS
No
ROUTINE OB CARE INCL VAG DEL
No
VAG DELIV ONLY
No
VAG DELIV ONLY; INCL PP CARE
EXT CEPHALIC VERSION W/WO
TOCOLYSIS
DELIV PLACENTA (SEPART PROC)
ANTEPARTUM CARE ONLY; 4-6 VISITS
ANTEPARTUM CARE ONLY; 7/MORE
VISITS
PP CARE ONLY (SEPART PROC)
No
No
No
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only ROUTINE OB CARE INCL C SECT
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
59622
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
Hosp Notification Required at time of
admission; Prior Authorzation
required for Basic Health Plan only
59812
No
Code
59514
59515
59525
59610
59612
59614
59618
59620
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
C DELIV ONLY;
No
C DELIV ONLY; INCL PP CARE
No
SUBTL/TOT HYST AFTER CESAREAN
DELIV
No
ROUT OB CARE-VAG DELIV-PREV C
DELIV
No
VAG DELIV ONLY AFTER PREV C DELIV;
No
VAG DELIV AFT PREV C DELIV; INCL PP
No
ROUT OB CARE-C DELIV-VAG TRY-PREV
C
No
C DELIV ONLY AFT VAG TRY-PREV C;
No
C DELIV AFT VAG TRY-PREV C; INCL PP
TX INCOMPL AB ANY TRIMES COMPL
SURG
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
59820
No
59821
59830
59840
59841
59850
No
No
Yes
Yes
Yes
Description
TX MISSED AB COMPL SURG; 1ST
TRIMES
TX MISSED AB COMPL SURG; 2ND
TRIMES
TX SEPTIC AB COMPLT SURGICALLY
INDUCED AB BY DILAT & CURET
INDUCED AB BY DILAT & EVACUATION
INDUCED AB BY INTRA-AMNIOTIC INJ
59851
59852
59855
Yes
Yes
Yes
INDUCED AB-INTRA-AMNIOT INJ; W/D&C
INDUCED AB BY INJ; W/HYSTEROTOMY
INDUCED AB BY VAG SUPPOS;
No
No
No
59856
Yes
No
59857
59866
Yes
Not Reimbursable
59870
59871
Yes
No
59897
Yes
59898
Yes
INDUCED AB-VAG SUPPOS; W/D&C/EVAC
INDUCED AB-VAG SUPPOS;
W/HYSTEROTMY
MULTIFETAL PG REDUCTION(S) (MPR)
UTERINE EVACU & CURET
HYDATIDIFORM
REMOV CERCLAGE SUT UNDER ANES
UNLISTED FETAL INVASV PROC INCL
ULTRASOUND GUID
UNLISTED LAP PROC-MATERNITY &
DELIV
59899
60000
60001
60100
Yes
Yes
Yes
No
UNLISTED PROC MATERN CARE & DELIV
I&D THYROGLOSSAL CYST INFEC
ASPIRAT &/OR INJ THYROID CYST
BX THYROID PERCUT CORE NEEDLE
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
60200
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
60210
Yes
60212
Yes
60220
Yes
60225
60240
Yes
Yes
60252
Yes
60254
Yes
60260
Yes
60270
Yes
60271
Yes
60280
Yes
60281
60300
Yes
No
60500
60502
Yes
Yes
Description
EXC CYST/ADENOMA THYROID
PART THYRO LOBEC UNI; W/WO
ISTHMSCT
PART THYRO LOBEC UNI; W/CNTRLAT
LOB
TOT THYR LOBEC UNI; W/WO
ISTHMUSEC
TOT THYROID LOBEC; W/CONTRALAT
LOBE
THYROIDECTOMY TOT/COMPLT
THYROIDECT-MALIG; W/LTD NECK
DISSEC
THYROIDECT-MALIG; W/RAD NECK
DISSEC
THYROIDECTOMY-REMOV REMAIN TISS
THYROIDECTOMY INCL SUBSTERNL
GLAND;
THYROIDECT INCL SUBSTERN GLND;
CERV
EXC THYROGLOSSAL DUCT CYST/SINUS
EXC THYROGLOSSAL DUCT CYST;
RECURR
ASPIR/INJ THYROID CYST
PARATHYROIDECTMY/EXPLOR
PARATHYROID
PARATHYROIDECTOMY; RE-EXPLOR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
60505
60512
Yes
Yes
60520
Yes
Description
PARATHYROIDECT; W/MEDIASTINAL
EXPLO
PARATHYROID AUTOTRANSPL
THYMECT PART/TOT; TRNCERV (SEP
PRO)
60521
Yes
THYMECT PART/TOT; STERN SPLIT (SP)
No
60522
60540
Yes
Yes
THYMECT; W/RAD MEDIAST DISSEC (SP)
ADRENALECTOMY (SEPART PROC)
No
No
60545
Yes
No
60600
Yes
ADRENALECT (SEP PRO); W/EXC TUMOR
EXC CAROTID BODY TUMOR; WO EXC
ART
60605
Yes
60650
Yes
60659
60699
Yes
Yes
61000
Yes
61001
Yes
61020
Yes
61026
Yes
EXC CAROTID BODY TUMOR; W/EXC ART
LAP SURG W/ADRENALECT
PART/COMPLT
UNLISTED LAP PROC-ENDOCRINE
SYSTEM
UNLISTED PROC ENDOCRINE SYST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
SUBDURAL TAP-FONTANEL INFANT; INIT
SUBDURAL TAP-FONTANEL; SUBSQT
TAPS
No
VENTRICULAR PUNCT-SUTURE; WO INJ
VENTRICULAR PUNCT; W/INJ DRUGDX/TX
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
61050
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
61055
Yes
61070
Yes
61105
Yes
61107
Yes
61108
61120
Description
CISTERNAL PUNCT; WO INJ (SEP PRO)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
CISTERNAL PUNCT; W/INJ DRUG-DX/TX
PUNCT SHUNT TUBE/RESERVOIRASPIRAT
TWIST DRILL HOLE SUBDUR/VENT
PUNCT;
No
No
Yes
Yes
TWIST DRILL HOLE; IMPLNT VENT CATH
TWIST DRILL HOLE; EVACUAT
HEMATOMA
BURR HOLE VENT PUNCT
No
No
61140
Yes
BURR HOLE/TREPHINE; W/BX-BRAIN/LES
No
61150
Yes
No
61151
Yes
BURR HOLE; W/DRAIN BRAIN ABSCESS
BURR HOLE; W/SUBSQT TAPPING
ABSCESS
61154
Yes
No
61156
61210
61215
Yes
Yes
Yes
No
No
No
61250
Yes
BURR HOLE W/EVACUATION HEMATOMA
BURR HOLE; W/ASPIRATINTRACEREBRAL
BURR HOLE; IMPLNT CATH (SEP PRO)
INSRT SUBQ RESERVOIR/PUMP
BURR HOLE SUPRATENTOR-NO OTHER
SURG
61253
Yes
BURR HOLE-INFRATENTORIAL-UNI/BILAT
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
61304
Yes
61305
Yes
61312
Yes
61313
Yes
61314
Yes
61315
Yes
61316
No
Description
CRANIECTOMY/-OTOMY;
SUPRATENTORIAL
CRANIECTOMY/-OTOMY;
INFRATENTORIAL
CRANIECTMY-SUPRATEN;
EXTRA/SUBDURAL
CRANIECTMY-SUPRATEN;
INTRACEREBRAL
CRANIECTMY-INFRATEN;
EXTRA/SUBDURAL
CRANIECT-INFRATENT;
INTRACEREBELLAR
INCISION & SUBQ PLACEMENT CRANIAL
BONE GRAFT
61320
Yes
CRANIECT DRAIN ABSCESS; SUPRATENT
No
61321
Yes
No
61322
Yes
61323
Yes
61330
61332
61333
61334
Yes
Yes
Yes
Yes
61340
Yes
CRANIECT DRAIN ABSCESS; INFRATENT
CRANI/CRANIOT DECOMP W/O EVAC
HEMAT; W/O LOBECT
CRANI/CRANIOT DECOMP W/O EVAC
HEMAT; W/LOBECT
DECOMP ORBIT ONLY TRANSCRAN
APPROCH
EXPLOR ORBIT; W/BX
EXPLOR ORBIT; W/REMOV LES
EXPLOR ORBIT; W/REMOV FB
OTHER CRANIAL DECOMP
SUPRATENTORIAL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
61343
Yes
CRANIECTOMY-SUBOCCIPIT W/LAMINEC
No
61345
Yes
No
61440
Yes
61450
Yes
61458
Yes
61460
Yes
61470
Yes
61480
Yes
61490
Yes
61500
61501
61510
Yes
Yes
Yes
61512
Yes
61514
Yes
OTHER CRANIAL DECOMP POST FOSSA
CRANIOT SECT TENT CEREBELI (SEP
PRO
CRANIECT-SUBTEMP-SECT GASSERIAN
GAN
CRANIECT SUBOCCIPITAL; EXPLOR
NERV
CRANIECT SUBOCCIPIT; SECT CRAN
NERV
CRANIEC SUBOCCIP; MEDULLARY
TRACTOT
CRANIECT SUBOCCIPIT;
PEDUNCULOTOMY
CRANIOTOMY LOBOTOMY INCL
CINGULOTMY
CRANIECTOMY; W/EXC TUMOR/OTHER
LES
CRANIECTOMY; OSTEOMYELITIS
CRANIECTOMY; EXC BRAIN TUMOR
CRANIECTMY; EXC MENINGOMASUPRATENT
CRANIECTOMY; EXC ABSCESSSUPRATENT
61516
Yes
CRANIECTOMY; EXC CYST-SUPRATENT
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61517
Yes
61518
61519
Yes
Yes
61520
Yes
61521
Yes
61522
61524
Yes
Yes
61526
Yes
61530
Yes
61531
Yes
61533
Yes
61534
Yes
61535
Yes
61536
Yes
61537
Yes
Description
IMPLANT BRAIN INTRACAVITARY
CHEMOTHERAPY AGENT
CRANIECT-POST FOSSA; EX
MENINGIOMA
CRANIECT-POST FOSSA; MENINGIOMA
CRANIECT-POST FOSA;
CEREBELLOPONTIN
CRANIECT; MIDLINE TUMOR @ BASE
SKUL
CRANIECTOMY INFRATENT; EXC
ABSCESS
CRANIECTOMY INFRATENT; EXC CYST
CRANIECT-TRANSTEMP; EXC
CEREBELLOPO
CRANIEC; COMBO W/POST FOSSA
CRANIOT
SUBDURAL IMPLNT STRIP ELECTRODES
CRANIOTOMY W/FLAP; IMPLNT
ELECTRODE
CRANIOT W/FLAP; EXC EPILEPTOG
FOCUS
CRANIOT W/FLP; REMOV ELECT (SEP
PRO
CRANIOT W/FLAP; EXC CEREBRAL
EPILEP
CRANIOT; LOBECT TEMPORL LOBE W/O
ELECCORTICGRPH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61538
Yes
61539
Yes
61540
Yes
61541
Yes
61542
Yes
61543
Yes
61544
61545
Yes
Yes
61546
Yes
61548
Yes
61550
Yes
61552
Yes
61556
Yes
61557
Yes
CRANIOTOMY; TOT HEMISPHERECTOMY
CRANIOT W/ELEV BN FLP;
PART/SUBTOTAL HEMISPHERCT
CRANIOT; COAGULATION CHOROID
PLEXUS
CRANIOTOMY; CRANIOPHARYNGIOMA
CRANIOTOMY-HYPOPHYSECTOMYINTRACRAN
HYPOPHYSECTOMY-TRANSNASAL
NONSTEREO
CRANIEC-CRANIOSYNOSTOSIS; 1
SUTURE
CRANIEC-CRANIOSYNOSTOSIS; MX
SUTURE
CRANIOT-CRANIOSYNOSTOSIS;
FRONTAL
CRANIOT CRANIOSYNOSTOSIS;
BIFRONTAL
61558
Yes
EXTEN CRANIEC-CRANIOSYNOS; NO GFT
Description
CRANIOTOMY W/FLAP; LOBECTOMY
TEMPORAL LOBE
CRANIOTOMY W/FLAP; LOBECTOMY NOT
TEMPORAL LOBE
CRANIOT; LOBECT NO TEMPORL LOBE
PART/TOT NO ECOG
CRANIOTMY; TRANSECT CORPUS
CALLOSUM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61559
61563
61564
Yes
Yes
Yes
61566
Yes
61567
61570
Yes
Yes
61571
Yes
61575
Yes
61576
Yes
61580
Yes
61581
Yes
61582
Yes
61583
Yes
61584
Yes
61585
Yes
61586
Yes
Description
EXTEN CRANIEC; RECONTOUR
W/OSTEOTOM
EXC BEN TUMOR; WO OPTIC NERV
EXC BEN TUMOR; W/OPTIC NERV
CRANIOT ELEV BN FLP; SELCTV
AMYGDALOHIPPOCAMPECT
CRANIOT ELEV BN FLP; MX SUBPIAL
TRANSECT W/ECOG
CRANIEC/CRANIOT; W/EXC FB BRAIN
CRANIECT; W/TX PENETRAT WOUND
BRAIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
TRANSORAL APPROACH SKULL BASE-BX
TRANSORAL-SKULL BASE; W/SPLIT
TONGU
CRANIOFAC-ANT CRAN; WO
MAXILLECTMY
No
CRANIOFAC-ANT CRAN; INCL MAXILLECT
CRANIOFAC APPROACH; ELEV FRONT
LOBE
CRANIOFAC APPROACH; RESEC FRONT
LOB
ORBITOCRAN APPROACH; WO ORBIT
EXENT
ORBITOCRAN APPROACH; W/ORBIT
EXENT
BICORON/TRANSZYGO APPRCH-ANT
CRANIA
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61590
Yes
61591
Yes
61592
Yes
61595
Yes
61596
Yes
61597
Yes
61598
Yes
61600
Yes
61601
Yes
61605
Yes
61606
Yes
61607
Yes
61608
Yes
Description
INFRATEMP APPROACH INCL
PAROTIDECT
INFRATEMP APPROACH INCL
MASTOIDECT
ORBITOCRAN ZYGOMAT APPROACH
OSTEOT
TRANSTEMP APPROACH INCL
MASTOIDECT
TRANSCOCHLR APPROACH INCL
LABYRINTH
TRNSCONDYL APPRO INCL RESECT C1C3
TRNSPETROS APPROACH INCL LIG
SINUS
RESECT/EXC LES ANT FOSSA;
EXTRADURL
RESECT/EXC LES ANT FOSSA;
INTRADURL
RESECT/EXC LES INFRATEMP;
XTRADURAL
RESECT/EXC LES INFRATEMP;
INTRADURL
RESECT/EXC LES PARASELLAR;
EXTRDURL
RESECT/EXC LES PARASELLAR;
INTRDURL
61609
61610
Yes
Yes
TRANSECT/LIG CAROTID ART; WO REPR
TRANSECT/LIG CAROTID ART; W/REPR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61611
Yes
61612
Yes
61613
Yes
61615
Yes
61616
Yes
61618
Yes
61619
Yes
61623
61624
Yes
Yes
61626
61630
Yes
Yes
61635
61640
Yes
Yes
61641
Yes
61642
Yes
SECNDRY REPR DURA; FREE TISS GFT
SECNDRY REPR DURA; LOCAL/REGION
FLP
ENDOVASC TEMP BALLOON ARTERIAL
OCCL HEAD/NECK
TRANSCATH OCCLUD PERCUT; CNS
TRANSCATH OCCLUD PERCUT; NONCNS
BALO ANGIOP ICRA PRQ
TCAT PLMT IV STENT ICRA W/BALO
ANGIOP IF PFRMD
BALO DILAT ICRA PRQ 1ST VSL
BALO DILAT ICRA PRQ EA VSL SM VASC
FAM
BALO DILAT ICRA PRQ EA VSL DIFF
VASC FAM
61680
Yes
SURG AV MALFORM; SUPRATENT-SIMPL
Description
TRANSECT CAROTID-PETROUS; WO
REPR
TRANSEC CAROTID-PETROUS; W/REPRGFT
OBLIT CAROTID ANEURY/FIST-DISSECT
RESECT/EXC LES POST FOSSA;
XTRADURL
RESECT/EXC LES POST FOSSA;
NTRADURL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61682
Yes
61684
Yes
61686
61690
61692
61697
Yes
Yes
Yes
Yes
61698
Yes
61700
Yes
61702
Yes
61703
Yes
61705
Yes
61708
Yes
61710
Yes
61711
Yes
61720
Yes
61735
Yes
Description
SURG AV MALFORM; SUPRATENT
COMPLX
SURG AV MALFORM; INFRATENT SIMPL
SURG AV MALFORM; INFRATENT
COMPLX
SURG AV MALFORM; DURAL SIMPL
SURG AV MALFORM; DURAL COMPLX
SURG COMPLEX INTRACRA ANEURY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
SURG VERTEBROBASILAR CIRCULATION
SURG ANEURY INTRACRAN; CAROTID
CIRC
SURG ANEURY INTRACRAN; VERTEBBASIL
SURG ANEURY-CERV-APPLIC CLAMPCAROT
SURG ANEURY; INTRACRAN OCCLUD
CAROT
SURG ANEURY; INTRACRAN
ELECTROTHROM
SURG ANEURY; INTRA-ART
EMBOLIZATION
No
ANASTOM ART EXTRA-INTRACRAN ART
CREAT LES-STEREOTAC; GLOBUS
PALLIDS
CREAT LES-STEREOTACTIC;
SUBCORTICAL
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
61750
Yes
STEREOTACTIC BX/EXC INTRACRAN LES
No
61751
Yes
No
61760
Yes
61770
Yes
61790
Yes
61791
Yes
61793
Yes
61795
Yes
61850
Yes
61860
Yes
61863
Yes
61864
Yes
61867
Yes
61868
Yes
STEREOTAC BX INTRACRAN LES; CT/MRI
STEREOTAC IMPLNT-ELECTRODECEREBRUM
STEREOTAC LOCALIZ W/CATH
BRACHYTHR
CREAT LES-STEREOTAC; GASSERIAN
GANG
CREAT LES-STEREOTAC; TRIGEM
MEDULRY
STEREOTACTIC RADIOSURG-1/>
SESSIONS
STEREOTAC VOLINTRA/EXTRACRAN/SPINL
IMPLNT NEUROSTIM ELECTRODESCORTICL
CRANIEC-IMPLNT NEUROSTIM-CEREBCORT
TWIST DRILL BURR HOLE CRANIOT/ECT
NO REC;1 ARRAY
TWIST DRILL BURR HOLE CRANIOT/ECT
NO REC; EA ADD
TWIST DRILL BURR HOLE CRANIOT/ECT
W/REC; 1 ARRAY
TWIST DRILL BURR HOLE CRANIOT/ECT
W/REC; EA ADD
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
61870
Yes
61875
Yes
61880
Yes
61885
Yes
61886
Yes
61888
Yes
62000
Yes
62005
62010
Yes
Yes
62100
Yes
62115
Yes
62116
Yes
62117
Yes
62120
Yes
62121
Yes
Description
CRANIECT-ELECTROD CEREBELLAR;
CORTI
CRANIECT-ELECTROD CEREBELLAR;
SUBCO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
REVIS/REMOV INTRACRAN ELECTRODES
INSRT/REPL CRANIAL NEUROSTIM
GEN/RECV; W/1 ARRAY
INSRT/REPL CRANIAL NEUROSTIM GEN;
W/ 2/> ARRAY
REVIS/REMOV CRANIAL NEUROSTIM
GEN
No
ELEVAT SKULL FX; SIMPL EXTRADURAL
ELEVAT SKULL FX; COMPOUND
EXTRADURL
ELEVAT SKULL FX; W/REPR DURA
CRANIOT-REPR CSF LEAK W/SURGOTORRH
REDUCT CRANIOMEGALIC SKULL; WO
GFT
REDUCT CRANIOMEGALIC SKULL;
W/PLSTY
No
REDUCT CRANIOMEGALIC; W/CRANIOT
REPR ENCEPHALOCELE INCL
CRANIOPLSTY
CRANIOT-REPR ENCEPHALOCE SKULL
BASE
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
62140
Yes
CRANIOPLASTY SKULL DEFECT; TO 5 CM
No
62141
Yes
No
62142
Yes
62143
Yes
62145
62146
62147
Yes
Yes
Yes
62148
Yes
62160
Yes
62161
Yes
62162
Yes
62163
Yes
62164
Yes
62165
62180
Yes
Yes
62190
Yes
CRANIOPLASTY SKULL DEFECT; > 5 CM
REMOV BONE FLAP/PROSTH PLATESKULL
REPLAC BONE FLAP/PROSTH PLATESKULL
CRANIOPLSTY-DEFEC W/REPR BRAIN
SURG
CRANIOPLASTY W/AUTOGFT; TO 5 CM
CRANIOPLASTY W/AUTOGFT; > 5 CM
INCI&RETRIEVAL SUBQ CRANIL BONE
GRAFT CRANIPLSTY
NEUROENDO IC PLCMT/REPLAC VENT
CATH SHNT SYS/EXT
NEUROENDO IC;DISSCT ADHS
FENSTRAT SEPTUM/IV CYST
NEUROENDO IC; EXC COLLOID CYST
PLCMT VENT CATH
NEUROENDO INTRACRANIAL;
W/RETRIEVAL FOREIGN BODY
NEUROENDO IC; EXC BRAIN TUMR
PLCMT EXT VENT CATH
NEUROENDO IC; W/EXC PITUIT TUMR
TRANSNASL APPRCH
VENTRICULOCISTERNOSTOMY
CREAT SHUNT;
SUBARACHNOID/SUBDURAL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
62192
Yes
CREAT SHUNT; SUBDURAL-PERITONEAL
No
62194
Yes
No
62200
Yes
62201
62220
Yes
Yes
62223
62225
Yes
Yes
62230
Yes
62252
Yes
62256
Yes
REPLAC/IRRIGA SUBARACHNOID CATH
VENTRICULOCISTERNOSTMY 3RD
VENTRICL
VENTRICULOCISTERNOST-3RD;
STEREOTAC
CREAT SHUNT; VENTRICULO-ATRIAL
CREAT SHUNT; VENTRICULOPERITONEAL
REPLAC/IRRIGA VENTRICULAR CATH
REPLAC/REVIS CSF SHUNT/OBSTRUC
VALV
REPROGRAMMING OF PROGRAMMABLE
CSF SHUNT
REMOV COMPLT CSF SHUNT; WO
REPLAC
62258
62263
Yes
Yes
No
No
62264
62268
62269
62270
62272
62273
Yes
Yes
Yes
No
Yes
No
REMOV COMPLT CSF SHUNT; W/REPLAC
PERC LYSIS EPIDUR ADHES-INCL RAD
PERQ LYSIS EPIDURL ADHES RAD LOC
MX SESS; 1 DAY
PERCUT ASPIRAT SPINAL CORD CYST
BX SPINAL CORD PERCUT NEEDLE
SPINAL PUNCT LUMBAR DX
SPINAL PUNCT THERAP-DRAIN FLUID
INJ EPIDURAL-BLOOD/CLOT PATCH
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
62280
No
Description
INJ NEUROLY W/WO OTH SUB;
SUBARACH
62281
No
INJ NEUROLY W/WO OTH SUBST; EPI C/T
No
62282
No
No
62284
Yes
62287
Yes
INJ NEUROLY W/WO OTH SUBST; EPI L/S
INJ PROC-MYELOGRPHY &/OR CATSPINAL
ASPIR/DECOMPRESS-NUC PULPOSLUMB
62290
No
62291
No
62292
Yes
62294
62310
62311
62318
62319
62350
62351
Yes
No
No
Yes
Yes
Yes
Yes
62355
Yes
62360
Yes
INJ PROC DISKOGRPHY EA LEVEL; LUMB
INJ PROC-DISKGRPHY EA LEV;
CRV/THOR
INJ PROC-CHEMONUCLEOLYSIS; 1/MX
LUM
INJ PROC ART-OCCLUD AV MALFM
SPINAL
INJ NOT LYTIC-EPIDUR; CERV/THOR
INJ NOT LYTIC-EPIDUR; LUMB/SAC
INJ NOT LYTIC-EPIDUR; CERV/THOR
INJ NOT LYTIC-EPIDUR; LUMB/SAC
IMPLNT EPIDUR CATH; WO LAMINECT
IMPLNT EPIDUR CATH; W/LAMINECT
REMOV PREV IMPLNT INTHEC/EPDUR
CATH
IMPLNT/REPLAC DEVIC-EPIDUR;
RESVOIR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
62361
Yes
62362
Yes
62365
Yes
62367
No
62368
No
63001
Yes
63003
Yes
63005
Yes
63011
Yes
63012
Yes
63015
Yes
63016
Yes
63017
Yes
63020
Yes
Description
IMPLNT/REPLC DEVIC-EPIDUR;
NONPROGM
IMPLNT/REPLAC DEVIC-EPIDUR;
PROGMBL
REMOV PREV IMPLNT SUBQ
RESVOIR/PUMP
ELEC ANALY PROGRM PUMP; WO
REPROGRM
ELEC ANALYS PROGRM PUMP;
W/REPROGRM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
LAMINECT W/EXPLOR 1-2 VERTEB; CERV
LAMINECT W/EXPLOR 1-2 VERTEB;
THORA
LAMINECT W/EXPLOR; LUMBAR EX
SPONDY
LAMINECT W/EXPLOR 1-2 SEGMT;
SACRAL
LAMINECT W/REMOV ABNL FACETSLUMBAR
No
LAMINECT W/EXPLOR > 2 SEGMT; CERV
LAMINECT W/EXPLOR > 2 SEGMT;
THORAC
LAMINECT W/EXPLOR > 2 SEGMT;
LUMBAR
LAMINOT W/DECOMP; 1 INTERSPACE
CERV
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
63030
Yes
63035
63040
63042
Yes
Yes
Yes
63043
Yes
63044
Yes
Description
LAMINOT W/ DECOMP; 1 INTERSPACE
LUM
LAMINOT; EA ADD INTERSPAC
CERV/LUMB
LAMINOTOMY RE-EXPLOR; CERV
LAMINOTOMY RE-EXPLOR; LUMBAR
LAMINOTOMY EA ADD CERV
INTERSPACE
LAMINOTOMY EA ADD LUMBAR
INTERSPACE
63045
Yes
LAMINECT 1 VERT SEGMT-UNI/BIL; CERV
No
63046
Yes
LAMINECT 1 VERT SEGMT-UNI/BIL; THOR
No
63047
63048
Yes
Yes
No
No
63050
Yes
63051
Yes
63055
Yes
63056
Yes
63057
Yes
63064
Yes
LAMINECT 1 VERT SEGMT-UNI/BIL; LUMB
LAMINECT 1 SEGMT-UNI/BIL; EA ADD
LAMINOPLASTY CERV W/DECOMP SP
CRD 2/> VERT SEG;
LAMINOPLASTY CERV 2/> SEG; RECON
POST BONY ELEM
TRANSPEDICULAR SNGL SEGMT;
THORACIC
TRANSPEDIC APPRCH W/DECOM 1 SEG;
L
TRANSPEDICULAR SNGL SEGMT; EA
ADD
COSTOVERTEBRAL THORACIC; SNGL
SEGMT
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
63066
Yes
63075
Yes
63076
Yes
63077
Yes
63078
Yes
63081
Yes
63082
Yes
63085
Yes
63086
Yes
63087
Yes
63088
Yes
63090
Yes
63091
Yes
63101
Yes
Description
COSTOVERTEB THORACIC; EA ADD
SEGMT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
DISKECT ANT; CERV SNGL INTERSPACE
DISKECT ANT; CERV EA ADD
INTERSPACE
No
DISKECT ANT; THORACIC 1 INTERSPACE
DISKECT; THORACIC EA ADD
INTERSPACE
VERTEBRAL CORPECTOMY; CERV 1
SEGMT
VERTEBRAL CORPECT; CERV EA AD
SEGMT
VERTEBRAL CORPECT; THORACIC 1
SEGMT
VERTEBRAL CORPECT; THORAC EA AD
SEG
VERTEB CORPECT LOW
THORACIC/LUMB; 1
VERTEB CORPECT THORAC/LUMB; EA
ADD
VERTEBRAL CORPECTOMY
LUMB/SACRAL; 1
VERTEB CORPECT LUMB/SACRAL; EA
ADD
VERT CORPECT W/DECOMPRS SC&/NRV
ROOT; THOR 1 SEG
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
63102
Yes
63103
Yes
63170
Yes
63172
Yes
63173
63180
63182
Yes
Yes
Yes
63185
Yes
63190
Yes
63191
Yes
63194
Yes
63195
Yes
63196
Yes
63197
63198
Description
VERT CORPECT W/DECOMPRS SC&/NRV
ROOT; LUMB 1 SEG
VERT CORPECT DECOMPRS SC&/NRV
ROOT; T/L EA ADD
LAMINECT W/MYELOTOMY
CERV/THORACIC
LAMINECT W/DRAIN CYST;
SUBARACHNOID
LAMINECT W/DRAIN CYST;
PERITONEAL/PLEURAL SPACE
LAMINECT & SECT LIGAMNT CERV; 1-2
LAMINECT & SECT LIGAMNT CERV; >2
LAMINECTOMY W/RHIZOTOMY; 1 OR 2
SEG
LAMINECTOMY W/RHIZOTOMY; > 2
SEGMT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
LAMINECT W/SECT SPINAL ACCES NERV
LAMINECTOMY W/1 SPINOTHALAMIC;
CERV
LAMINECT W/1 SPINOTHALAM;
THORACIC
LAMINECT W/BOTH SPINOTHALAMIC;
CERV
LAMINECT W/BOTH SPINOTHALAM;
THORAC
Yes
LAMINECT-2 STAGES W/IN 14 DA; CERV
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
63199
Yes
63200
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
LAMINECT-2 STAGE W/IN 14 DA; THORAC
LAMINECTOMY W/RELEASE CORD
LUMBAR
No
No
63250
Yes
LAMINECTOMY-EXC AV MALFORM; CERV
No
63251
Yes
No
63252
Yes
LAMINECT-EXC AV MALFORM; THORACIC
LAMINECT-EXC AV MALFORM;
THORACOLUM
63265
Yes
No
63266
Yes
63267
Yes
63268
Yes
LAMINECT-EXC LES-EXTRADURAL; CERV
LAMINECT-EXC LES-EXTRADURAL;
THORAC
LAMINECT EXC LES-EXTRADURAL;
LUMBAR
LAMINECT-EXC LES-EXTRADURAL;
SACRAL
63270
Yes
No
63271
Yes
63272
Yes
63273
Yes
63275
Yes
LAMINECT-EXC LES-INTRADURAL; CERV
LAMINECT-EXC LES-INTRADURAL;
THORAC
LAMINECT-EXC LES-INTRADURAL;
LUMBAR
LAMINECT-EXC LES-INTRADURAL;
SACRAL
LAMINECT BX NEOPLSM; EXTRADURLCERV
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
63276
Yes
63277
Yes
63278
Yes
63280
Yes
63281
Yes
63282
Yes
63283
Yes
63285
Yes
63286
Yes
63287
Yes
63290
Yes
63295
Yes
63300
63301
Yes
Yes
Description
LAMINECT BX NEOPLSM; EXTRADURLTHOR
LAMINECT BX NEOPLSM; EXTRADURLLUMB
LAMINECT BX NEOPLSM; EXTRADURSACRL
LAMINECT; INTRADUR EXTRAMEDUL
CERV
LAMINECT; INTRADUR EXTRAMED
THORAC
LAMINECT; INTRADUR EXTRAMEDUL
LUMB
LAMINECT-BX NEOPLSM; INTRADUR
SACRL
LAMINECT; INTRADUR INTRAMEDUL
CERV
LAMINECT; INTRADUR INTRAMEDUL
THORA
LAMINECT; INTRAMEDULLARY
THORACULUM
LAMINECTOMY; COMBO EXTRAINTRADURL
OSTEOPLASTIC RECON DORS SP FLW
PRIM INTRASP PROC
VERTEBRAL CORPECT; EXTRADURAL
CERV
VERTEB CORPECT; TRANSTHORACIC
63302
Yes
VERTEB CORPECT; THORACOLUMBAR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
63303
Yes
63304
Yes
63305
Yes
63306
Yes
63307
Yes
63308
Yes
63600
Yes
63610
Yes
63615
Yes
63650
Yes
63655
Yes
63660
Yes
63685
63688
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
VERTEB CORPECT; TRANSPERITONEAL
VERTEBRAL CORPECT; INTRADURAL
CERV
VERTEB CORPECT; INTRADURTRANSTHORA
VERTEB CORPEC; INTRADURTHORACOLUMB
VERTEB CORPECT; INTRADURTRANSPERIT
No
No
Yes
VERTEBRAL CORPECT; EA ADD SEGMT
CREAT LES-CORD-STEREOTACTIC
PERCUT
STEREOTACTIC STIM-CORD-PERQ SEP
PRO
STEREOTACTIC BX/EXC LES SPINAL
CORD
PERCUT IMPLNT ELECT ARRAY
EPIDURAL
LAMINECT IMPLNT ELECTRODE
EPIDURAL
REVIS/REMOV SPINAL
ELECTRODE/ARRAY
INSRT/REPL SPINAL NEUROSTIM PULSE
GEN/RECV
Yes
REVIS IMPLNT SPINAL NEUROSTIM GEN
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
63700
Yes
REPR MENINGOCELE; < 5 CM DIAMETER
No
63702
Yes
No
63704
Yes
63706
Yes
63707
63709
63710
63740
Yes
Yes
Yes
Yes
63741
Yes
REPR MENINGOCELE; > 5 CM DIAMETER
REPR MYELOMENINGOCELE; < 5 CM
DIAM
REPR MYELOMENINGOCELE; > 5 CM
DIAM
REPR DURAL/CSF LEAK WO
LAMINECTOMY
REPR DURAL/CSF LEAK W/LAMINECT
DURAL GFT SPINAL
CREAT SHUNT LUMBAR; W/LAMINECT
CREAT SHUNT LUMB; PERQ WO
LAMINECT
63744
Yes
REPLAC LUMBOSUBARACHNOID SHUNT
No
63746
64400
64402
Yes
No
No
No
No
No
64405
64408
64410
No
No
No
REMOV LUMBOSUBARACH SHUNT SYST
INJ ANES AGENT; TRIGEMINAL NERV
INJ ANES AGENT; FACIAL NERV
INJ ANES AGENT; GREATER OCCIPT
NERV
INJ ANES AGENT; VAGUS NERV
INJ ANES AGENT; PHRENIC NERV
64412
64413
64415
No
No
No
INJ ANES AGENT; SPINAL ACCES NERV
INJ ANES AGENT; CERV PLEXUS
INJ ANES AGENT; BRACHIAL PLEXUS
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
64416
64417
No
No
64418
No
64420
No
64421
64425
64430
No
No
No
64435
64445
No
No
64446
No
64447
No
64448
No
64449
64450
Description
INJ ANES AGT; BRACH PLEXUS CONT
CATH DAILY MGMT
INJ ANES AGENT; AXILRY NERV
INJ ANES AGENT; SUPRASCAPULAR
NERV
INJ ANES AGENT; INTERCOSTAL NERV 1
INJ ANES AGENT; INTERCOSTAL NERVMX
INJ ANES AGENT; ILIOINGUINAL NERV
INJ ANES AGENT; PUDENDAL NERV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
INJ ANES AGENT; PARACERVICAL NERV
INJ ANES AGENT; SCIATIC NERV
INJ ANES AGT; SCIATIC NRV CONT CATH
DAILY MGMT
INJECTION ANESTHETIC AGENT;
FEMORAL NERVE SINGLE
INJ ANES AGT; FEM NRV CONT INFUS
CATH DAILY MGMT
INJ ANES; LUMB PLEXUS POST CONT
INFUS DAILY MGMT
INJ ANES AGENT; OTHER PERIPHERAL
64470
No
INJ ANES FACET JT; CERV/THOR-1LEVEL
No
64472
No
INJ ANES FACET JT; CERV/THOR-EA ADD
No
64475
No
INJ ANES FACET JT; LUMB/SAC-1LEVEL
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
64476
No
INJ ANES FACET JT; LUMB/SAC-EA ADD
No
64479
No
INJ ANES EPIDUR; CERV/THOR 1 LEVEL
No
64480
64483
64484
No
No
No
No
No
No
64505
No
INJ ANES EPIDUR; CERV/THOR-EA ADD
INJ ANES EPIDUR; LUMB/SAC 1 LEVEL
INJ ANES EPIDUR; LUMB/SAC-EA ADD
INJ ANES AGENT; SPHENOPALATINE
GANG
64508
No
INJ ANES AGENT; CAROTID SINUS (SEP)
No
64510
No
No
64517
64520
64530
No
No
No
INJ ANES AGENT; STELLATE GANGLION
INJECTION ANESTHETIC AGT; SUP
HYPOGASTRIC PLEXUS
INJ ANES AGENT; LUMBAR/THORACIC
INJ ANES AGENT; CELIAC PLEXUS
64550
Yes
64553
Yes
64555
Yes
64560
Yes
64561
Yes
Description
APPLIC SURFACE NEUROSTIMULATOR
PERQ IMPLNT ELECTRODE; CRANIAL
NERV
PERQ IMPLNT ELECTRODES;
PERIPHERAL
PERQ IMPLNT ELECTRODES;
AUTONOMIC
PERQ IMPL NEUROSTIM ELEC; SAC
NERV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
64565
Yes
64573
Yes
64575
Yes
64577
Yes
64580
Description
PERQ IMPLNT ELECTRODES;
NEUROMUSCUL
INCS IMPLNT ELECTRODE; CRANIAL
NERV
INCS IMPLNT ELECTRODES;
PERIPHERAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
INCS IMPLNT ELECTRODES; AUTONOMIC
INCS IMPLNT ELECTRODES;
NEUROMUSCUL
No
No
64581
Yes
INCI IMPL NEUROSTIM ELEC; SAC NERVE
No
64585
Yes
No
64590
Yes
REVIS/REMOV PERIPHERAL ELECTRODE
INSRT/REPL PERIPHERAL NEUROSTIM
PULSE GEN/RECV
64595
Yes
REVIS/REMOV PERIPHERAL PULSE GEN
No
64600
Yes
DESTRCT TRIGEMINAL; SUPRAORBITAL
No
64605
Yes
DESTRCT TRIGEMOMAL; 2ND & 3RD DIV
No
64610
64612
Yes
Yes
No
No
64613
Yes
DESTRCT TRIGEMINAL; W/RADIOLOGIC
DESTRUC; MUSC INNERV-FACIAL NRV
DESTRCT NEUROLYT; CERV SPINAL
MUSCL
64614
Yes
DESTRUC; EXTRMTY &/OR TRUNK MUSC
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
64620
64622
Yes
Yes
DESTRUC-NEUROLYTIC INTERCOST NRV
DESTRUC FACET JT NRV; L/S-1 LEVEL
No
No
64623
Yes
No
64626
Yes
64627
Yes
64630
64640
Yes
Yes
DESTRUC FACET JT NRV; L/S-EA AD LEV
DESTRUC FACET NRV; CERV/THOR 1
LEV
DESTRUC FACET NRV; CRV/THOR-EA
ADD
DESTRCT NEUROLYTIC; PUDENDAL
NERV
DESTRCT; OTHER PERIPHERAL NERV
64650
Yes
64653
Yes
64680
Yes
64681
64702
64704
Yes
Yes
Yes
64708
Yes
64712
Yes
64713
Yes
CHEMODNRVTJ ECCRINE GLNDS BTH AX
CHEMODNRVTJ ECCRINE GLNDS OTH
AREA PR D
DESTRUC NEURLYT AGT W/WO RAD
MON; CELIAC PLEXUS
DESTRUC NEURLYT AGT; SUPERIOR
HYPOGASTRIC PLEXUS
NEUROPLASTY; DIGITAL 1/BOTH SAME
NEUROPLASTY; NERV HAND/FT
NEUROPLSTY PERIPHRL NERV; NOT
SPECI
NEUROPLSTY PERIPHERAL NERV;
SCIATIC
NEUROPLSTY PERIPHRL; BRACHIAL
PLEXS
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
64714
Yes
64716
Yes
Description
NEUROPLSTY PERIPHERL; LUMBAR
PLEXUS
NEUROPLSTY/TRANSPOSIT; CRANIAL
NERV
64718
Yes
NEUROPLASTY; ULNAR NERV @ ELBOW
No
64719
Yes
No
64721
Yes
NEUROPLASTY; ULNAR NERV @ WRIST
NEUROPLASTY; MEDIAN @ CARPAL
TUNNEL
64722
64726
64727
Yes
Yes
Yes
64732
Yes
64734
No
No
No
No
No
No
Yes
DECOMP; UNSPECIFIED NERV (SPECIFY)
DECOMP; PLANTAR DIGITAL NERV
INT NEUROLYSIS W/USE OR MICRO
TRANSECT/AVULSION SUPRAORBITAL
NERV
TRANSECT/AVULSION INFRAORBITAL
NERV
64736
Yes
TRANSECTION/AVULSION MENTAL NERV
No
64738
64740
Yes
Yes
TRANSECT INFERIOR ALVEOLAR NERV
TRANSECT/AVULSION LINGUAL NERV
No
No
64742
Yes
No
64744
64746
Yes
Yes
TRANSECT FACIAL NERV DIFF/COMPLT
TRANSECT/AVULSION GREATR OCCIP
NERV
TRANSECT/AVULSION PHRENIC NERV
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
64752
Yes
64755
Yes
Description
TRANSECT VAGUS NERV
TRANSTHORACIC
TRANSECT/VAGI LTD TO PROX
STOMACH
64760
Yes
TRANSECT/AVULSION VAGUS NERV ABD
No
64761
Yes
No
64763
Yes
64766
Yes
64771
Yes
64772
Yes
TRANSECT/AVULSION PUDENDAL NERV
TRANSECT OBTURATOR NERV
EXTRAPELVIC
TRANSECT OBTURATOR NERV
INTRAPELVIC
TRANSECT OTHR CRANIAL NERV
EXTRADUR
TRANSECT OTHER SPINAL NERV
EXTRADUR
64774
Yes
No
64776
Yes
64778
Yes
EXC NEUROMA; CUT NERV SURG IDENT
EXC NEUROMA; DIGIT NERV 1/BOTH
SAME
EXC NEUROMA; DIGIT NERV EA ADD
DIGT
64782
Yes
EXC NEUROMA; HAND/FT EX DIGIT NERV
No
64783
Yes
No
64784
64786
Yes
Yes
EXC NEUROMA; HAND/FT EA ADD NERV
EXC NEUROMA; MAJOR NERV EX
SCIATIC
EXC NEUROMA; SCIATIC NERV
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
64787
64788
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
64790
64792
64795
64802
Yes
Yes
Yes
Yes
EXC NEUROFIBROMA; MAJ PERIPHERAL
EXC NEUROFIBROMA; EXTEN
BX NERV
SYMPATHECTOMY CERV
No
No
No
No
64804
64809
64818
Yes
Yes
Yes
No
No
No
64820
64821
64822
Yes
Yes
Yes
SYMPATHECTOMY CERVICOTHORACIC
SYMPATHECTOMY THORACOLUMBAR
SYMPATHECTOMY LUMBAR
SYMPATHECTOMY DIG ARTS W/MAGNIFIEA
SYMPATHECTOMY; RADIAL ARTERY
SYMPATHECTOMY; ULNAR ARTERY
64823
Yes
SYMPATHECTOMY; SUP PALMAR ARCH
No
64831
Yes
No
64832
Yes
64834
Yes
SUTURE DIGITAL NERV HAND/FT; 1 NERV
SUTURE DIGITAL NERV HAND/FT; EA
ADD
SUTURE 1 NERV HAND/FT; COMMON
SENSO
64835
Yes
No
64836
64837
64840
Yes
Yes
Yes
SUTURE 1 NERV HAND/FT; MED MOTOR
SUTURE 1 NERV HAND/FT; ULNAR
MOTOR
SUTURE EA ADD NERV HAND/FT
SUTURE POST TIBIAL NERV
Description
IMPLNT NERV END INTO BONE/MUSCL
EXC NEUROFIBROMA; CUT NERV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
64856
Yes
64857
64858
Yes
Yes
64859
64861
64862
Yes
Yes
Yes
Description
SUTURE MAJ NERV ARM/LEG;
W/TRANSPOS
SUTURE MAJ NERV ARM/LEG; WO
TRANSPO
SUTURE SCIATIC NERV
SUTURE EA ADD MAJOR PERIPHERAL
NERV
SUTURE BRACHIAL PLEXUS
SUTURE LUMBAR PLEXUS
64864
Yes
SUTURE FACIAL NERV; EXTRACRANIAL
No
64865
64866
64868
64870
Yes
Yes
Yes
Yes
No
No
No
No
64872
64874
Yes
Yes
64876
Yes
SUTURE FACIAL NERV; INFRATEMPORAL
ANASTOM; FACIAL-SPINAL ACCES
ANASTOM; FACIAL-HYPOGLOSSAL
ANASTOM; FACIAL-PHRENIC
SUTURE NERV; W/SECNDRY/DELAY
SUTURE
SUTURE NERV; REQ EXTEN MOBILIZAT
SUTURE NERV; W/SHORTEN BONE
EXTREM
64885
Yes
NERV GFT HEAD/NECK; TO 4 CM LENGTH
No
64886
Yes
NERV GFT HEAD/NECK; > 4 CM LENGTH
No
64890
64891
Yes
Yes
NERV GFT 1 STRAND HAND/FT; TO 4 CM
NERV GFT 1 STRAND HAND/FT; > 4 CM
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
64892
64893
Yes
Yes
64895
Yes
64896
Yes
64897
Description
NERV GFT 1 STRAND ARM/LEG; TO 4 CM
NERV GFT 1 STRAND ARM/LEG; > 4 CM
NERV GFT MX STRAND HAND/FT; TO 4
CM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
NERV GFT MX STRAND HAND/FT; > 4 CM
NERV GFT MX STRAND ARM/LEG; TO 4
CM
No
No
64898
Yes
NERV GFT MX STRAND ARM/LEG; > 4 CM
No
64901
Yes
NERV GFT EA ADD NERV; SNGL STRAND
No
64902
64905
Yes
Yes
NERV GFT EA ADD NERV; MX STRANDS
NERV PEDICLE TRANSF; FIRST STAGE
No
No
64907
64910
64911
64999
Yes
Yes
Yes
Yes
No
Yes
Yes
No
65091
Yes
65093
65101
Yes
Yes
65103
Yes
NERV PEDICLE TRANSF; SECOND STAGE
NERVE REPAIR W/ALLOGRAFT
NEURORRAPHY W/VEIN AUTOGRAFT
UNLISTED PROC NERV SYST
EVISCERAT OCULAR CONTENT; WO
IMPLNT
EVISCERAT OCULAR CONTENTS;
W/IMPLNT
ENUCLEATION EYE; WO IMPLNT
ENUCLEAT EYE; MUSCL NO ATTACHIMPLT
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
65105
Yes
65110
Yes
65112
Yes
65114
Yes
65125
Yes
65130
Yes
65135
Yes
65140
65150
Yes
Yes
65155
65175
Yes
Yes
65205
No
65210
Description
ENUCLEAT EYE; MUSCL ATTACHEDIMPLNT
EXENTERATION ORBITAL CONTENTS;
ONLY
EXENTERAT ORBITAL CONTENTS;
W/BONE
EXENTERAT ORBITAL CONTENTS;
W/FLAP
MODIF OCULAR IMPLNT W/PLC PEGS
(SP)
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
INSRT OCULAR IMPLNT 2ND; AFTR EVISC
INSRT OCULAR IMPLNT 2ND; AFTR
ENUCL
No
INSRT OCULAR IMPLNT; MUSCL ATTACH
REINSRT OCULAR IMPLNT; W/WO GFT
REINSRT OCULAR IMPLNT;
W/REINFORCE
REMOV OCULAR IMPLNT
No
No
No
No
REMOV FB EXT EYE; CONJUNC SUPERF
REMOV FB EXT EYE; CONJUNC
EMBEDDED
65220
No
REMOV FB EXT EYE; CORNEAL WO LAMP
No
65222
65235
No
No
REMOV FB EXT EYE; CORNEAL W/LAMP
REMOV FB IO; ANT CHAMBER/LENS
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
65260
Yes
65265
Yes
65270
65272
65273
No
No
Yes
65275
No
65280
No
65285
65286
No
No
65290
65400
65410
No
Yes
No
65420
Yes
65426
Yes
65430
No
65435
Yes
65436
Yes
Description
REMOV FB IO; POST SEGMT MAGNETIC
REMOV FB IO; POST SEGMT
NONMAGNETC
REPR LACERAT; CONJUNC W/WO
SCLERA
REPR LACERAT; CONJUNC WO HOSP
REPR LACERAT; CONJUNC W/HOSP
REPR LACERAT; CORNEA
NONPERFORAT
REPR LACERAT; CORNEA PERFORATING
REPR LACERAT; CORNEA W/REPOSIT
TISS
REPR LACERAT; APPLIC TISS GLUE
REPR WOUND EXTRAOCULAR
MUSCL/TENDON
EXC LES CORNEA EX PTERYGIUM
BX CORNEA
EXC/TRANSPOSITION PTERYGIUM; WO
GFT
EXC/TRANSPOSITION PTERYGIUM;
W/GFT
SCRAPING CORNEA DX SMEAR &/OR
CULT
REMOV CORNEAL EPITHEL; W/WO
CHEMOCA
REMOV CORNEAL EPITHELIUM;
W/CHELAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
65450
65600
65710
Yes
Yes
Yes
65730
Yes
65750
Yes
65755
65760
65765
65767
65770
65771
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
65772
Yes
65775
Yes
65780
Yes
65781
Yes
65782
Yes
65800
Yes
65805
Yes
Description
DESTRCT LES CORNEA-CRYOTHERAPY
MX PUNCTURES ANT CORNEA
KERATOPLASTY; LAMELLAR
KERATOPLASTY; PENETRAT (EX
APHAKIA)
KERATOPLASTY; PENETRATING
(APHAKIA)
KERATOPLSTY; PENETRAT
(PSEUDOAPHAK)
KERATOMILEUSIS
KERATOPHAKIA
EPIKERATOPLASTY
KERATOPROSTHESIS
RADIAL KERATOTOMY
CORNEAL RELAXING INCS-ASTIGMATISM
CORNEAL WEDGE RESECTASTIGMATISM
OCULR SURFCE RECNSTR; AMNIOTIC
MEMBRANE TPLNT
OCULR SURFCE RECNSTR; LIMBAL STEM
CELL ALLOGFT
OCULR SURFCE RECNSTR; LIMBAL
CONJUNCT AUTOGFT
PARACENTESIS ANT CHAMBR; W/DX
ASPIR
PARACENTESIS ANT CHAMB; RELS
AQUEOS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
65810
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
65815
65820
65850
Yes
Yes
Yes
65855
Yes
65860
Yes
65865
Yes
65870
Yes
65875
Yes
65880
Yes
65900
65920
65930
66020
66030
66130
Yes
Yes
Yes
No
No
Yes
66150
Yes
66155
Yes
Description
PARACENTESIS; W/REMOV VITREOUS
PARACENTESIS (SEP PRO); W/REMOV
BLD
GONIOTOMY
TRABECULOTOMY AB EXT
TRABECULOPLSTY-LASER-1/MORE
SESSION
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
SEVERING ADHESIONS (SEPART PROC)
SEVERING ADHESIONS;
GONIOSYNECHIAE
No
SEVERING ADHESIONS; ANT SYNECHIAE
SEVERING ADHESIONS; POST
SYNECHIAE
SEVERING ADHESIONS;
CORNEOVITREAL
REMOV EPITHEL DNGROWTH ANT
CHAMBER
REMOV IMPLNT MAT ANT SEGMT EYE
REMOV BLD CLOT ANT SEGMT EYE
INJ ANT CHAMBER (SEP PRO); AIR/LIQ
INJ ANT CHAMBER (SEP PRO); MEDS
EXC LES SCLERA
No
FISTULIZ SCLERA; TREPHINAT W/IRIDEC
FISTULIZAT SCLERA;
THERMOCAUTERIZAT
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
66160
66165
Yes
Yes
66170
66172
Yes
Yes
66180
Yes
66185
Description
FISTULIZAT SCLERA; SCLERECT
W/PUNCH
FISTULIZAT SCLERA; IRIDENCLEISIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Yes
FISTULIZ SCLER; TRABECULECT AB EXT
FISTULIZAT SCLERA; TRABECULECT
AQUEOUS SHUNT-EXTRAOCULAR
RESERVOIR
REVIS AQUEOUS SHUNT-EXTOCULAR
RESER
66220
66225
Yes
Yes
REPR SCLERAL STAPHYLOMA; WO GFT
REPR SCLERAL STAPHYLOMA; W/GFT
No
No
66250
Yes
REVIS OPERATIVE WOUND ANT SEGMT
No
66500
Yes
IRIDOTOMY (SEP PRO); EX TRANSFIXION
No
66505
Yes
No
66600
Yes
66605
Yes
IRIDOTOMY (SEP PRO); W/TRANSFIXION
IRIDECTOMY W/CORNEO SECT; REMOV
LES
IRIDECTOMY W/CORNEO SECT;
W/CYCLECT
No
66625
Yes
IRIDECT; PERIPHERAL GLAU (SEP PRO)
No
66630
Yes
IRIDECTOMY; SECTOR GLAU (SEP PRO)
No
66635
Yes
IRIDECTOMY; "OPTICAL" (SEPART PROC)
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
66680
66682
66700
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
66710
Yes
66711
Yes
66720
Yes
66740
Yes
66761
Description
REPR IRIS CILIARY BODY
SUTURE IRIS CILIARY BODY (SEP PRO)
CILIARY BODY DESTRCT; DIATHERMY
CILIARY BDY DESTRUC;
CYCLOPHOTOCOAG TRANSSCLERAL
CILIARY BODY DESTRCTION;
CYCLOPHOTOCOAGULAT ENDO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
CILIARY BODY DESTRCT; CRYOTHERAPY
CILIARY BODY DESTRCT;
CYCLODIALYSIS
IRIDOTOMY/IRIDECTOMY BY LASER
SURG
66762
Yes
IRIDOPLASTY BY PHOTOCOAGULATION
No
66770
Yes
DESTRCT CYST/LES IRIS/CILIARY BODY
No
66820
Yes
No
66821
Yes
DISCISSION 2ND CATARACT; STAB INCS
DISCISSION 2ND CATARACT; LASER
SURG
66825
Yes
No
66830
Yes
No
66840
Yes
REPOSIT IO LENS REQ INCS (SEP PRO)
REMOV 2ND CATARACT W/CORNEOSCLERAL
REMOV LENS MAT; ASPIRT TECH
1/MORE
66850
Yes
REMOV LENS MAT; PHACOFRAGMENTAT
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
66852
66920
Yes
Yes
66930
66940
Yes
Yes
66982
Yes
66983
Yes
66984
66985
66986
66990
66999
Yes
Yes
Yes
No
Yes
67005
Yes
Description
REMOV LENS MAT; PARS PLANA
APPROACH
REMOV LENS MAT; INTRACAPSULAR
REMOV LENS MAT;INTRACAP-DISLOC
LENS
REMOV LENS MAT; EXTRACAPSULAR
REMOV EXTR CATARACT W/INSERT OF
INTRAOCU LENS
INTRACAPSULAR CATARACT EXTRAC
W/IOL
EXTRACAPSULAR CATARACT REMOV
IOL
INSRT IOL PROSTH (SECNDRY IMPLNT)
EXCHG IO LENS
USE OF OPHTHALMIC ENDOSCOPE
UNLISTED PROC ANT SEGMT EYE
REMOV VITREOUS ANT APPROACH;
PART
67010
Yes
REMOV VITREOUS ANT; SUBTL REMOV
No
67015
67025
Yes
Yes
No
No
67027
67028
67030
Yes
Yes
Yes
ASPIRAT/VITREOUS/SUBRETINAL FLUID
INJ VITREOUS SUBSTITUTE (SEP PRO)
IMPLNT INTRAVITREAL DRUG DELIV
SYST
INTRAVITREAL INJ-AGENT (SEP PRO)
DISCISSION VITREOUS STRANDS
67031
Yes
SEVERING VITREOUS STRANDS-LASER
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
67036
Yes
67038
Yes
67039
Yes
67040
67041
67042
67043
Yes
Yes
Yes
Yes
67101
Yes
67105
Yes
67107
Yes
67108
67110
Yes
Yes
67112
67113
67115
67120
67121
Yes
Yes
Yes
Yes
Yes
67141
Yes
Description
VITRECTOMY MECH PARS PLANA
APPROACH
VITRECTOMY MECH; W/MEMBRN
STRIPPING
VITRECTOMY MECH; W/FOCAL
ENDOLASER
VITRECTOMY MECH; W/PANRETINAL
PHOTO
VIT FOR MACULAR PUCKER
VIT FOR MACULAR HOLE
VIT FOR MEMBRANE DISSECT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
REPR RETINAL DETACH; CRYOTHERAPY
REPR RETINAL DETACH;
PHOTOCOAGULAT
REPR RETINAL DETACH; SCLERAL
BUCKL
No
REPR RETINAL DETACH; W/VITRECTOMY
REPR RETINAL DETACH; INJ AIR/GAS
REPR RETINAL DETACH; PREV OPERAT
ON
REPAIR RETINAL DETACH, CPLX
RELEASE ENCIRCLING MAT
REMOV IMPLNT MAT; EXTRAOCULAR
REMOV IMPLNT MAT POST SEGMT; IO
PROPHYLAXIS RETINAL DETACH;
CRYOTHE
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
67145
67208
Yes
Yes
67210
Yes
67218
67220
67221
Yes
Yes
Yes
67225
Yes
67227
Yes
67228
67229
Yes
Yes
67250
Yes
67255
67299
Yes
Yes
67311
Yes
67312
Description
PROPHYLAXIS RETINAL DETACH;
PHOTOCO
DESTRCT LES RETINA; CRYOTHERAPY
DESTRCT LES RETINA;
PHOTOCOAGULAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
DESTRCT LES RETINA; RADIATION-IMPLT
DESTRUC LES CHOROID-1/> SESSION
DESTRUC; PHOTODYNAMIC THPY
DSTRUC LES CHROID;PHOTODYN TX 2
EYE
DESTRCT RETINOPATHY;
CRYOTHERAPY
DESTRCT RETINOPATHY;
PHOTOCOAGULAT
TR RETINAL LES PRETERM INF
SCLERAL REINFORCE (SEP PRO); WO
GFT
No
No
No
No
No
Yes
SCLERAL REINFORCE (SEP PRO); W/GFT
UNLISTED PROC POST SEGMT
STRABISMUS SURG; 1 HORIZONTAL
MUSCL
STRABISMUS SURG; 2 HORIZONTAL
MUSCL
67314
Yes
STRABISMUS SURG; 1 VERTICAL MUSCL
No
67316
Yes
STRABISMUS SURG; 2/MORE VERTICAL
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
67318
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
67320
Yes
67331
Yes
67332
Yes
67334
Yes
67335
Description
STRABISMUS SURG SUPER OBLIQUE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
TRANSPOSITION EXTRAOCULAR MUSCL
STRABISMUS SURG-PT W/PREV EYE
SURG
STRABISMUS SURG-PT W/SCARRING
MUSCL
No
No
Yes
STRABISMUS SURG-POST FIXA SUTURE
PLCMT ADJUSTABLE SUTURESTRABISMUS
67340
Yes
STRABISMUS SURG EXPLOR &/OR REPR
No
67343
Yes
No
67345
67346
67350
67399
Yes
Yes
Yes
Yes
RELEASE EXTEN SCAR TISS (SEP PRO)
CHEMODENERVATION EXTRAOCULAR
MUSCL
BIOPSY, EYE MUSCLE
BX EXTRAOCULAR MUSCL
UNLISTED PROC OCULAR MUSCL
No
Yes
No
No
67400
Yes
ORBITOTOMY WO BONE FLAP; W/WO BX
No
67405
Yes
No
67412
Yes
67413
Yes
ORBITOTOMY WO BONE FLAP; W/DRAIN
ORBITOTOMY WO BONE FLP; W/REMOV
LES
ORBITOTOMY WO BONE FLP; W/REMOV
FB
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
67414
Yes
67415
No
67420
Yes
67430
67440
Yes
Yes
67445
67450
67500
67505
Yes
Yes
No
No
67515
67550
67560
67570
67599
No
Yes
Yes
Yes
Yes
67700
67710
67715
67800
67801
67805
67808
Description
ORBITOTOMY WO FLAP; W/REMOV BONE
FINE NEEDLE ASPIRAT ORBIT
CONTENTS
ORBITOTOMY W/BONE FLAP; W/REMOV
LES
ORBITOTOMY W/BONE FLAP; W/REMOV
FB
ORBITOTOMY W/BONE FLAP; W/DRAIN
ORBITOTOMY W/BONE FLP; W/REMOV
BONE
ORBITOTOMY W/BONE FLAP; EXPLOR
RETROBULBAR INJ; MEDS
RETROBULBAR INJ; ALCOHOL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
INJ THERAP AGENT TENON'S CAPSULE
ORBITAL IMPLNT; INSRT
ORBITAL IMPLNT; REMOV/REVIS
OPTIC NERV DECOMP
UNLISTED PROC ORBIT
BLEPHAROTOMY DRAIN ABSCESS
EYELID
SEVERING TARSORRHAPHY
CANTHOTOMY (SEPART PROC)
EXC CHALAZION; SNGL
EXC CHALAZION; MX SAME LID
EXC CHALAZION; MX DIFF LIDS
No
No
No
No
No
No
No
No
No
No
No
Yes
EXC CHALAZION; GEN ANES &/OR HOSP
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
67810
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
67820
No
67825
No
67830
67835
Yes
Yes
67840
67850
Yes
Yes
67875
Yes
67880
Yes
67882
67900
Yes
Yes
67901
Yes
67902
67903
Yes
Yes
67904
Yes
67906
Yes
67908
Yes
Description
BX EYELID
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
CORRECT TRICHIASIS; EPILAT-FORCEPS
CORREC TRICHIASIS; EPILA NOT
FORCPS
No
CORRECT TRICHIASIS; INCS LID MARGIN
CORRECT TRICHIASIS; INCS LID W/GFT
EXC LES LID WO CLO/W SMPL DIREC
CLO
DESTRCT LES LID MARGIN
No
No
No
No
No
TEMPORARY CLO EYELIDS BY SUTURE
CONSTRUCT INTERMARGINAL
ADHESIONS
No
CONSTRCT ADHESIONS; W/TRANSPOSIT
REPR BROW PTOSIS
REPR BLEPHAROPTOSIS;
W/SUTURE/OTHER
REPR BLEPHAROPTOSIS; W/FASCIAL
SLNG
REPR BLEPHAROPTOSIS; RESECT-INT
No
No
REPR BLEPHAROPTOSIS; RESECT-EXT
REPR BLEPHAROPTOSIS; SUPER
RECTUS
REPR BLEPHAROPTOSIS; CONJUNCTARSO
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
67909
67911
Yes
Yes
67912
67914
Yes
Yes
67915
Yes
67916
67917
67921
Yes
Yes
Yes
67922
Yes
67923
67924
Yes
Yes
67930
No
67935
67938
67950
67961
67966
67971
67973
67974
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
REDUCTION OVERCORRECTION PTOSIS
CORRECT LID RETRACTION
CORR LAGOPHTHALMOS W/IMPL UPPER
EYELID LID LOAD
REPR ECTROPION; SUTURE
REPR ECTROPION;
THERMOCAUTERIZATION
REPAIR ECTROPION; EXCISION TARSAL
WEDGE
REPAIR OF ECTROPION; EXTENSIVE
REPR ENTROPION; SUTURE
REPR ENTROPION;
THERMOCAUTERIZATION
REPAIR ENTROPION; EXCISION TARSAL
WEDGE
REPAIR OF ENTROPION; EXTENSIVE
SUTURE RECENT WOUND LID; PART
THICK
SUTURE RECENT WOUND LID; FULL
THICK
REMOV EMBEDDED FB EYELID
CANTHOPLASTY
EXC & REPR LID; TO 1/4 LID MARGIN
EXC & REPR EYELID > 1/4 LID MARGIN
RECON LID; UP TO 2/3 LID 1 STAGE
RECON LID; TOT LID LOWER 1 STAGE
RECON LID; TOT LID UPPER 1 STAGE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
67975
67999
68020
68040
68100
68110
68115
Yes
Yes
No
No
No
No
No
68130
68135
68200
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
No
No
RECON LID-TRANSF FLAP; 2ND STAGE
UNLISTED PROC EYELIDS
INCS CONJUNC DRAINAGE CYST
EXPRESSION CONJUNC FOLLICLES
BX CONJUNC
EXC LES CONJUNC; UP TO 1 CM
EXC LES CONJUNC; OVER 1 CM
EXC LES CONJUNC; W/ADJACENT
SCLERA
DESTRCT LES CONJUNC
SUBCONJUNCTIVAL INJ
No
No
No
No
No
No
No
No
No
No
68320
Yes
CONJUNCTIVOPLASTY; W/CONJUNC GFT
No
68325
Yes
No
68326
Yes
68328
Yes
68330
68335
Yes
Yes
68340
Yes
68360
68362
Yes
Yes
CONJUNCTIVOPLASTY; W/BUCCAL GFT
CONJUNCTIVOPLASTY CUL-DE-SAC;
W/GFT
CONJUNCTIVOPL CUL-DE-SAC; BUCCL
GFT
REPR SYMBLEPHARON;
CONJUNCTIVOPLSTY
REPR SYMBLEPHARON; W/FREE GFT
REPR SYMBLEPHARON; DIVIS
SYMBLEPHAR
CONJUNC FLAP; BRIDGE/PART (SEP
PRO)
CONJUNC FLAP; TOT
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
68371
68399
68400
68420
68440
Yes
Yes
Yes
Yes
Yes
Description
HARVESTING CONJUNCTIVAL
ALLOGRAFT LIVING DONOR
UNLISTED PROC CONJUNC
INCS DRAINAGE LACRIMAL GLAND
INCS DRAINAGE LACRIMAL SAC
SNIP INCS LACRIMAL PUNCTUM
68500
Yes
EXC LACRIMAL GLAND EX TUMOR; TOT
No
68505
68510
68520
68525
Yes
Yes
Yes
Yes
No
No
No
No
68530
Yes
68540
Yes
68550
68700
68705
68720
68745
Yes
Yes
Yes
Yes
Yes
68750
Yes
68760
Yes
EXC LACRIMAL GLAND EX TUMOR; PART
BX LACRIMAL GLAND
EXC LACRIMAL SAC
BX LACRIMAL SAC
REMOV FB/DACRYOLITH LACRIMAL
PASSG
EXC LACRIMAL GLAND TUMOR;
FRONTAL
EXC LACRIMAL GLAND TUMOR;
OSTEOTOMY
PLASTIC REPR CANALICULI
CORRECT EVERTED PUNCTUM CAUT
DACRYOCYSTORHINOSTOMY
CONJUNCTIVORHINOSTOMY; WO TUBE
CONJUNCTIVORHINOSTOMY; W/INSRT
TUBE
CLO LACRIMAL PUNCTUM;
THERMOCAUT
68761
Yes
CLO LACRIMAL PUNCTUM; BY PLUG EA
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
68770
Yes
68801
No
68810
No
68811
No
68815
68816
68840
Yes
Yes
Yes
68850
68899
69000
69005
No
Yes
No
No
69020
69090
69100
69105
69110
69120
No
Not Reimbursable
No
No
Yes
Yes
DRAIN EXT AUDITORY CANAL ABSCESS
EAR PIERCING
BX EXT EAR
BX EXT AUDITORY CANAL
EXC EXT EAR; PART SIMPL REPR
EXC EXT EAR; COMPLT AMPUTA
No
Not Reimbursable
No
No
No
No
69140
Yes
No
69145
Yes
EXC EXOSTOSIS EXT AUDITORY CANAL
EXC SOFT TISS LES EXT AUDITRY
CANAL
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
CLO LACRIMAL FISTULA (SEPART PROC)
DILAT LACRIMAL PUNCTUM W/WO
IRRIGA
No
PROBE NASOLACRIM DUCT W/WO IRRIG;
PROBE NASOLACRIM DUCT; REQ GEN
ANES
No
PROBE NASOLAC DUCT; W/INSERT TUBE
PROBE NL DUCT W/BALLOON
PROBING LACRIMAL CANALICULI
INJ CONTRAST MEDIUM
DACRYOCYSTOGPHY
UNLISTED PROC LACRIMAL SYST
DRAIN EXT EAR ABSCESS; SIMPL
DRAIN EXT EAR ABSCESS; COMPLIC
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
69150
Yes
69155
Yes
Description
RAD EXC AUDITRY CANAL LES; WO
DISSC
RAD EXC AUDITRY CANAL LES;
W/DISSEC
69200
No
REMOV FB-EXT AUDIT CANAL; WO ANES
No
69205
No
REMOV FB-EXT AUDIT CANAL; W/ANES
No
69210
69220
69222
No
No
No
No
No
No
69300
Not Reimbursable
69310
Yes
REMOV IMPACTED CERUMEN (SEP PRO)
DEBRID MASTOIDEC CAVITY SIMPL
DEBRID MASTOIDEC CAVITY COMPLX
OTOPLASTY PROTRUD EAR W/WO
REDUCT
RECON EXT AUDITORY CANAL (SEP
PRO)
69320
69399
Yes
Yes
69400
No
69401
No
69405
69420
No
No
69421
No
RECON EXT AUDITORY CANAL; 1 STAGE
UNLISTED PROC EXT EAR
EUSTACHIAN INFLAT TRNSNASAL;
W/CATH
EUSTACHIAN INFLAT TRNSNASL; WO
CATH
EUSTACHIAN TUBE CATH
TRANSTYMPANIC
MYRINGOTOMY INCL ASPIRAT
MYRINGOTOMY W/ASPIRAT REQ GEN
ANES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
69424
No
Description
VENTILAT TUBE REMOV-INSRT BY
ANOTHR
69433
69436
No
No
TYMPANOSTOMY LOCAL/TOPICAL ANES
TYMPANOSTOMY GEN ANES
No
No
69440
69450
69501
69502
69505
69511
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
69530
Yes
69535
69540
Yes
No
69550
Yes
69552
69554
69601
Yes
Yes
Yes
MID EAR EXPLOR-POSTAURICULAR INCS
TYMPANOLYSIS TRANSCANAL
TRANSMASTOID ANTROTOMY
MASTOIDEC; COMPLT
MASTOIDEC; MODIF RADICAL
MASTOIDEC; RADICAL
PETROUS APICECTOMY W/RAD
MASTOIDEC
RESECT TEMPORAL BONE EXT
APPROACH
EXC AURAL POLYP
EXC AURAL GLOMUS TUMOR;
TRANSCANAL
EXC AURAL GLOMUS TUMR;
TRANSMASTOID
EXC AURAL GLOMUS TUMOR; EXTEN
REVIS MASTOIDEC; RESULT-COMPLT
69602
Yes
No
69603
Yes
69604
Yes
REVIS MASTOIDEC; RESULT-MODIF RAD
REVIS MASTOIDEC; RESULT-RAD
MASTOID
REVIS MASTOIDEC; RESULTTYMPANOPLST
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
69605
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
69610
69620
No
Yes
69631
Yes
69632
Yes
69633
Yes
69635
Yes
69636
Yes
69637
Yes
69641
Yes
69642
69643
Yes
Yes
69644
Yes
69645
Yes
69646
69650
69660
Yes
Yes
Yes
Description
REVIS MASTOIDEC; W/APICECTOMY
TYMPANIC MEMB REPR W/WO SITE
PREP W/WO PATCH
MYRINGOPLASTY
TYMP WO MASTOIDEC; WO OSSICUL
CHAIN
TYMP WO MASTOIDEC; W/OSSICUL
CHAIN
TYMP WO MASTOIDEC; W/CHAIN &
PROSTH
TYMP W/ANTROTMY; WO OSSICULAR
CHAIN
TYMP W/ANTROTOMY; W/OSSICULAR
CHAIN
TYMP W/ANTROTOMY; W/CHAIN &
PROSTH
TYMP W/MASTOIDEC; WO OSSICULR
CHAIN
TYMP W/MASTOIDEC; W/OSSICULAR
CHAIN
TYMP W/MASTOIDEC; W/RECON WALL
TYMP W/MASTOIDEC; RECON CANAL
WALL
TYMP W/MASTOIDEC; RADICAL/COMPLT
TYMP W/MASTOIDEC; RAD W/CHAIN
RECON
STAPES MOBILIZATION
STAPEDECTOMY/STAPEDOTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
69661
Yes
69662
69666
69667
69670
69676
Yes
Yes
Yes
Yes
Yes
69700
Yes
69710
Not Reimbursable
69711
Not Reimbursable
69714
69715
Yes
Yes
69717
69718
Yes
Yes
69720
Yes
69725
Yes
69740
Yes
69745
69799
Yes
Yes
Description
STAPEDECTOMY; W/FOOTPLATE DRILL
OUT
REVIS STAPEDECTOMY/STAPEDOTOMY
REPR OVAL WINDOW FISTULA
REPR ROUND WINDOW FISTULA
MASTOID OBLIT (SEPART PROC)
TYMPANIC NEURECTOMY
CLO POSTAURICULAR FISTULA (SEP
PRO)
IMPLNT ELECTROMAGNET BONE
HEARING
REMOV ELECTROMAGNETIC BONE
HEARING
IMPLANT; OSSEOINTEGRATED,
TEMPORAL BONE
IMPLANT; W/MASTOIDECTOMY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
REPLAC; OSSEOINTEGRATED IMPLANT
REPLAC; W/MASTOIDECTOMY
DECOMP FACIAL NERV; LATGENICULATE
DECOMP FACIAL NERV; MEDGENICULATE
No
No
SUTURE FACIAL NERV; LAT-GENICULATE
SUTURE FACIAL NERV; MEDGENICULATE
UNLISTED PROC MID EAR
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
69801
69802
69805
69806
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
Yes
Yes
69820
69840
69905
69910
Yes
Yes
Yes
Yes
69915
Yes
69930
69949
Yes
Yes
69950
Yes
FENESTRATION SEMICIRCULAR CANAL
REVIS FENESTRATION OR
LABYRINTHECTOMY; TRANSCANAL
LABYRINTHECTOMY; W/MASTOIDEC
VESTIB NERV SECT
TRANSLABYRINTHINE
COCHLEAR DEVICE IMPLNT W/WO
MASTOID
UNLISTED PROC INNER EAR
VESTIBULAR NERV SECTTRANSCRANIAL
69955
69960
69970
Yes
Yes
Yes
TOT FACIAL NERV DECOMP &/OR REPR
DECOMP INT AUDITORY CANAL
REMOV TUMOR TEMPORAL BONE
No
No
No
69979
69990
Yes
Yes
UNLISTED-TEMPORAL BONE-MID FOSSA
USE OPER MICROSCOPE
No
No
70010
No
No
70015
70030
70100
No
No
No
MYELOGRAPHY POST FOSSA-RAD S & I
CISTERNOGRAPHY + CONTRAST-RAD S
&I
RAD EXAM EYE DETECTION FB
RAD EXAM MANDIB; PART < 4 VIEWS
Description
LABYRINTHOTOMY; TRANSCANAL
LABYRINTHOTOMY; W/MASTOIDEC
ENDOLYMPHATIC SAC OR; WO SHUNT
ENDOLYMPHATIC SAC OR; W/SHUNT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
70110
No
70120
70130
No
No
70134
70140
No
No
70150
No
70160
70170
70190
No
No
No
70200
No
70210
No
70220
70240
No
No
70250
No
70260
70300
No
No
RAD EXAM; ORBITS COMPLT MINI 4 VIEW
RAD EXAM SINUSES PARANASAL <3
VIEWS
RAD EXAM SINUSES PARANASAL
COMPLT-3
RAD EXAM SELLA TURCICA
RADIOLOGIC EXAMINATION SKULL; LESS
THAN 4 VIEWS
RADIOLOGIC EXAM SKULL; COMPLETE
MINIMUM 4 VIEWS
RAD EXAM TEETH; SNGL VIEW
70310
No
RAD EXAM TEETH; PART < FULL MOUTH
Description
RAD EXAM MANDIB; COMPLT MINI 4
VIEW
RAD EXAM MASTOIDS; < 3 VIEWS-SIDE
RAD EXAM MASTOIDS; COMPLT MINI 3
RAD EXAM INT AUDITORY MEATI
COMPLT
RAD EXAM FACIAL BONES; < 3 VIEWS
RAD EXAM FACIAL BONES; COMPLT MIN
3
RAD EXAM NASAL BONES COMPLT MINI
3
DACRYOCYSTOGRAPHY-RAD S & I
RAD EXAM; OPTIC FORAMINA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
70320
No
Description
RAD EXAM TEETH; COMPLT FULL
MOUTH
70328
No
RAD EXAM TMJ OPEN & CLO MOUTH; UNI
No
70330
70332
70336
70350
70355
70360
70370
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
70371
No
RAD EXAM TMJ OPEN & CLO MOUTH; BIL
TMJ ARTHROGRAPHY-RAD S & I
MRI TEMPOROMANDIBULAR JT
CEPHALOGRAM ORTHODONTIC
ORTHOPANTOGRAM
RAD EXAM; NECK SOFT TISS
RAD EXAM; PHARYNX INCL FLUORO
COMPLX DYNAMIC PHARYNGEAL &
SPEECH
70373
70380
70390
70450
70460
No
No
No
Yes
Yes
No
No
No
Yes
Yes
70470
Yes
LARYNGOGRAPHY CONTRAST-RAD S & I
RAD EXAM SALIVARY GLAND CALCU
SIALOGRAPHY-RAD S & I
CAT HEAD/BRAIN; WO CONTRAST MAT
CAT HEAD/BRAIN; W/CONTRAST MAT
CAT HEAD; WO CONTRAST THEN
CONTRAST
70480
70481
Yes
Yes
Yes
Yes
70482
Yes
70486
Yes
CAT ORBIT/SELLA/EAR; WO CONTRAST
CAT ORBIT/SELLA/EAR; W/CONTRAST
CAT ORBIT; WO CONTRAST THEN
CONTRST
CAT MAXILLOFACIAL AREA; WO
CONTRAST
No
No
Yes
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
70487
Yes
70488
70490
70491
Yes
Yes
Yes
70492
70496
70498
70540
70542
Yes
Yes
Yes
Yes
Yes
70543
70544
70545
70546
70547
70548
70549
70551
70552
70553
70554
70555
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
70557
Yes
70558
Yes
Description
CAT MAXILLOFACIAL AREA;
W/CONTRAST
CAT MAXILLOFAC; WO THEN
W/CONTRAST
CAT SOFT TISS NECK; WO CONTRAST
CAT SOFT TISS NECK; W/CONTRAST
CAT TISS NECK; WO THEN W/CONTRAST
CT ANGIO HEAD W/OUT CONTRAST
CT ANGIO NECK W/OUT CONTRAST
MRI ORBIT FACE/NECK
MRI ORBIT FACE/NECK W/CONTRAST
MRI ORBIT FACE/NECK W/OUT
CONTRAST
MRI ANGIO HEAD W/O CONTRAST
MRI ANGIO HEAD W/ CONTRAST
MRI ANGIO HEAD W/W/O CONTRAST
MRI ANGIO NECK W/O CONTRAST
MRI ANGIO NECK W/CONTRAST
MRI ANGIO NECK W/WO CONTRAST
MRI BRAIN; WO CONTRAST
MRI BRAIN; W/CONTRAST
MRI BRAIN; WO THEN W/CONTRAST
FMRI BRAIN BY TECH
FMRI BRAIN BY PHYS/PSYCH
MRI BRAIN DUR OPN INTRACRAN PROC;
W/O CONTRST
MRI BRAIN DUR OPN INTRACRAN PROC;
W/CONTRST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
70559
Yes
Description
MRI BRAIN DUR INTRACRAN;NO
CONTRST FLWED CONTRST
71010
71015
No
No
RAD EXAM CHEST; SNGL VIEW FRONTAL
RAD EXAM CHEST; STEREO FRONTAL
No
No
71020
No
No
71021
71022
No
No
71023
No
RAD EXAM CHEST 2 VIEWS FRONT & LAT
RAD EXAM CHEST-FRONT & LAT;
W/APICL
RAD EXAM CHEST; WO OBLIQ PROJ
RAD EXAM CHEST FRONT & LAT;
W/FLUOR
71030
No
No
71034
71035
71040
71060
No
No
No
No
RAD EXAM CHEST COMPLT MINI 4 VIEWS
RAD EXAM CHEST COMPLT;
W/FLOUROSCPY
RAD EXAM CHEST SPECIAL VIEWS
BRONCHOGRAPHY UNILAT-RAD S & I
BRONCHOGRAPHY BILAT-RAD S & I
No
No
No
No
71090
71100
71101
71110
71111
71120
No
No
No
No
No
No
INSRT PACEMAKER FLUORO & -RAD S & I
RAD EXAM RIBS UNILAT; 2 VIEWS
RAD EXAM RIBS UNILAT; W/PA CHEST
RAD EXAM RIBS BILAT; 3 VIEWS
RAD EXAM RIBS BILAT; W/PA CHEST
RAD EXAM; STERNUM MINI 2 VIEWS
No
No
No
No
No
No
71130
71250
No
Yes
RAD EXAM; STERNOCLAVICULAR JT/JTS
CAT THORAX; WO CONTRAST MAT
No
Yes
Yes
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
71260
71270
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
Yes
71275
71550
71551
71552
Yes
Yes
Yes
Yes
71555
72010
Yes
No
72020
72040
72050
No
No
No
72052
No
72069
No
72070
No
72072
72074
No
No
72080
72090
72100
Description
CAT THORAX; W/CONTRAST MAT
CAT THORAX; WO THEN W/CONTRAST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
CT SCAN ANGIO CHEST W/O CONTRAST
MRI CHEST
MRI CHEST W/CONTRAST
MRI CHEST W/WO CONTRAST
MRI ANGIO CHEST W/WO CONTRAST
MAT
RAD EXAM SPINE-ENTIRE-AP & LAT
RAD EXAM SPINE SNGL VIEW SPEC
LEVEL
RAD EXAM SPINE CERV; AP & LAT
RAD EXAM SPINE CERV; MINI 4 VIEWS
RAD EXAM SPINE CERV; COMPLT
W/OBLIQ
RAD EXAM SPINE THORACOLUMBAR
STAND
Yes
Yes
Yes
Yes
No
No
No
RAD EXAM SPINE; THORACIC AP & LAT
RAD EXAM SPINE; THORAC W/SWIM
VIEW
RAD EXAM SPINE; THORACIC COMPLT
RAD EXAM SPINE; THORACOLUM AP &
LAT
RAD EXAM SPINE; SCOLIOSIS STUDY
No
RAD EXAM SPINE LUMBOSACR; AP & LAT
Yes
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
72110
No
72114
No
72120
72125
72126
No
Yes
Yes
72127
72128
72129
Yes
Yes
Yes
72130
72131
72132
Yes
Yes
Yes
72133
Yes
72141
Yes
72142
Yes
72146
Yes
72147
Yes
72148
Yes
Description
RAD EXAM SPINE LUMBOSACRAL;
W/OBLIQ
RAD EXAM SPINE LUMBOSACRAL;
W/BEND
RAD EXAM SPINE LUMBOSACRAL MINI 4
CAT CERV SPINE; WO CONTRAST
CAT CERV SPINE; W/CONTRAST
CAT CERV SPINE; WO THEN
W/CONTRAST
CAT THORACIC SPINE; WO CONTRAST
CAT THORACIC SPINE; W/CONTRAST
CAT THORACIC SPINE; WO THEN
W/CONTR
CAT LUMBAR SPINE; WO CONTRAST
CAT LUMBAR SPINE; W/CONTRAST
CAT LUMBAR SPINE; WO THEN
W/CONTRST
MRI SPINAL CANAL CERV; WO
CONTRAST
MRI SPINAL CANAL CERV; W/CONTRAST
MRI SPINAL CANAL THORAC; WO
CONTRST
MRI SPINAL CANAL THORAC;
W/CONTRAST
MRI SPINAL CANAL LUMB; WO
CONTRAST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
72149
Yes
72156
Yes
72157
Yes
72158
Yes
72159
72170
Yes
No
72190
72191
72192
72193
72194
72195
72196
72197
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
72198
72200
Yes
No
72202
No
72220
72240
72255
No
No
No
Description
MRI SPINAL CANAL LUMBAR;
W/CONTRAST
MRI SPINAL WO THEN W/CONTRAST;
CERV
MRI SPINAL WO THEN W/CONTRST;
THORA
MRI SPINAL WO THEN W/CONTRAST;
LUMB
MRI ANGIO SPINAL CANAL W/WO
CONTRST
RAD EXAM PELVIS; AP ONLY
RAD EXAM PELVIS; COMPLT MINI 3 VIEW
CT ANGIO PELVIS W/O CONTRAST
CAT PELVIS; WO CONTRAST
CAT PELVIS; W/CONTRAST
CAT PELVIS; WO THEN W/CONTRAST
MRI PELVIS W/O CONTRAST
MRI PELVIS
MRI PELVIS W/O CONTRAST
MRI ANGIO PELVIS W/WO CONTRAST
MAT
RAD EXAM SACROILIAC JT; < 3 VIEWS
RAD EXAM SACROILIAC JT; 3/MORE
VIEW
RAD EXAM SACRUM & COCCYX MIN 2
VIEW
MYELOGRAPHY CERV-RAD S & I
MYELOGRAPHY THORACIC-RAD S & I
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
72265
No
72270
72275
72285
72291
72292
72295
73000
73010
73020
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
73030
No
73040
No
73050
73060
73070
No
No
No
73080
No
73085
No
73090
No
73092
73100
No
No
Description
MYELOGRAPHY LUMBOSACRAL-RAD S &
I
MYELOGRAPHY TWO/MORE REGIONS
RADIOLOGIC S&I
EPIDUROGRAPHY RAD S&I
DISKOGRAPHY CERV/THOR RAD S&I
PERQ VERTEBROPLASTY, FLUOR
PERQ VERTEBROPLASTY, CT
DISKOGRAPHY LUMBAR-RAD S & I
RAD EXAM; CLAV COMPLT
RAD EXAM; SCAPULA COMPLT
RAD EXAM SHOULDER; 1 VIEW
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
RAD EXAM SHOULDER; COMPLT MINI 2
RAD EXAM SHLDER ARTHROGRAPHY-S
&I
RAD EXAM; AC JT BILAT W/WO
DISTRACT
RAD EXAM; HUMERUS MINI 2 VIEWS
RAD EXAM ELBOW; AP & LAT VIEWS
RAD EXAM ELBOW; COMPLT MINI 3
VIEWS
RAD EXAM ELBOW ARTHROGRAPHY-S &
I
No
RAD EXAM; FOREARM AP & LAT VIEWS
RAD EXAM; UPPER EXTREM INFANT MIN
2
RAD EXAM WRIST; AP & LAT VIEWS
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
73110
No
73115
73120
73130
73140
73200
73201
No
No
No
No
Yes
Yes
73202
Yes
73206
73218
73219
73220
73221
73222
73223
Yes
Yes
Yes
Yes
Yes
Yes
Yes
73225
73500
73510
Yes
No
No
73520
No
73525
73530
No
No
Description
RAD EXAM WRIST; COMPLT MINI 3
VIEWS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
RAD EXAM WRIST ARTHROGRAPHY-S & I
RAD EXAM HAND; 2 VIEWS
RAD EXAM HAND; MINI 3 VIEWS
RAD EXAM FINGER(S) MINI 2 VIEWS
CAT UPPER EXTREM; WO CONTRAST
CAT UPPER EXTREM; W/CONTRAST
CAT UPPER EXTREM; WO THEN
W/CONTRST
No
No
No
No
Yes
Yes
CT ANGIO UPPER EXTR W/O CONTRAST
MRI UPPER EXTR W/O CONTRAST
MRI UPPER EXTR W/CONTRAST
MRI UPPER EXTREM OTHER THAN JT
MRI ANY JT UPPER EXTREM
MRI UPPER EXTR W/ CONTRAST
MRI UPPER EXTR W/O CONTRAST
MRI ANGIO UPPER EXTREM W/WO
CONTRST
RAD EXAM HIP; UNILAT 1 VIEW
RAD EXAM HIP; COMPLT MINI 2 VIEWS
RAD EXAM HIPS BILAT W/AP VIEW
PELVS
RAD EXAM HIP ARTHROGRAPHY-RAD S
&I
RAD EXAM HIP DURING OR PROC
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
73540
No
73542
73550
73560
73562
No
No
No
No
73564
73565
No
No
73580
73590
No
No
73592
73600
No
No
73610
No
73615
73620
73630
73650
73660
73700
73701
No
No
No
No
No
Yes
Yes
73702
Yes
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
RAD EXAM PELVIS & HIPS INFANT/CHILD
RAD EXAM S I JT ARTHROGRPHY RAD
S&I
RAD EXAM FEMUR AP & LAT VIEWS
RAD EXAM KNEE; ONE/TWO VIEWS
RAD EXAM KNEE; THREE VIEWS
RAD EXAM KNEE; COMPLT 4/MORE
VIEWS
RAD EXAM KNEE; BOTH STANDING AP
No
RAD EXAM KNEE ARTHROGRAPHY-S & I
RAD EXAM; TIB & FIB AP & LAT VIEWS
RAD EXAM; LOWER EXTREM INFANT MIN
2
RAD EXAM ANK; AP & LAT VIEWS
No
No
RAD EXAM ANK; COMPLT MINI 3 VIEWS
RAD EXAM ANK ARTHROGRAPHY-RAD S
&I
RAD EXAM FT; AP & LAT VIEWS
RAD EXAM FT; COMPLT MINI 3 VIEWS
RAD EXAM; CALCAN MINI 2 VIEWS
RAD EXAM; TOE(S) MINI 2 VIEWS
CAT LOWER EXTREM; WO CONTRAST
CAT LOWER EXTREM; W/CONTRAST
CAT LOWER EXTREM; WO THEN
W/CONTRST
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
73706
73718
73719
73720
73721
73722
Yes
Yes
Yes
Yes
Yes
Yes
73723
Yes
73725
74000
Yes
No
74010
No
74020
74022
74150
74160
74170
74175
74181
74182
74183
74185
74190
74210
74220
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
CT ANGIO LOWER EXTR W/O CONTRAST
MRI LOWER EXTR W/O CONTRAST
MRI LOWER EXTR W/ CONTRAST
MRI LOWER EXTREM OTHER THAN JT
MRI ANY JT LOWER EXTREM
MRI LOWER EXTR W/ CONTRAST
MRI LOWER EXTR W/O CONTRAST & W/
CONTRAST
MRI ANGIO LOWER EXTREM W/WO
CONTRST
RAD EXAM ABD; SNGL AP VIEW
RAD EXAM ABD; AP & ADD OBLIQ &
CONE
RAD EXAM ABD; COMPLT INCL
DECUBITUS
RAD EXAM ABD; COMPLT ACUTE ABD
CAT ABD; WO CONTRAST
CAT ABD; W/CONTRAST
CAT ABD; WO THEN W/CONTRAST
CT ANGIO ABD W/WO CONTRAST
MRI ABD
MRI ABD W/CONTRAST
MRI ABD W/WO CONTRAST
MRI ANGIO ABD W/WO CONTRAST MAT
PERITONEOGRAM-RAD S & I
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
RAD EXAM; PHARYNX &/OR CERV ESOPH
RAD EXAM; ESOPH
No
No
Yes
Yes
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
74230
74235
74240
74241
No
No
No
No
74245
No
74246
No
74247
No
74249
No
74250
No
74251
74260
74270
No
No
No
74280
No
74283
No
74290
No
74291
74300
Description
SWALLOWING FUNCT PHARYNX &/OR
ESOPH
REMOV FB ESOPH W/CATH-RAD S & I
RAD EXAM GI TRACT UPPER; WO KUB
RAD EXAM GI TRACT UPPER; W/KUB
RAD EXAM GI TRACT UPPER; W/SM
BOWEL
RAD EXAM GI UP-AIR CONTRAST; WO
KUB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
RAD EXAM GI UP-AIR CONTRAST; W/KUB
RAD EXAM GI-AIR CONTRST; W/SM
BOWEL
No
RAD EXAM SM BOWEL INCL MX SERIAL
RAD EXAM SM BOWEL; VIA
ENTEROCLYSIS
DUODENOGRAPHY HYPOTONIC
RAD EXAM COLON; B E W/WO KUB
RAD EXAM COLON; AIR CONTRASTBARIUM
THERAP ENEMA-CM/AIR REDUC
OBSTRUCTN
No
No
No
No
No
No
No
No
No
CHOLECYSTOGRAPHY ORAL CONTRAST
CHOLECYSTOGRPY ORAL CONTRST;
REPEAT
No
CHOLANGIOGRAPHY; INTRAOP-RAD S & I
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
74301
No
74305
No
74320
Description
CHOLANGIOGRPHY; ADD SET-INTRAOPS&I
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
CHOLANGIOGRAPHY; POSTOP-RAD S & I
CHOLANGIOG PERQ TRANSHEPATIC-S &
I
74327
74328
No
No
POSTOP BILI DUCT STONE REMOV-S & I
ENDO CATH-BILI DUCT SYST-RAD S & I
No
No
74329
No
No
74330
74340
No
No
ENDO CATH-PANCREAT DUCT SYST-S & I
COMBO ENDO CATH-BILI/PANCREAT-S &
I
INTRO LONG GI TUBE W/MX FILMS-S & I
74350
No
PERCUT PLCMT GASTRO TUBE-RAD S & I
No
74355
74360
No
No
PERQ PLCMT ENTEROCLYSIS TUBE-S & I
INTRALUMINAL DILAT STRICT-RAD S & I
No
No
74363
No
No
74400
No
74410
No
74415
No
PERQ TRANSHEPAT DILAT STRICT-S & I
UROGRAPHY IV W/WO KUB W/WO
TOMOGPHY
UROGRAPHY INFUSION DRIP &/OR
BOLUS
UROGRAPHY DRIP/BOLUS;
W/NEPHROTOM
74420
No
UROGRAPHY RETROGRADE W/WO KUB
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
74425
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
74430
No
CYSTOGRAPHY MINI 3 VIEWS-RAD S & I
No
74440
No
No
74445
No
74450
No
74455
No
VASOGRPHY/VESICULOGRPHY-RAD S & I
CORPORA CAVERNOSOGRAPHY-RAD S
&I
URETHROCYSTOGRAPHY RETROGRADES&I
URETHROCYSTOGRPHY VOIDING-RAD S
&I
74470
74475
No
No
No
No
74480
No
74485
No
74710
74740
No
YES
74742
74775
YES
No
75552
Yes
75553
75554
Yes
Yes
RAD EXAM-RENAL CYST-TRNSLUMB-S & I
INTRO INTRACATH-RENAL PELVIS-S & I
INTRO URETERAL CATH-RENAL PELVS&I
DILAT NEPHROST/URETERS/URETHRAS&I
PELVIMETRY W/WO PLACENTAL
LOCALIZ
HYSTEROSALPINGOGRAPHY-RAD S & I
TRANSCERV CATH FALLOPIAN TUBE-S &
I
PERINEOGRAM
CARDIAC MRI-MORPHOLOGY; WO
CONTRAST
CARDIAC MRI-MORPHOLOGY;
W/CONTRAST
CARDIAC MRI-FUNCT; COMPLT STUDY
Description
UROGRAPHY ANTEGRADE-RAD S & I
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
75555
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
75556
75557
75558
75559
75560
75561
75562
75563
75564
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
75600
No
75605
No
75625
No
75630
No
75635
75650
Yes
No
75658
No
75660
75662
Description
CARDIAC MRI-FUNCT; LTD STUDY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
No
No
No
No
No
No
No
No
No
CARDIAC MRI VELOCITY-FLOW MAPPING
CARDIAC MRI FOR MORPH
CARDIAC MRI FLOW/VELOCITY
CARDIAC MRI W/STRESS IMG
CARDIAC MRI FLOW/VEL/STRESS
CARDIAC MRI FOR MORPH W/DYE
CARD MRI FLOW/VEL W/DYE
CARD MRI W/STRESS IMG & DYE
HT MRI W/FLO/VEL/STRS & DYE
AORTOGRPHY THORACIC WO SERIALOGS&I
AORTOGRAPHY THORACIC-SERIALOG-S
&I
AORTOGRAPHY ABD-SERIALOG-RAD S &
I
AORTOGRAPHY ABD+BILAT ILIOFEM-S &
I
CT ANGIO ABD AORTA BILAT
ILIOFEMORAL L/E
ANGIO CERVICOCEREBRAL CATH-S&I
ANGIO BRACHIAL RETROGRADE-RAD S &
I
ANGIO EXT CAROTID UNILAT SELECTS&I
No
ANGIO EXT CAROTID BILAT SELECT-S&I
No
No
No
No
No
Yes
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
75665
No
ANGIO CAROTID CEREBRAL UNILAT-S & I
No
75671
No
ANGIO CAROTID CEREBRAL BILAT-S & I
No
75676
75680
No
No
No
No
75685
75705
75710
75716
No
No
No
No
ANGIO CAROTID CERV UNILAT-RAD S & I
ANGIO CAROTID CERV BILAT-RAD S & I
ANGIO VERTEBRAL CERV/INTRACRANS&I
ANGIO SPINAL SELECT-RAD S & I
ANGIO EXTREM UNILAT-RAD S & I
ANGIO EXTREM BILAT-RAD S & I
75722
No
ANGIO RENAL UNILAT SELECT-RAD S & I
No
75724
No
No
75726
No
75731
No
ANGIO RENAL BILAT SELECT-RAD S & I
ANGIO VISCERAL SELEC/SUPRASELECS&I
ANGIO ADRENAL UNILAT SELECT-RAD
S&I
75733
No
ANGIO ADRENAL BILAT SELEC-RAD S & I
No
75736
No
ANGIO PELVIC SELEC/SUPRASELEC-S & I
No
75741
75743
No
No
No
No
75746
No
ANGIO PULM UNILAT SELECT-RAD S & I
ANGIO PULM BILAT SELECT-RAD S & I
ANGIO PULM-NONSELECT CATH-RAD S &
I
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
75756
75774
75790
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
75801
No
75803
No
Description
ANGIO INT MAMMARY-RAD S & I
ANGIO SELECT EA ADD VESSEL-S&I
ANGIO AV SHUNT-RAD S & I
LYMPHANGIOG EXTREM ONLY UNILATS&I
LYMPHANGIOG EXTREM ONLY BILAT-S &
I
75805
No
LYMPHANGIO PELVIC/ABD UNILAT-S & I
No
75807
No
No
75809
75810
No
No
75820
No
LYMPHANGIOG PELVIC/ABD BILAT-S & I
SHUNTOGM INVESTIGAT PREV PLACEDS&I
SPLENOPORTOGRAPHY-RAD S & I
VENOGRAPHY EXTREM UNILAT-RAD S &
I
75822
No
75825
No
75827
No
75831
No
75833
No
75840
No
No
No
No
No
No
VENOGRAPHY EXTREM BILAT-RAD S & I
VENOGRAPHY CAVAL INFERIOR-RAD S &
I
No
VENOGRAPHY CAVAL SUPER-RAD S & I
VENOGRPHY RENAL UNILAT SELECT-S &
I
VENOGRAPHY RENAL BILAT SELECT-S &
I
VENOGRPHY ADRENAL UNILAT SELECTS&I
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
75842
No
75860
No
75870
75872
75880
No
No
No
75885
No
75887
No
75889
No
75891
No
75893
No
75894
No
75896
No
Description
VENOGRAPHY ADRENAL BILAT SELECTS&I
VENOGRAPHY VENOUS SINUS/JUGULAR
CATHETER RAD S&I
VENOGRPHY SUPER SAGIT SINUS-RAD
S&I
VENOGRAPHY EPIDURAL-RAD S & I
VENOGRAPHY ORBITAL-RAD S & I
PERQ TRANSHEPAT PORTOG W/EVAL-S
&I
PERQ TRANSHEPAT PORTOG WO EVALS&I
HEPAT VENOG WEDGED/FREE W/EVALS&I
HEPAT VENOG WEDGED/FREE WO EVALS&I
VENOUS SAMPL-CATH W/WO ANGIO-S &
I
TRANSCATH THERAP EMBOLIZAT-RAD
S&I
TRANSCATH THERAP INFUSION-RAD S &
I
75898
No
ANGIO-EXIST CATH F/U STUDY-THERAP
No
75900
No
No
75901
No
EXCHG PREV PLCD ART CATH-RAD S & I
MECH REMV PERICATH OBST CV DEV
SEP ACSS RAD S&I
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
75902
75940
75945
No
No
No
75946
No
75952
Yes
75953
Yes
75954
Yes
75956
No
75957
No
75958
No
75959
No
75960
No
75961
No
75962
No
75964
No
Description
MECH REMV INTRALUM OBST CV DEV
THRU LUMN RAD S&I
PERCUT PLCMT IVC FILTER-RAD S & I
INTRAVASC US RAD S/I; INITIAL VESSL
INTRAVASC US S/I; EA ADD NON-CORN
TRANSCATHETER REPR INFRARENAL
ABD AORTIC ANEURY
TRANSCATHETER PLACEMNT
PROX/DIST EXTEN PROSTETH
ENDVSC REP ILIAC ART ANEUR AV
MAL/TRAUMA RAD S&I
EVASC RPR DTA COVERAGE L SUBCLA
ORIGIN RS&I
EVASC RPR DTA X COVERAGE L SUBCLA
ORIGIN RS&I
PLMT PROX XTN PROSTH EVASC RPR
DTA RS&I
PLMT DSTL XTN PROSTH AFTER EVASC
RPR DTA RS&I
TRANSCATH INTRO INTRAVASC STENT
RAD S&I EA VES
TRANSCATH RETRIEVAL PERQ IV FB-S&I
TRANSLUM BALLOON ANGIOPL PERIPHS&I
TRANSLUM BALLOON ANGIOPL EA ADDS&I
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
75966
No
75968
75970
No
No
75978
75980
No
No
75982
No
75984
No
75989
No
75992
No
75993
No
75994
No
75995
No
75996
No
75998
No
Description
TRANSLUM BALOON ANGIOPL RENAL-S
&I
TRNSLUM BALN ANGIOPL EA ADD
VISCER
TRANSCATH BX-RAD S & I
TRANSLUM BALLOON ANGIOPL VENOUSS&I
PERQ TRANSHEP BILI DRAIN-RAD S&I
PERQ PLCMT CATH-INOPER OBSTRCTS&I
CHANGE PERQ DRAIN CATH W/MONITS&I
RAD GUID PERC DRAIN ABSC W/CATHS&I
TRANSLUM ATHERECT PERIPHER ARTS&I
TRANSLUM ATHERECT EA ADD PERIPHS&I
TRANSLUMNL ATHERECT RENAL-RAD S
&I
TRANSLUM ATHERECT VISCERAL-RAD
S&I
TRANSLUM ATHERECT EA ADD VISCERS&I
FLUORO GUID CVAD PLACEMENT
REPLACEMENT/REMOVAL
76000
No
FLUORO (SEP) TO 1HR-NOT 71023/71034
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
76001
No
Description
FLUORO-TIME > 1HR-ASSIST NON-RAD
MD
76003
No
FLUORO LOCALIZ NEEDLE BX/ASPIRAT
No
76005
76006
No
No
No
No
76010
No
76012
Not Reimbursable
76013
76020
76040
76061
Not Reimbursable
No
No
No
FLUORO GUID NEEDLE-SPINE INJ PROC
RAD EXAM STRESS VIEW(S) ANY JT
RAD EXAM NOSE-RECTUM FB-SNGLCHILD
RAD SUPERVSN/INTERPRE
PERCUTANEOUS VERTEBROPLASTY
RAD SUPERVSN/INTERPRE UNDER CT
GUIDANCE
BONE AGE STUDIES
BONE LENGTH STUDIES
RAD EXAM OSSEOUS SURVEY; LTD
Not Reimbursable
No
No
No
76062
76065
76066
No
No
No
RAD EXAM OSSEOUS SURVEY; COMPLT
RAD EXAM OSSEOUS SURVEY INFANT
JT SURVEY SNGL VIEW 1/MORE JT
No
No
No
76070
No
No
76071
No
76075
No
76076
No
CT BONE DENSITY STUDY 1/MORE SITES
CT BONE DENSITY STUDY APENDICULAR
SKELETON
DXA BONE DENSITY STUDY 1/MORE
SITE; AXIAL SKEL
DXA BONE DENSITY STUDY 1/> SITE;
APPNDICULR SKEL
No
No
Not Reimbursable
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
76077
No
76078
No
76080
No
76082
No
76083
No
76086
No
76088
76090
76091
76092
No
No
No
No
76093
Yes
76094
Yes
76095
No
76096
76098
No
No
76100
No
Description
DXA BONE DENSITY STUDY 1/> SITES;
VERT FX ASSESS
RADIOGRAPH ABSORPTIOMETRY 1/>
SITES
RAD EXAM ABSC/FISTUL/SINUS TRACS&I
CMPT AIDED DETECT PHYS REV FOR
INTEPR; DX MAMMO
CMPT AIDED DETECT PHYS REV FOR
INTEPR; SCR MAMMO
MAMMARY DUCTOGM-SNGL DUCT-RAD S
&I
MAMMARY DUCTOGM-MX DUCTS-RAD S
&I
MAMMO; UNILAT
MAMMO; BILAT
SCREENING MAMMO BILAT
MRI BREAST WO &/OR W/CONTRAST;
UNI
MRI BREAST WO &/OR W/CONTRAST; BIL
STEREOTACT LOCAL BRST BX-EA-RAD
S&I
PREOP PLCMT LOCAL WIRE BREAST-S &
I
RAD EXAM SURG SPECMN
RAD EXAM 1 PLNE BOD SECT-NOT
W/UROG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
76101
No
76102
No
76120
No
76125
No
76140
76150
Not Reimbursable
No
76350
Yes
76355
76360
No
No
76362
No
76370
No
76376
No
76377
76380
No
No
76390
Yes
76393
Yes
Description
RAD EXAM COMPLX MOTION BODY;
UNILA
RAD EXAM COMPLX MOTION BODY;
BILAT
CINERADIOGRAPHY EX WHERE SPEC
INCL
CINERADIOGRAPHY-COMPLEMENT
ROUTINE
CONS X-RAY EXAM MADE ELSEWHERE
WRIT
XERORADIOGRAPHY
SUBTRACTION CONJUNCTION
W/CONTRAST
CT GUIDANCE STEREOTACTIC LOCALIZ
CT GUIDANCE NEEDLE BX-RAD S & I
COMPUTED TOMOGRPH GUID&MON
VISCERAL TISSUE ABLAT
CT GUIDANC PLCMT RADIAT THERAP
FLD
3D RNDR I&R CT MRI US/OTH X REQ
POSTPCX
3D RNDR I&R CT MRI US/OTH REQ
POSTPCX
CT LTD/LOCALIZ F/U STUDY
MAGNETIC RESONANCE
SPECTROSCOPY
NEEDLE PLACEMNT; MAGNETIC
RESONANCE GUIDANCE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Not Reimbursable
No
Yes
No
No
No
No
No
No
No
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
76394
76400
Yes
Yes
76496
Yes
76497
Yes
76498
76499
76506
Yes
Yes
No
76510
No
76511
No
76512
No
76513
No
76514
No
76516
No
76519
76529
No
No
76536
No
Description
MR GUIDANCE & MONITOR VISCERAL
TISSUE ABLATION
MRI BONE MARROW BLD SUPPLY
UNLISTED FLUOROSCOPIC PROCEDURE
UNLISTED COMPUTED TOMOGRAPHY
PROCEDURE
UNLISTED MAGNETIC RESONANCE
PROCEDURE
UNLISTED DX RAD PROC
ECHO B-SCAN/REAL TIME W/A-MODE
OPHTHALMIC US DX; B-SCAN&QUAN ASCAN SAME ENCNTR
OPHTHALMIC US DX; QUANTITATIVE ASCAN ONLY
OPHTHALMIC US DX; B-SCAN W/WO NONQUAN A-SCAN
OPHTHALMIC US DX; ANT SEG US BSCAN/BIOMICROSCPY
OPHTHALMIC US DX; CORNEAL
PACHYMETRY UNI/BIL
OPHTH BIOMETRY-ULTRASND ECHO ASCAN
OPHTH BIOMET A-SCAN; W/IO LENS
POWR
OPHTH ULTRASONIC FB LOCALIZ
ECHO-SOFT TISS HEAD B-SCAN
W/IMAGE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
76604
No
76645
No
76700
No
Description
ECHO CHEST B-SCAN W/IMAGE
DOCUMEN
ECHO BREAST(S) B-SCAN W/IMAGE
DOCUM
ECHO ABD B-SCAN W/IMAGE DOC;
COMPLT
76705
No
ECHO ABD B-SCAN W/IMAGE DOC; LTD
No
76770
76775
76776
No
No
No
No
No
No
76778
76800
No
No
76801
No
76802
76805
76810
No
No
No
76811
No
76812
76813
76814
No
No
No
76815
No
ECHO RETROPERITON B-SCAN; COMPLT
ECHO RETROPERITON B-SCAN; LTD
US EXAM K TRANSPL W/DOPPLER
ECHO TRANSPL KIDNEY B-SCAN
W/DOCUMN
ECHO SPINAL CANAL & CONTENTS
RTU PG UTRUS 1 TRI TRANSABD
APPRCH; 1/1ST GEST
RTU PG UTRUS 1 TRI TRANSABD
APPRCH; EA ADD GEST
ECHO PG UTERUS B-SCAN; COMPLT
ECHO PG UTERUS; COMPLT MX GEST
RTU PG UTRUS DTL FETL ANAT EX
TRANSABD; 1/1 GEST
RTU PG UTRUS DTL FETL ANAT EX
TRANSABD; EA GEST
OB US NUCHAL MEAS, 1 GEST
OB US NUCHAL MEAS, ADD-ON
ECHO PG UTERUS B-SCAN W/DOCUMN;
LTD
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
76816
No
76817
76818
No
No
76819
No
76820
No
76821
No
76825
No
76826
No
76827
No
76828
76830
No
No
76831
No
76856
No
Description
ECHO PG UTERUS B-SCAN W/DOC;
REPEAT
US PG UTERUS REAL TIME W/IMAGE
DOC TRANSVAGINAL
FETAL BIOPHYSICAL PROFILE
PROFILE FETAL BIOPHYSICAL W/NONSTRESS TEST
DOPPLER VELOCIMETRY FETAL;
UMBILICAL ARTERY
DOPPLER VELOCIMETRY FETAL; MIDDLE
CEREBRAL ART
ECHO FETAL-CV SYST-REAL TIME
W/DOC
ECHO FETAL-CV SYST-REAL TIME;
REPET
DOPPLER ECHO FETAL PULSED WAVE
&/CONT WAVE; CMPL
DOPPLER ECHO FETAL PULSE
WAVE&/CONT WAVE; REPEAT
ECHO TRANSVAGINAL
SIS INCLUDING COLOR FLOW DOPPLER
WHEN PERFORMED
ECHO PELVIC B-SCAN W/DOCUMN;
COMPLT
76857
76870
76872
No
No
No
ECHO PELVIC B-SCAN W/DOCUMEN; LTD
ECHO SCROTUM & CONTENTS
ULTRASOUND TRANSRECTAL;
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
76873
No
76880
76885
76886
No
No
No
76930
No
76932
No
76936
No
76937
No
76940
No
76941
No
76942
No
76945
No
76946
No
76948
No
76950
No
Description
US TRNSRECTL; PROSTATE BRACHYTX
PLAN-SEP PROC
U/S EXTREM NON-VASCUL B-SCAN
W/DOC
U/S INFANT HIPS; DYNAMIC
U/S INFANT HIPS; LTD, STATIC
ULTRASON GUIDAN
PERICARDIOCENTESIS
ULTRASON GUIDAN ENDOMYOCARD BXS&I
US GUID COMPRESS REPR PSEUDOANEURY
US GUID VASC ACSS PTNTL ACSS SITE
W/PERM REC&RPT
ULTRASOUND GUID&MONITORING
VISCERAL TISSUE ABLAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
US GUID IN UTERO FETAL TRNSFUS-S&I
ULTRASON GUIDAN NEEDLE BX-RAD S &
I
No
US GUID CHORIONIC VILLUS SAMPL-S&I
ULTRASON GUIDAN AMNIOCENTESIS-S &
I
No
ULTRASON GUIDAN ASPIRAT OVA-S & I
ECHO PLCMT-RAD THERAP FIELDS BSCAN
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
76965
76970
76975
76977
76986
76998
76999
77001
77002
77003
77011
77012
77013
77014
77021
77022
77031
77032
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Description
US GUID INTERST RADIOELEMENT
APPLIC
ULTRASOUND STUDY F/U
GI ENDO ULTRASND-RAD S & I
US BONE DENSITY MEASUR & INTERP
ECHO INTRAOPERATIVE
US GUIDE, INTRAOP
UNLISTED ULTRASOUND PROC
FLUOROGUIDE FOR VEIN DEVICE
NEEDLE LOCALIZATION BY XRAY
FLUOROGUIDE FOR SPINE INJECT
CT SCAN FOR LOCALIZATION
CT SCAN FOR NEEDLE BIOPSY
CT GUIDE FOR TISSUE ABLATION
CT SCAN FOR THERAPY GUIDE
MR GUIDANCE FOR NEEDLE PLACE
MRI FOR TISSUE ABLATION
STEREOTACT GUIDE FOR BRST BX
GUIDANCE FOR NEEDLE, BREAST
77051
No
COMPUTER DX MAMMOGRAM ADD-ON
No
77052
77053
77054
77055
77056
77057
77058
No
No
No
No
No
No
Yes
COMP SCREEN MAMMOGRAM ADD-ON
X-RAY OF MAMMARY DUCT
X-RAY OF MAMMARY DUCTS
MAMMOGRAM, ONE BREAST
MAMMOGRAM, BOTH BREASTS
MAMMOGRAM, SCREENING
MRI, ONE BREAST
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
77059
77071
77072
77073
77074
77075
77076
77077
77078
77079
77080
77081
77082
77083
77084
77261
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
77262
77263
No
No
THERAP RAD TX PLANNING; INTERMED
THERAP RAD TX PLANNING; COMPLX
No
No
77280
No
No
77285
No
THERAP RAD SIMULAT-AIDED FIELD; SIM
THERAP RAD SIMULAT-AID FLD;
INTERMD
77290
No
THERAP RAD SIMULAT-AID FLD; COMPLX
No
77295
No
No
77299
Yes
TX RAD SIM-AIDED FIELD SETTING; 3-D
UNLIST PROC THERAP RAD TX
PLANNING
Description
MRI, BOTH BREASTS
X-RAY STRESS VIEW
X-RAYS FOR BONE AGE
X-RAYS, BONE LENGTH STUDIES
X-RAYS, BONE SURVEY, LIMITED
X-RAYS, BONE SURVEY COMPLETE
X-RAYS, BONE SURVEY, INFANT
JOINT SURVEY, SINGLE VIEW
CT BONE DENSITY, AXIAL
CT BONE DENSITY, PERIPHERAL
DXA BONE DENSITY, AXIAL
DXA BONE DENSITY/PERIPHERAL
DXA BONE DENSITY, VERT FX
RADIOGRAPHIC ABSORPTIOMETRY
MAGNETIC IMAGE, BONE MARROW
THERAP RAD TX PLANNING; SIMPL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
77300
No
77301
77305
No
No
77310
No
77315
No
77321
No
77326
No
77327
No
77328
No
77331
No
77332
No
77333
No
77334
No
77336
No
77370
No
Description
BASIC RAD DOSIMETRY CALCULAT-BY
MD
INTENS MOD RADIOTX DOSE-VOL
HSTOGM
TELETHERAPY ISODOSE PLAN; SIMPL
TELETHERAPY ISODOSE PLAN;
INTERMED
TELETHERAPY ISODOSE PLAN; COMPLX
SPEC TELETHERAP PORT PLAN
PARTICLES
BRACHYTHERAP ISODOSE CALCUL;
SIMPL
BRACHYTHERAP ISODOS CALCUL;
INMTERM
BRACHYTHERAP ISODOSE CALCUL;
COMPLX
SPEC DOSIMETRY-PRESCRIB BY TX
PHYS
TX DEVICES DESIGN & CONSTRUCT;
SMPL
TX DEVIC DESIGN & CONSTRUCT;
INTERM
TX DEVIC DESIGN & CONSTRUCT;
COMPLX
CONT MED PHYSICS CONS PER WK
THER
SPECIAL MED RADIATION PHYSICS
CONS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
77371
77372
77373
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
77399
Yes
Description
SRS, MULTISOURCE
SRS, LINEAR BASED
SBRT DELIVERY
UNLIST PROC MED RAD PHYSICS
DOSIMET
77401
77402
77403
77404
No
No
No
No
RAD TX DELIV SUPERF/ORTHO VOLTAGE
RAD TX DELIV-1 TX AREA; TO 5 MEV
RAD TX DELIV-1 TX AREA; 6-10 MEV
RAD TX DELIV-1 TX AREA; 11-19 MEV
No
No
No
No
77406
77407
77408
77409
No
No
No
No
RAD TX DELIV-1 TX AREA; 20MEV/GRTER
RAD TX DELIV-2 TX AREAS; TO 5 MEV
RAD TX DELIV-2 TX AREAS; 6-10 MEV
RAD TX DELIV-2 TX AREAS; 11-19 MEV
No
No
No
No
77411
No
RAD TX DELIV-2 TX AREAS; 20 MEV/GRT
No
77412
No
RAD TX DELIV-3/MORE AREAS; TO 5 MEV
No
77413
No
RAD TX DELIV-3/MORE AREAS; 6-10 MEV
No
77414
No
RAD TX DELIV-3/MORE AREAS; 11-19MEV
No
77416
77417
No
No
No
No
77418
No
RAD TX DELIV-3/MORE AREAS; 20 MEV
THERAP RAD PORT FILM
INTENS MOD TX DEL VIA TEMPORLLY
MOD BEAM-TX SESS
Yes
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
77427
No
77431
No
77432
77435
77470
No
No
No
77499
Yes
77520
Yes
77522
Yes
77523
77525
77600
77605
Yes
Yes
No
No
77610
No
77615
No
77620
No
77750
77761
Description
RADIATION TX MGMT-FIVE TREATMENTS
RADIAT THERAP MGMT W/COMPLT
COURSE
STEREOTACT RAD TX MGMT CEREBRAL
LES
SBRT MANAGEMENT
SPECIAL TX PROC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
UNLISTED PROC THERAP RAD TX MGMT
PROTON BEAM DELIV-1 TX AREAW/SETUP
Yes
Yes
No
PROTON BEAN DELIV; SIMPLE W/COMP
PROTON BEAM DELIV 1-2 AREASW/SETUP
PROTON BEAN DELIV; COMPLEX
HYPERTHERMIA EXT GEN; SUPERF
HYPERTHERMIA EXT GEN; DEEP
HYPERTHERM-INTERSTIT PROBE;
5/LESS
HYPERTHERM-INTERSTIT PROBE; > 5
APP
HYPERTHERMIA GEN-INTRACAVIT
PROBE
INFUS/INSTILL RADIOELEMENT SOL INCL
3 MO FLW UP
No
INTRACAVIT RADIOELEM APPLIC; SIMPL
Yes
Yes
Yes
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
77762
No
77763
No
77776
No
77777
No
77778
No
77781
No
77782
No
77783
No
77784
77789
No
No
77790
No
77799
78000
78001
Yes
No
No
78003
No
78006
No
Description
INTRACAVIT RADIOELEM APPLIC;
INTERM
INTRACAVIT RADIOELEM APPLIC;
COMPLX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
INTERSTITIAL RADIOELEM APPLIC; SMPL
INTERSTIT RADIOELEM APPLIC;
INTERMD
No
INTERSTIT RADIOELEM APPLIC; COMPLX
REMOTE AFTERLOAD BRACHYTHERAP;
1-4
REMOTE AFTERLOAD BRACHYTHERAP;
5-8
REMOTE AFTERLOAD BRACHYTHERAP;
9-12
REMOTE AFTERLOAD BRACHYTHERAP;
> 12
SURFACE APPLIC RADIOELEMENT
SUPERVS HANDLING LOADRADIOELEMENT
No
UNLIST PROC CLINICAL BRACHYTHERAP
THYROID UPTAKE; SNGL DETERM
THYROID UPTAKE; MX DETERM
THYROID UPTAKE; STIM
SUPRESS/DISCHG
THYROID IMAGING W/UPTAKE; 1
DETERM
No
No
No
No
No
No
No
Yes
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78007
78010
No
No
Description
THYROID IMAGING W/UPTAKE; MX
DETERM
THYROID IMAGING; ONLY
78011
No
THYROID IMAGING; W/VASCULAR FLOW
No
78015
No
THYROID CA METASTAS IMAG; LTD AREA
No
78016
No
No
78018
78020
78070
No
No
No
78075
No
78099
78102
78103
Yes
No
No
THYROID CA METASTASES IMAG; W/ADD
THYROID CA METASTAS IMAG; WHOLE
BOD
THYROID CA METS UPTAKE
PARATHYROID IMAGING
ADRENAL IMAGING CORTEX &/OR
MEDULLA
UNLIST ENDOCRIN PROC DX NUCLEAR
MED
BONE MARROW IMAGING; LTD AREA
BONE MARROW IMAGING; MX AREAS
78104
No
78110
No
78111
No
78120
No
78121
No
BONE MARROW IMAGING; WHOLE BODY
PLASMA VOLU RADIOPHARM (SEP PRO);
1
PLASMA VOL RADIOPHARM (SEP PRO);
MX
RED CELL VOLUM DETERM (SEP PRO); 1
RED CELL VOLUM DETERM (SEP PRO);
MX
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78122
78130
No
No
78135
No
78140
No
78185
78190
78191
No
No
No
78195
No
78199
78201
78202
78205
78206
Yes
No
No
No
No
78215
No
78216
No
78220
78223
78230
78231
Description
WHOLE BLD VOL DETER W/SEP
PLASM/RBC
RED CELL SURVIVAL STUDY
RED CELL SURVIVAL STUDY; DIFF
ORGAN
LABELED RED CELL SEQUESTRATION
DIFF
SPLEEN IMAGING ONLY W/WO VASCUL
FLO
KINETICS STUDY PLATELET SURVIVAL
PLATELET SURVIVAL STUDY
LYMPHATICS & LYMPH GLANDS IMAGING
UNLIST HEMATOPOIETIC PROC-DX
NUCLER
LIVER IMAGING; STATIC ONLY
LIVER IMAGING; W/VASCULAR FLOW
LIVER IMAGING (SPECT);
LIVER IMAG (SPECT); W/VASC FLOW
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
LIVER & SPLEEN IMAGING; STATIC ONLY
LIVER & SPLEEN IMAG; W/VASCULAR
FLO
LIVER FUNCT STUDY W/HEPATOBILI
AGEN
HEPATOBILI DUCT SYST IMAG INCL GB
SALIVARY GLAND IMAGING
No
No
No
No
No
SALIVARY GLAND IMAG; W/SERIAL IMAG
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78232
78258
78261
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
78262
78264
No
No
78267
No
78268
No
78270
78271
No
No
78272
78278
78282
78290
No
No
No
No
78291
No
VIT B-12 ABSORP STUDY; WO INTRINSIC
VIT B-12 ABSORP STUDY; W/INTRINSIC
VIT B-12 ABSORP COMBO W/WO
INTRINSC
ACUTE GI BLD LOSS IMAGING
GI PROT LOSS
BOWEL IMAGING
PERITONEAL-VENOUS SHNT PATENCY
TEST
78299
78300
78305
78306
Yes
No
No
No
UNLISTED GI PROC DX NUCLEAR MEDS
BONE &/OR JT IMAGING; LTD AREA
BONE &/OR JT IMAGING; MX AREAS
BONE &/OR JT IMAGING; WHOLE BODY
Yes
No
No
No
78315
No
BONE &/OR JT IMAGING; 3 PHASE STUDY
No
78320
No
BONE &/OR JT IMAGING; TOMO (SPECT)
No
Description
SALIVARY GLAND FUNCT STUDY
ESOPH MOTILITY
GASTRIC MUCOS IMAGING
GASTROESOPHAGEAL REFLUX STUDY
GASTRIC EMPTYING STUDY
UREA BREATH TEST C14 ISOTOPIC;
ACQN ANALYSIS
UREA BREATH TEST C14 ISOTOPIC;
ANALYSIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
78350
No
Description
BONE DENSITY-1/> SITES; SNGL
PHOTON
78351
No
BONE DENSITY-1/>SITES; DUAL PHOTON
No
78399
Yes
Yes
78414
78428
No
No
78445
No
78456
No
78457
No
78458
No
78459
Not Reimbursable
78460
No
78461
No
78464
No
78465
No
UNLISTED MS PROC DX NUCLEAR MEDS
DETERM CENTRAL C-V HEMODYNAMIC
1/MX
CARDIAC SHUNT DETECTION
NON-CARDIAC VASCULAR FLOW
IMAGING
ACUTE VEN THROMBOSIS IMAGPEPTIDE
VENOUS THROMBOSIS IMAG-VENOGRM;
UNI
VENOUS THROMBOSIS IMAG-VENOGRM;
BIL
MYOCARDIAL IMAG-PET-METABOLIC
EVAL
MYOCARDIAL PERFUS IMAG; SNGL
STUDY
MYOCARDIAL PERFUS IMAG; MX
STUDIES
MYOCARD PERFUS IMAG; SPECT 1 STDY
AT REST/STRSS
MYOCARD PERFUS IMAG; SPECT MX
STDY REST&/STRESS
78466
No
MYOCARDIAL IMAG PLANAR; QUAL/QUAN
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78468
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
78469
No
MYOCARDIAL IMAG; TOMOGRPH SPECT
No
78472
No
CARDIAC BLD POOL IMAG; SNGL STUDY
No
78473
No
No
78478
No
78480
78481
No
No
CARDIAC BLD POOL IMAG; MX STUDIES
MYOCARDIAL PERFUS STUDY
QUAL/QUAN
MYOCARD PERFUS STUDY W/EJECT
FRACT
CARDIAC BLD POOL 1ST PASS; SNGL
78483
No
78491
Not Reimbursable
78492
Not Reimbursable
78494
No
78496
No
78499
Yes
78580
78584
Description
MYOCARDIAL IMAG; W/EJECT FRACT
CARDIAC BLD POOL IMAG 1ST PASS; MX
MYOCARD IMAG-PET-PERFUS; SNGL
STUDY
MYOCARD IMAG-PET-PERFUS; MX
STUDIES
CARD BLD POOL IMAG-GATED SPECTREST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
Yes
No
CARD BLD POOL IMAG-GATED-1 STUDY
UNLISTED CARDIOVASC PROC DX
NUCLEAR
PULM PERFUSION IMAGING
PARTICULATE
No
No
PULM PERFUS PARTICULATE; 1 BREATH
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78585
No
78586
No
78587
No
78588
No
78591
No
78593
No
78594
78596
No
No
78599
78600
Yes
No
78601
No
78605
No
78606
No
78607
No
78608
Not Reimbursable
Description
PULM PERFUS PARTICULATE;
REBREATH
PULM VENTILAT IMAG AEROSOL; 1 PROJ
PULM VENTILAT IMAG AEROSOL; MX
PROJ
PULM PERF IMAG-PARTIC W/VENTAEROSL
PULM VENTILAT IMAG GASEOUS 1
BREATH
PULM VENTILAT GASEOUS
W/REBREATH; 1
PULM VENTILAT GASEOUS W/REBRTH;
MX
PULM QUAN DIFF FUNCT STUDY
UNLIST RESPIR PROC DX NUCLEAR
MEDS
BRAIN IMAGING LTD PROC; STATIC
BRAIN IMAG LTD PROC; W/VASCULAR
FLO
BRAIN IMAGING COMPLT STUDY; STATIC
BRAIN IMAG COMPLT STUDY; W/VASC
FLO
BRAIN IMAGING COMPLT STUDY;
(SPECT)
BRAIN IMAG POSITRON TOMOG;
METABOLC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78609
Not Reimbursable
78610
78615
No
No
78630
No
78635
No
78645
78647
78650
78660
No
No
No
No
78699
78700
78701
78704
Yes
No
No
No
78707
No
78708
No
78709
No
78710
78715
No
No
Description
BRAIN IMAG POSITRON TOMOG;
PERFUSON
BRAIN IMAGING VASCULAR FLOW ONLY
CEREBRAL BLD FLOW
CEREBROSPINAL FLUID IMAG;
CISTERNOG
CEREBROSPINAL FLUID;
VENTRICULOGRPY
CEREBROSPINAL FLUID IMAG; SHUNT
EVL
CSF FLOW IMAG; TOMO (SPECT)
CSF LEAKAGE DETECTION & LOCALIZ
RADIOPHARM DACRYOCYSTOGRAPHY
UNLISTED NERV SYST PROC DX
NUCLEAR
KIDNEY IMAGING; STATIC ONLY
KIDNEY IMAGING; W/VASCULAR FLOW
KIDNEY IMAGING; W/FUNCT STUDY
KIDNEY IMAG W/FLO-FUNC; 1 W/O
PHARM
KIDNEY IMAG W/FLO & FUNC; 1
W/PHARM
KIDNEY IMAG FLO-FUNC; MX W&WO
PHARM
KIDNEY IMAGING, TOMOGRAPHIC
(SPECT)
KIDNEY VASCULAR FLOW ONLY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78725
78730
78740
78760
No
No
No
No
78761
No
78799
Yes
78800
No
78801
No
78802
No
78803
No
78804
78805
No
No
78806
No
78807
No
78811
Yes
78812
78813
Yes
Yes
Description
KIDNEY FUNT NON-IMAGE
RADIOISOTOPIC
URIN BLADDER RESIDUAL STUDY
URETERAL REFLUX STUDY
TESTICULAR IMAGING
TESTICULAR IMAGING; W/VASCULAR
FLOW
UNLISTED G U PROC DX NUCLEAR MEDS
RADOPHARM LOC TUMR/DSTRB
RADOPHARM AGT; LTD AREA
RADOPHARM LOC TUMR/DSTRB
RADOPHARM AGT; MX AREAS
RADPHARM LOC TUMR/DSTRB AGT;
WHOLE BDY 1 DA IMAG
RADPHARM LOC TUMR/DSTRB AGT;
TOMOGRAPHIC
RADPHRM LOC TUMR/DSTRB
AGT;WHOLE BDY 2/> DA IMAG
RADIOPHARM LOCALIZ ABSCESS; LTD
RADIOPHARM LOCALIZ ABSC; WHOLE
BODY
RADIOPHARM LOCALIZ ABSCESS;
(SPECT)
TUMOR IMAGING PET; LTD AREA EG
CHEST HEAD/NECK
TUMOR IMAGING PET; SKULL BASE TO
MID THIGH
TUMOR IMAGING PET; WHOLE BODY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
78814
Yes
78815
Yes
78816
78890
78891
Yes
Bundled
Bundled
78999
Yes
79005
No
79101
No
79200
No
79300
No
79403
No
79440
No
79445
No
79999
80047
80048
80050
Yes
No
No
No
Description
TUMOR IMAG PET W/CONCURRNT CT;
LTD AREA
TUMOR IMAG PET W/CONCURRNT CT;
SKUL BASE MID THI
TUMOR IMAG PET W/CONCURRNT CT;
WHOLE BDY
GEN AUTO DATA; SIMPL TO 30 MIN
GEN AUTO DATA; COMPLX > 30 MIN
UNLISTED MISC PROC DX NUCLEAR
MEDS
RADIOPHARMACEUTICAL THERAPY
ORAL ADMNISTRATION
RADIOPHARMACEUTICAL THERAPY IV
ADMNISTRATION
RADIOPHARMACEUTICAL THERAPY
INTRACAVITARY ADMIN
RADIOPHARM TX INTERSTITIAL RAD
COLLOID ADMIN
RADOPHRM TX MONOCLONAL ANTIBODY
IV INFUSION
RADIOPHARMACEUTICAL THERAPY
INTRA-ARTICULR ADMIN
RADIOPHARM TX INTRA-ARTERIAL
PARTICULATE ADMIN
RADIOPHARMACEUTICAL THERAPY
UNLISTED PROCEDURE
METABOLIC PANEL IONIZED CA
BASIC METABOLIC PANEL
GENERAL HEALTH PANEL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
Yes
Yes
Bundled
Bundled
Yes
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
80051
80053
80055
80061
80069
80074
80076
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
80100
No
DRUG SCREEN; MX DRUG CLASSES EA
No
80101
80102
80103
80150
80152
80154
80156
80157
80158
80160
80162
80164
80166
80168
80170
80172
80173
80174
80176
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
DRUG SCREEN; SNGL DRUG CLASS EA
DRUG CONFIRM EA PROC
TISS PREP DRUG ANALY
AMIKACIN
AMITRIPTYLINE
BENZODIAZEPINES
CARBAMAZEPINE
CARBAMAZEPINE; FREE
CYCLOSPORINE
DESIPRAMINE
DIGOXIN
DIPROPYLACETIC ACID
DOXEPIN
ETHOSUXIMIDE
GENTAMICIN
GOLD
HALOPERIDOL
IMIPRAMINE
LIDOCAINE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
ELECTROLYTE PANEL
COMP METABOLIC PANEL
OBSTETRIC PANEL
LIPID PANEL
RENAL FUNCTION PANEL
ACUTE HEPATITIS PANEL
HEPATIC FUNCTION PANEL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
80178
80182
80184
80185
80186
80188
80190
80192
80194
80195
80196
80197
80198
80200
80201
80202
80299
80400
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
80402
No
80406
No
80408
80410
No
No
80412
No
80414
No
Description
LITHIUM
NORTRIPTYLINE
PHENOBARBITAL
PHENYTOIN; TOT
PHENYTOIN; FREE
PRIMIDONE
PROCAINAMIDE
PROCAINAMIDE; W/METABOLITES
QUINIDINE
SIROLIMUS
SALICYLATE
TACROLIMUS
THEOPHYLLINE
TOBRAMYCIN
TOPIRAMATE
VANCOMYCIN
QUAN DRUG NES
ACTH STIM PANEL; ADRENAL INSUFF
ACTH STIM PANEL; 21 HYDROXYLASE
DEF
ACTH STIM PANEL; 3 BETAHYDROXYDEHY
ALDOSTERONE SUPPRESSION EVAL
PANEL
CALCITONIN STIM PANEL
CORTICOTROPIC RELEAS HORMONE
STIM
CHORION GONADOTRO STIM;
TESTOSTERON
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
80415
80416
80417
No
No
No
80418
No
80420
80422
No
No
80424
No
80426
80428
No
No
80430
No
80432
No
80434
No
80435
80436
No
No
80438
No
80439
No
80440
No
Description
CHORION GONADOT STIM; ESTRADIOL
RES
RENAL VEIN RENIN STIM PANEL
PERIPHERAL VEIN RENIN STIM PANEL
COMBO RAPID PITUITARY EVAL PANEL
DEXAMETHASONE SUPPRESS PANEL 48
HR
GLUCAGON TOLERANCE; INSULINOMA
GLUCAGON TOLERANC;
PHEOCHROMOCYTOMA
GONADOTROPN RELEAS HORMONE
STIM PAN
GROWTH HORMONE STIM PANEL
GROWTH HORMONE SUPPRESSION
PANEL
INSULIN-INDUCED C-PEPTIDE SUPPRESS
INSULIN TOLERANC PANEL; ACTH
INSUFF
INSULIN TOLERANC; GROWTH HORMON
DEF
METYRAPONE PANEL
THYROTROPIN RELEAS HORMON STIM;
1HR
THYROTROPIN RELEAS HORMON STIM;
2HR
THYROTROP RELEAS HORMON;
HYPERPROLA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
80500
80502
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
81000
81001
No
No
81002
81003
No
No
81005
81007
81015
81020
No
No
No
No
Description
CLINIC PATH CONS; LTD WO REVIEW
CLINIC PATH CONS; COMP W/REVIEW
UA DIPSTIK/TABLET; NON-AUTO
W/MICRO
UA DIP STICK/TABLET; AUTO W/MICRO
UA DIP STIK/TABLT;WO MICRO NONAUTO
UA DIP STIK/TABLET; WO MICRO AUTO
UA; QUAL/SEMIQUAN EX
IMMUNOASSAYS
UA; BACTERURIA SCRN NON-CULT KIT
UA; MICRO ONLY
UA; 2 OR 3 GLASS TEST
81025
81050
81099
82000
82003
No
No
No
No
No
URIN PG TEST VISUAL COLOR COMPAR
VOLUM MEASUR TIMED COLLEC EA
UNLISTED UA PROC
ACETALDEHYDE BLD
ACETAMINOPHEN
No
No
No
No
No
82009
No
ACETONE/OTHER BODIES SERUM; QUAL
No
82010
82013
82016
82017
82024
No
No
No
No
No
No
No
No
No
No
82030
No
ACETONE/OTHER BODIES SERUM; QUAN
ACETYLCHOLINESTERASE
ACYLCARNITINES; QUAL EA SPEC
ACYLCARNITINES; QUAN EA SPEC
ADRENOCORTICOTROPIC HORMONE
ADENOSINE 5'-MONOPHOSPHATE
CYCLIC
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82040
82042
82043
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
82044
82055
82075
82085
82088
82101
82103
82104
82105
No
No
No
No
No
No
No
No
No
Description
ALBUMIN; SERUM
ALBUMIN; URIN QUAN
ALBUMIN; URIN MICROALBUMIN QUAN
ALBUMIN; URIN MICROALBUMIN
SEMIQUAN
ALCOHOL; ANY SPECMN EX BREATH
ALCOHOL; BREATH
ALDOLASE
ALDOSTERONE
ALKALOIDS URIN QUAN
ALPHA-1-ANTITRYPSIN; TOT
ALPHA-1-ANTITRYPSIN; PHENOTYPE
ALPHA-FETOPROTEIN; SERUM
82106
82107
82108
82120
82127
82128
82131
82135
82136
82139
82140
82143
82145
82150
82154
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ALPHA-FETOPROTEIN; AMNIOTIC FLUID
ALPHA-FETOPROTEIN L3
ALUMINUM
AMINES VAG FLUID-QUAL
AMINO ACIDS; 1-QUAL EA SPEC
AMINO ACIDS; MX QUAL EA SPEC
AMINO ACIDS; SINGL QUAN EA SPEC
AMINOLEVULINIC ACID DELTA
AMINO ACIDS 2 TO 5-QUAN-EA SPEC
AMINO ACIDS 6/>-QUAN-EA SPEC
AMMONIA
AMNIOTIC FLUID SCAN
AMPHETAMINE/METHAMPHETAMINE
AMYLASE
ANDROSTANEDIOL GLUCURONIDE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82157
82160
82163
82164
82172
82175
82180
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
82190
82205
82232
82239
82240
82247
82248
82252
82261
No
No
No
No
No
No
No
No
No
82270
No
82271
No
82272
No
82274
82286
82300
82306
82307
No
No
No
No
No
Description
ANDROSTENEDIONE
ANDROSTERONE
ANGIOTENSIN II
ANGIOTENSIN I- CONVERTING ENZYME
APOLIPOPROTEIN EA
ARSENIC
ASCORBIC ACID BLD
ATOMIC ABSORP SPECTROSCPY EA
ANALYT
BARBITURATES NES
BETA-2 MICROGLOBULIN
BILE ACIDS; TOT
BILE ACIDS; CHOLYLGLYCINE
BILIRUBIN; TOT
BILIRUBIN; DIRECT
BILI; FECES QUAL
BIOTINIDASE EA SPEC
BLD OCCULT; FECES 1-3 SIMULT
DETERM
BLD OCLT PROXIDASE ACTV QUAL OTH
SRCS
BLD OCLT PROXIDASE ACTV QUAL
FECES 1 SPEC
BLD OCCLT FECL HGB IMMUOAS QUAL
FEC
BRADYKININ
CADMIUM
CALCIFEDIOL
CALCIFEROL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82308
82310
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
82331
82340
82355
82360
82365
82370
No
No
No
No
No
No
82373
82374
82375
82376
82378
82379
82380
82382
82383
82384
82387
82390
82397
82415
82435
82436
82438
Description
CALCITONIN
CALCIUM; TOT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
CALCIUM; AFTER CALCIUM INFUSN TEST
CALCIUM; URIN QUAN TIMED SPECMN
CALCU; QUAL ANALY
CALCU; QUAN ANALY CHEM
CALCU; INFRARED SPECTROSCOPY
CALCU; X-RAY DIFFRACTION
CARBOHYDRATE DEFICIENT
TRANSFERRIN
CARBON DIOXIDE
CARBON MONOXIDE; QUAN
CARBON MONOXIDE; QUAL
CARCINOEMBRYONIC ANTIG
No
No
No
No
No
No
No
No
No
No
No
No
CARNITINE (TOT & FREE) QUAN EA SPEC
CAROTENE
CATECHOLAMINES; TOT URIN
CATECHOLAMINES; BLD
CATECHOLAMINES; FRACTIONATED
CATHEPSIN-D
CERULOPLASMIN
CHEMILUMINESCENT ASSAY
CHLORAMPHENICOL
CHLORIDE; BLD
CHLORIDE; URIN
CHLORIDE; OTHER SOURCE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
82441
82465
82480
82482
82485
No
No
No
No
No
82486
No
82487
No
82488
No
82489
No
82491
No
82492
82495
82507
82520
82523
82525
82528
82530
82533
82540
No
No
No
No
No
No
No
No
No
No
82541
No
Description
CHLORINATED HYDROCARBONS
SCREEN
CHOL SERUM TOT
CHOLINESTERASE; SERUM
CHOLINESTERASE; RBC
CHONDROITIN B SULFATE QUAN
CHRMATOGRPHY QUAL; COLUMN ANLYT
NES
CHRMATGRPHY QUAL; PAPR 1-DIM
ANALYT
CHRMATGRPHY QUAL; PAPR 2-DIM
ANALYT
CHRMATGRPHY QUAL; THIN LAYER
ANALYT
CHROMATOG QUAN COLMN; 1 ANALYTE
NES
CHROMATOGRAPHY QUAN COLUMN;
MULT
CHROMIUM
CITRATE
COCAINE/METABOLITE
COLLAGEN CROSS LINKS-ANY METHD
COPPER
CORTICOSTERONE
CORTISOL; FREE
CORTISOL; TOT
CREATINE
CHROMATOG/SPECTROM-ANALYT NES;
QUAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
82542
No
82543
No
82544
82550
82552
No
No
No
82553
82554
82565
82570
82575
82585
82595
82600
82607
No
No
No
No
No
No
No
No
No
82608
82610
82615
82626
82627
82633
82634
82638
82646
Description
CHROMATOG/SPECTROM-ANALYT NES;
QUAN
CHROMATOG ANALYT NES; ISOTOPE DIL1
CHROMATOG ANALYT NES; ISOTOP DILMX
CREATINE KINASE; TOT
CREATINE KINASE; ISOENZYMES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
CREATINE KINASE; MB FRACTION ONLY
CREATINE KINASE; ISOFORMS
CREATININE; BLD
CREATININE; OTHER SOURCE
CREATININE; CLEARANCE
CRYOFIBRINOGEN
CRYOGLOBULIN
CYANIDE
CYANOCOBALAMIN
CYANOCOBALAMIN; UNSATURATED
BINDING
CYSTATIN C
CYSTINE & HOMOCYSTINE URIN QUAL
DEHYDROEPIANDROSTERONE
No
No
No
No
No
DEHYDROEPIANDROSTERONE-SULFATE
DESOXYCORTICOSTERONE 11DEOXYCORTISOL 11DIBUCAINE NUMBER
DIHYDROCODEINONE
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82649
82651
82652
82654
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
82656
No
Description
DIHYDROMORPHINONE
DIHYDROTESTOSTERONE
DIHYDROXYVITAMIN D 1 25DIMETHADIONE
ELASTASE PANCREATIC FECAL
QUALITATIVE/SEMIQUAN
82657
No
ENZYM ACTIV-CELLS/TISS NES; NONRAD
No
82658
82664
82666
82668
82670
82671
82672
82677
82679
82690
82693
82696
82705
82710
82715
82725
82726
82728
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
82731
No
ENZYM ACTIV-CELLS/TISS NES; RAD-EA
ELEC-PHORE TECH NES
EPIANDROSTERONE
ERYTHROPOIETIN
ESTRADIOL
ESTROGENS; FRACTIONATED
ESTROGENS; TOT
ESTRIOL
ESTRONE
ETHCHLORVYNOL
ETHYLENE GLYCOL
ETIOCHOLANOLONE
FAT/LIPIDS FECES; QUAL
FAT/LIPIDS FECES; QUAN
FAT DIFF FECES QUAN
FATTY ACIDS NONESTERIFIED
VERY LONG CHAIN FATTY ACIDS
FERRITIN
FETAL FIBRONECTIN-CERV/VAG
SECRETNS
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82735
82742
82746
82747
82757
82759
82760
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
82775
No
82776
82784
82785
82787
82800
82803
No
No
No
No
No
No
82805
82810
82820
No
No
No
FLUORIDE
FLURAZEPAM
FOLIC ACID; SERUM
FOLIC ACID; RBC
FRUCTOSE SEMEN
GALACTOKINASE RBC
GALACTOSE
GALACTOSE-1-PHOSP URIDYL TRNS;
QUAN
GALACTOSE-1-PHOSP URIDYL TRNS;
SCRN
GG; IGA, IGD, IGG, IGM, EA
GG; IGE
GG; IMMUNOGLOBULIN SUBCLASSES
GASES BLD PH ONLY
GASES BLD ANY COMBO
GASES BLD COMBO; W/O2 SAT EX
OXIMTR
GAS BLD O2 SAT ONLY EX OXIMETRY
HGB-O2 AFFINITY
82926
82928
82938
82941
82943
82945
82946
82947
No
No
No
No
No
No
No
No
GASTRIC ACID FREE & TOT EA SPECMN
GASTRIC ACID FREE/TOT; EA SPECMN
GASTRIN AFTER SECRETIN STIM
GASTRIN
GLUCAGON
GLUCOSE, BODY FLUID
GLUCAGON TOLERANCE TEST
GLU; QUAN
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82948
82950
82951
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
82952
No
82953
No
82955
No
82960
No
82962
82963
82965
82975
82977
82978
82979
82980
82985
No
No
No
No
No
No
No
No
No
83001
No
83002
83003
No
No
GLU; TOLBUTAMIDE TOLERANCE TEST
GLU-6-PHOSPHATE DEHYDROGENASE;
QUAN
GLU-6-PHOSPHATE DEHYDROGENASE;
SCRN
GLU BLD MONITR CLEARED-FDA-HOME
USE
GLUCOSIDASE BETA
GLUTAMATE DEHYDROGENASE
GLUTAMINE
GLUTAMYLTRANSFERASE GAMMA
GLUTATHIONE
GLUTATHIONE REDUCTASE RBC
GLUTETHIMIDE
GLYCATED PROT
GONADOTROPIN; FOLLICLE STIM
HORMONE
GONADOTROPIN; LUTEINIZING
HORMONE
GROWTH HORMONE HUMAN
83008
No
GUANOSINE MONOPHOSPHATE CYCLIC
Description
GLU; BLD REAGENT STRIP
GLU; POST GLU DOSE
GLU; TOLERANCE TEST 3 SPECMN
GLU; TOLERANCE EA ADD BEYOND 3
SPEC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
83009
83010
83012
No
No
No
83013
No
83014
83015
83018
No
No
No
83020
No
83021
No
83026
83030
83033
83036
No
No
No
No
83037
No
83037
83045
83050
83051
83055
83060
83065
No
No
No
No
No
No
No
Description
H PYLORI BLOOD TEST UREASE NONRADIOACTV ISOTOPE
HAPTOGLOBIN; QUAN
HAPTOGLOBIN; PHENOTYPES
H PYLORI; BREATH TEST UREASE NONRADACTV ISOTOPE
HELICOBACTER PYLORI; DRUG
ADMINISTRATION
HEAVY METAL; SCREEN
HEAVY METAL; QUAN EA
HGB FRACTION-QUANTITAT: ELECPHORE
HEMOGLOB FRACT & QUAN;
CHROMATOGR
HGB; COPPER SULFATE METHD NONAUTO
HGB; F CHEM
HGB; F QUAL TEST FECAL
HGB; GLYCATED
HGB GLYCOSYLATED DEV CLEARED FDA
HOME USE
HGB GLYCOSYLATED DEV CLEARED FDA
HOME USE
HGB; METHEMOGLOBIN QUAL
HGB; METHEMOGLOBIN QUAN
HGB; PLASMA
HGB; SULFHEMOGLOBIN QUAL
HGB; SULFHEMOGLOBIN QUAN
HGB; THERMOLABILE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83068
83069
83070
83071
83080
83088
83090
83150
83491
83497
83498
83499
83500
83505
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
83516
No
83518
No
83519
83520
83525
83527
83528
83540
83550
83550
83570
No
No
No
No
No
No
No
No
No
Description
HGB; UNSTABLE SCREEN
HGB; URIN
HEMOSIDERIN; QUAL
HEMOSIDERIN; QUAN
B-HEXOSAMINIDASE EA ASSAY
HISTAMINE
HOMOCYSTINE
HOMOVANILLIC ACID
HYDROXYCORTICOSTEROIDS 17HYDROXYINDOLACETIC ACID 5HYDROXYPROGESTERONE 17-D
HYDROXYPROGESTERONE 20HYDROXYPROLINE; FREE
HYDROXYPROLINE; TOT
IMMNASSY ANALYT NOT AB/INFEC AG;
MX
IMMUNOASSY ANALYT NOT AB/INFECT; 1
IMMNASSY ANALYTE QUAN;
RADIOPHARM
IMMUNOASSAY ANALYTE QUAN; NOS
INSULIN; TOT
INSULIN; FREE
INTRINSIC FACTOR
IRON
CALCIUM; IONIZED
IRON BINDING CAPACITY
ISOCITRIC DEHYDROGENASE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
83582
83586
83593
83605
83615
83625
83630
83631
No
No
No
No
No
No
No
No
83632
83633
83634
83655
No
No
No
No
83661
83662
No
No
83663
83664
83670
83690
83695
83698
No
No
No
No
No
No
83700
83701
No
No
83704
No
Description
KETOGENIC STEROIDS FRACTIONATION
KETOSTEROIDS 17-; TOT
KETOSTEROIDS 17-; FRACTIONATION
LACTATE
LACTATE DEHYDROGENASE
LDH; ISOENZYMES SEPART & QUAN
LACTOFERRIN FECAL QUALITATIVE
LACTOFERRIN FECAL QUAN
LACTOGN HUMN PLACENT HUMN C
SOMATOM
LACTOSE URIN; QUAL
LACTOSE URIN; QUAN
LEAD
LECITHIN-SPHINGOMYELIN RATIO; QUAN
L/S RATIO; FOAM STABILITY TEST
L/S RATIO; FLUORESCENCE
POLARIZATION
L/S RATIO; LAMELLAR BODY DENSITY
LEUCINE AMINOPEPTIDASE
LIPASE
LIPOPROTEIN A
ASSAY LIPOPROTEIN PLA2
LIPOPROTEIN BLD ELECTROP
SEP&QUAN
LIPOPROTEIN BLD HR SUBCLASSES
LIPOPROTEIN BLD QUAN
NUMBERS&SUBCLASSES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
83718
No
83719
No
83721
83727
83735
83775
83785
No
No
No
No
No
83788
No
83789
83805
83825
83835
83840
83857
83858
No
No
No
No
No
No
No
83864
No
83866
83872
83873
83874
83880
83883
No
No
No
No
No
No
Description
LIPOPROTEIN DIRECT MEASUR; HDL
CHOL
LIPOPROT DIRECT MEASUR; VLDL CHOL
LIPOPROTEIN DIRECT MEASUR; LDL
CHOL
LUTEINIZING RELEASING FACTOR
MAGNESIUM
MALATE DEHYDROGENASE
MANGANESE
MASS & TANDEM SPECTR ANAL NES;
QUAL
MASS & TANDEM SPECTR ANAL NES;
QUAN
MEPROBAMATE
MERCURY QUAN
METANEPHRINES
METHADONE
METHEMALBUMIN
METHSUXIMIDE
MUCOPOLYSACCHARIDES ACID; QUAN
MUCOPOLYSACCHARIDES ACID;
SCREEN
MUCIN SYNOVIAL FLUID
MYELIN BASIC PROT CSF
MYOGLOBIN
NALORPHINE
NEPHELOMETRY EA ANALYTE NES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83885
83887
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
83890
No
83891
No
83892
No
83893
No
83894
No
83896
83897
No
No
83898
No
83900
No
83901
No
83902
No
83903
No
83904
No
83905
No
Description
NICKEL
NICOTINE
MOLECULAR DX; MOLEC
ISOLAT/EXTRACT
MOLEC DX; ISOLA/EXTRAC NUCLEIC
ACID
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
MOLECULAR DX; ENZYMATIC DIGESTION
MOLEC DX; DOT/SLOT BLOT
PRODUCTION
No
MOLEC DX; SEPARAT GEL ELECT-PHORE
MOLECULAR DX; NUCLEIC ACID PROBE
EA
MOLEC DX; NUCLEIC ACID TRANSF
No
No
No
No
MOLEC DX; AMPLIF NUC ACID 1 PAIR-EA
MOLEC AMP NUCLEIC ACID MLTX 1ST 2
SEQ
MOLEC DX; AMPL NUCLEIC ACIDMXPLEX
MOLECULAR DX; REVERSE
TRANSCRIPTION
MOLEC DX; MUTATION SCAN-PHYS
PROP-1
No
MOLEC DX; MUTATION ID-SEQUENC-1-EA
MOLEC DX; MUTAT ID-ALLELE
TRANSCRIP
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
83906
No
83907
No
83908
83909
83912
83913
No
No
No
No
83914
83915
83916
83918
83919
83921
83925
83930
83935
83937
83945
83950
83970
83986
83992
83993
84022
84030
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
MOLEC DX; MUTAT ID-ALLELE TRANSLAT
MOLEC LSS CELLS PRIOR NUCLEIC ACID
XTRJ
MOLEC SIGNAL AMP NUCLEIC ACID EA
SEQUENCE
MOLEC SEP&ID HR TQ
MOLECULAR DX; INTERPT & REPORT
MOLECULAR, RNA STABILIZATION
MUTATION ID ENZYMATIC LIG/PRIMER
XTN 1 SGM EA
NUCLEOTIDASE 5'OLIGOCLONAL IMMUNOGLOBULIN
ORGANIC ACIDS QUAN EA SPEC
ORGANIC ACIDS; QUAL EA SPEC
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ORGANIC ACID, SINGLE, QUANTITATIVE
OPIATES
OSMOLALITY; BLD
OSMOLALITY; URIN
OSTEOCALCIN
OXALATE
ONCOPROTEIN HER-2/NEU
PARATHORMONE
PH BODY FLUID EX BLD
PHENCYCLIDINE
ASSAY FOR CALPROTECTIN FECAL
PHENOTHIAZINE
PHENYLALANINE BLD
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84035
84060
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
84061
84066
84075
No
No
No
PHOSPHATASE ACID; FORENSIC EXAM
PHOSPHATASE ACID; PROSTATIC
PHOSPHATASE ALKALINE
No
No
No
84078
No
PHOSPHATASE ALKALINE; HEAT STABLE
No
84080
84081
No
No
No
No
84085
84087
84100
84105
84106
84110
84119
84120
84126
84127
84132
84133
84134
84135
84138
84140
84143
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
PHOSPHATASE ALKALINE; ISOENZYMES
PHOSPHATIDYLGLYCEROL
PHOSPHOGLUCONATE 6DEHYDROGENA RBC
PHOSPHOHEXOSE ISOMERASE
PHOSPHORUS INORGANIC
PHOSPHORUS INORGANIC; URIN
PORPHOBILINOGEN URIN; QUAL
PORPHOBILINOGEN URIN; QUAN
PORPHYRINS URIN; QUAL
PORPHYRINS URIN; QUAN & FRACT
PORPHYRINS FECES; QUAN
PORPHYRINS FECES; QUAL
POTASSIUM; SERUM
POTASSIUM; URIN
PREALBUMIN
PREGNANEDIOL
PREGNANETRIOL
PREGNENOLONE
17-HYDROXYPREGNENOLONE
Description
PHENYLKETONES QUAL
PHOSPHATASE ACID; TOT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84144
84146
84150
84152
84153
84154
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
84155
No
84156
No
84157
No
84160
No
84163
No
84165
No
84166
No
84181
No
84182
84202
84203
84206
84207
84210
No
No
No
No
No
No
Description
PROGESTERONE
PROLACTIN
PROSTAGLANDIN EA
PSA; COMPLEX
PROSTATE SPEC ANTIG; TOT
PROSTATE SPEC ANTIG; FREE
PROTEIN TOTAL EXCEPT
REFRACTOMETRY; SERUM
PROTEIN TOTAL EXCEPT BY
REFRACTOMETRY; URINE
PROTEIN TOTAL EXCEPT
REFRACTOMETRY; OTHER SOURCE
PROTEIN TOTAL BY REFRACTOMETRY
ANY SOURCE
PREGNANCY-ASSOCIATED PLASMA
PROTEIN-A PAPP-A
PROTEIN; ELECTROPHORETIC
FRACTIONATN&QUAN SERUM
PROTEIN; ELECTROPHORETIC
FRACTIONATN&QUAN OTH FL
PROTEIN; WESTERN BLOT W/I&R
BLOOD/OTH BODY FLUID
PROT; WESTERN BLOT IMMUNOL PROBEBAND ID EA
PROTOPORPHYRIN RBC; QUAN
PROTOPORPHYRIN RBC; SCREEN
PROINSULIN
PYRIDOXAL PHOSPHATE
PYRUVATE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84220
84228
84233
84234
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305
84307
No
No
No
No
No
No
No
No
No
No
No
No
No
No
84311
84315
No
No
84375
84376
No
No
84377
84378
84379
No
No
No
Description
PYRUVATE KINASE
QUININE
RECEPTOR ASSAY; ESTROGEN
RECEPTOR ASSAY; PROGESTERONE
RECPTR ASSAY; ENDOCRN NOT
ESTR/PROG
RECEPTOR ASSAY; NON-ENDOCRINE
RENIN
RIBOFLAVIN
SELENIUM
SEROTONIN
SEX HORMONE BINDING GLOB
SIALIC ACID
SILICA
SODIUM; SERUM
SODIUM; URIN
SODIUM; OTHER SOURCE
SOMATOMEDIN
SOMATOSTATIN
SPECTROPHOTOMETRY ANALYTE NES
SPEC GRAVITY
SUGARS CHROMAT TLC/PAPER
CHROMATOG
SUGARS; 1 QUAL EA SPECMN
SUGARS; MULTIPLE QUALITATIVE EACH
SPECIMEN
SUGARS; 1 QUAN EA SPECMN
SUGARS; MX QUAN EA SPECMN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84392
84402
84403
84425
84430
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
84479
84480
84481
84482
84484
84485
84488
84490
84510
84512
No
No
No
No
No
No
No
No
No
No
Description
SULFATE URIN
TESTOSTERONE; FREE
TESTOSTERONE; TOT
THIAMINE
THIOCYANATE
THYROGLOBULIN
THYROXINE; TOT
THYROXINE; REQUIRING ELUTION
THYROXINE; FREE
THYROXINE BINDING GLOB
THYROID STIM HORMONE
THYROID STIM IMMUNOGLOBULINS
TOCOPHEROL ALPHA
TRANSCORTIN
TRANSFERASE; ASPARTATE AMINO
TRANSFERASE; ALANINE AMINO
TRANSFERRIN
TRIGLYCERIDES
THYROID HORMONE UPTAKE/BINDNG
RATIO
TRIIODOTHYRONINE T3; TOT (TT3)
TRIIODOTHYRONINE T3; FREE
TRIIODOTHYRONINE T3; REVERSE
TROPONIN, QUAN
TRYPSIN; DUODENAL FLUID
TRYPSIN; FECES QUAL
TRYPSIN; FECES QUAN 24-HR COLLEC
TYROSINE
TROPONIN, QUAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84520
84525
84540
84545
84550
84560
84577
84578
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
84580
84583
84585
84586
84588
84590
84591
84597
84600
No
No
No
No
No
No
No
No
No
84620
84630
84681
84702
84703
84704
No
No
No
No
No
No
84830
84999
85002
No
No
No
Description
UREA NITRO; QUAN
UREA NITRO; SEMIQUANTITATIVE
UREA NITRO URIN
UREA NITRO CLEARANCE
URIC ACID; BLD
URIC ACID; OTHER SOURCE
UROBILINOGEN FECES QUAN
UROBILINOGEN URIN; QUAL
UROBILINOGEN URIN; QUAN TIMED
SPECM
UROBILINOGEN URIN; SEMIQUAN
VANILLYLMANDELIC ACID URIN
VASOACTIVE INTESTINAL PEPTIDE
VASOPRESSIN
VITAMIN A
VITAMIN, NOT OTHERWISE SPECIFIED
VITAMIN K
VOLATILES
XYLOSE ABSORPT TEST BLD &/OR URIN
ZINC
C-PEPTIDE
GONADOTROPIN CHORIONIC; QUAN
GONADOTROPIN CHORIONIC; QUAL
HCG, FREE BETACHAIN TEST
OVULATION TEST VISUAL COLOR
COMPAR
UNLISTED CHEM PROC
BLEEDING TIME
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
85004
85007
No
No
85008
85009
85013
No
No
No
85014
85018
No
No
85025
No
85027
85032
85041
85044
No
No
No
No
85045
No
85046
85048
85049
85055
No
No
No
No
85060
85097
85130
Description
BLOOD COUNT; AUTOMATED
DIFFERENTIAL WBC COUNT
BLD CT; MANUAL DIFF WBC CT
BLD CT; MANUAL SMEAR WO DIFF
PARAME
BLD CT; DIFF WBC CT BUFFY COAT
BLD CT; SPUN MICROHEMATOCRIT
BLD CT; OTHER THAN SPUN
HEMATOCRIT
BLD CT; HGB
BLD CT; HG/PLTLT CT AUTO/COMPLT
WBC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
BLD CT; HG & PLATELET CT AUTOMATED
MANUAL CELL COUNT EACH
BLD CT; RED BLD CELL ONLY
BLD CT; RETICULOCYTE CT MANUAL
BLD CT; RETICULOCYTE CT FLO
CYTOMET
BLD COUNT;RETICS AUTO 1/>CELLULR
PARAMTR DIR MSR
BLD CT; WHITE BLD CELL
PLATELET, AUTOMATED
RETICULATED PLATELET ASSAY
BLD SMEAR PERIPHRL INTRPT
W/REPORT
No
No
BONE MARROW; SMEAR INTERPT ONLY
CHROMOGENIC SUBSTRATE ASSAY
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
85170
85175
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
85210
85220
85230
85240
No
No
No
No
CLOTTING; FACT II PROTHROMBIN SPEC
CLOTTING; FACTOR V LABILE FACTOR
CLOTTING; FACTOR VII
CLOTTING; FACTOR VIII 1 STAGE
No
No
No
No
85244
85245
No
No
CLOTTING; FACTOR VIII RELATED ANTIG
CLOT; VIII VW RISTOCETIN COFACTOR
No
No
85246
No
CLOTTING; FACT VIII VW FACTOR ANTIG
No
85247
85250
85260
85270
85280
85290
85291
85292
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
85293
85300
No
No
CLOT; VIII VON WILLEBRAND MX-METRIC
CLOTTING; FACTOR IX
CLOTTING; FACTOR X
CLOTTING; FACTOR XI
CLOTTING; FACTOR XII
CLOTTING; FACTOR XIII
CLOTTING; FACT XIII SCRN SOLUBILITY
CLOTTING; PREKALLIKREIN ASSAY
CLOTTING; HI MOLECULAR WT
KININOGEN
CLOT INHIB/ANTICOAG; ANTITHRMBN III
85301
85302
No
No
CLOT INHIB/ANTCG;ANTTHRMB III ANTIG
CLOT INHIB/ANTICOAG; PROT C ANTIG
No
No
85303
No
CLOT INHIB/ANTICOAG;PROT C ACTIVITY
No
Description
CLOT RETRACTION
CLOT LYSIS TIME WHOLE BLD DILUT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
85305
85306
85307
85335
85337
85345
85347
85348
85360
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
85362
No
85366
No
85370
No
85378
No
85379
No
85380
85384
85385
No
No
No
Description
CLOT INHIB/ANTICOAG; PROT S TOT
CLOT INHIB/ANTICOAG; PROT S FREE
ACTIVATED PROTEIN C
FACTOR INHIBIT TEST
THROMBOMODULIN
COAGULATION TIME; LEE & WHITE
COAGULATION TIME; ACTIVATED
COAGULATION TIME; OTHER METHD
EUGLOBULIN LYSIS
FIBRN DEGRAD PROD; AGGLUTSEMIQUAN
FIBRIN DEGRADAT PRODUCTS;
PARACOAG
FIBRIN DEGRADATION PRODUCTS;
QUAN
FIBRN DEGRAD PROD D-DIMER;
SEMIQUAN
FIBRIN DEGRADAT PROD D-DIMER;
QUAN
FDP D-DIMER; ULTRASENSITIVE
QUAL/SEMIQUAN
FIBRINOGEN; ACTIVITY
FIBRINOGEN; ANTIG
85390
85396
85400
No
No
No
FIBRINOLYSN/COAGULOPATHY SCREEN
FIBRINOLYSINS;
FIBRINOLYTIC FACT & INHIB; PLASMIN
No
No
No
85410
No
FIBRNOLYTC FACT/INHIB;ALPHA-2ANTIPL
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
85415
No
85420
No
85421
85441
No
No
85445
85460
85461
85475
85520
85525
No
No
No
No
No
No
85530
85536
No
No
85540
85547
85549
No
No
No
85555
85557
85576
85597
85610
No
No
No
No
No
85611
No
Description
FIBRNOLYTC FACT/INHIB;PLSMNGN
ACTIV
FBRNLYTC FACT/INHIB;PLSMNGN NO
ANTI
FBRNLYTC FACT/INHIB;PLSMNGN ANTIG
HEINZ BODIES; DIRECT
HEINZ BOD; INDUCED ACETYL
PHENYLHYD
HGB/RBC FETAL-HEMORR; DIFF LYSIS
HGB/RBC FETAL-HEMORR; ROSETTE
HEMOLYSIN; ACID
HEPARIN ASSAY
HEPARIN NEUTRALIZATION
HEPARIN-PROTAMINE TOLERANCE TEST
IRON STAIN, PERIPHERAL BLOOD
LEUKOCYTE ALKALINE PHOSPHATASE
W/CT
MECH FRAGILITY RBC
MURAMIDASE
OSMOTIC FRAGILITY RBC;
UNINCUBATED
OSMOTIC FRAGILITY RBC; INCUBATED
PLATELET; AGGREGATION EA AGENT
PLATELET NEUTRALIZATION
PROTHROMBIN TIME
PROTHRMBN TIME; SUB PLASMA FRACT
EA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
85612
No
85613
85635
No
No
85651
85652
85660
85670
85675
85705
85730
85732
85810
No
No
No
No
No
No
No
No
No
85999
86000
No
No
86001
No
86003
No
86005
86021
86022
No
No
No
86023
86038
No
No
Description
RUSSELL VIPER VENOM TIME;
UNDILUTED
RUSSELL VIPER VENOM TIME; DILUTED
REPTILASE TEST
SED RATE ERYTHROCYTE NONAUTOMATED
SED RATE, ERYTHROCYTE; AUTO
SICKLING RBC REDUCTION
THROMBIN TIME; PLASMA
THROMBIN TIME; TITER
THROMBOPLASTIN INHIBIT; TISS
P T T; PLASMA/WHOLE BLD
P T T; SUBSTIT PLASMA FRACT EA
VISCOSITY
UNLIST HEMATOLOGY & COAGULATION
PRO
AGGLUTININS FEBRILE EA ANTIG
ALLERGEN SPEC; IgG QUANTITATIVE OR
SEMI
ALLERG SPEC IGE; QUAN/SEMI-QUAN,
EA
ALLERG SPEC IGE; QUAL MXALLERG
SCRN
ANTIB IDENT; LEUKOCYTE ANTIB
ANTIB IDENT; PLATELET ANTIB
ANTIB ID; PLATELET ASSOC
IMMUNOGLOB
ANTINUCLEAR ANTIB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86039
86060
86063
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
86077
No
86078
No
86079
86140
86141
No
No
No
86146
86147
No
No
BLD BNK PHYS SERV; DIF X-MATCH/EVAL
BLD BNK PHYS SERV; INVESTIGAT
REACT
BLD BNK PHYS SERV;AUTH DEVIAT
STAND
C-REACTIVE PROT
C-REACTV PROTEIN; HIGH SENSITIVITY
BETA 2 GLYCOPROTEIN I ANTIBODY,
EACH
CARDIOLIPIN ANTIB
86148
86155
86156
86157
No
No
No
No
ANTI-PHOSPHATIDYLSERINE ANTIBODY
CHEMOTAXIS ASSAY SPEC METHD
COLD AGGLUTININ; SCREEN
COLD AGGLUTININ; TITER
No
No
No
No
86160
No
No
86161
86162
86171
No
No
No
86185
No
COMPLEMENT; ANTIG EA COMPONENT
COMPLEMENT; FUNCT ACTIVIT EA
COMPON
COMPLEMENT; TOT HEMOLYTIC
COMPLEMENT FIXA TESTS EA ANTIG
COUNTERIMMUNOELECTROPHORESIS
EA
86200
No
CYCLIC CITRULLINATED PEPTIDE ANTB
No
Description
ANTINUCLEAR ANTIB; TITER
ANTISTREPTOLYSIN 0; TITER
ANTISTREPTOLYSIN 0; SCREEN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86215
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
86225
86226
No
No
86235
86243
No
No
86255
86256
86277
86280
No
No
No
No
86294
No
86300
No
86301
No
86304
86308
86309
No
No
No
86310
86316
No
No
86317
No
86318
No
Description
DEOXYRIBONUCLEASE ANTIB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
DNA ANTIB; NATIVE/DOUBLE STRANDED
DNA ANTIB; SNGL STRANDED
EXTRACT NUCLR ANTIG ANTIB ANY
METHD
FC RECEPTOR
No
No
FLUORES NONINFECT AGENT ANTIB; EA
FLUORESCENT ANTIB; TITER EA ANTIB
GROWTH HORMONE HUMAN ANTIB
HEMAGGLUTINATION INHIBIT TEST
IMMUNOASSAY FOR TUMOR ANTIGEN,
QUANTATIVE OR SEMI
IMMUNOASSAY TUMOR ANTIGEN,
QUANT CA 15-3
IMMUNOASSAY TUMOR ANTIGEN,
QUANT, CA 19-98
IMMUNOASSAY TUMOR ANTIGEN,
QUANT, CA 125
HETEROPHILE ANTIB; SCREENING
HETEROPHILE ANTIB; TITER
HETEROPHILE ANTIB; TITER AFTR
ABSRP
IMMUNOASSAY TUMOR ANTIG EA
IMMUNOASSAY INFEC AGENT AB QUAN
NOS
IMMNASSY INFEC AGNT ANTIB SNGL
STEP
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86320
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
86325
No
86327
86329
No
No
86331
86332
No
No
86334
No
86335
86336
86337
86340
86341
No
No
No
No
No
86343
86344
No
No
86353
86355
86356
86357
86359
No
No
No
No
No
86360
86361
No
No
Description
IMMUNOELECTROPHORESIS; SERUM
IMMUNOELEC-PHORE; OTHER FLDS
CONCEN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
IMMUNOELECTROPHORESIS; CROSSED
IMMUNODIFFUSION; NES
IMMUNODIFFUSION; GEL DIFFUS QUAL
EA
IMMUNE COMPLX ASSAY
IMMUNOFIXATION ELECTROPHORESIS;
SERUM
IMMUNOFIXATION ELECTROPHORESIS;
OTH FL W/CONC
INHIBIN A
INSULIN ANTIB
INTRINSIC FACTOR ANTIB
ISLET CELL ANTIBODY
No
No
LEUKOCYTE HISTAMINE RELEASE TEST
LEUKOCYTE PHAGOCYTOSIS
LYMPHOCYTE TRANSFORM
MITOGEN/ANTIG
B CELLS TOT CNT
MONONUCLEAR CELL ANTIGEN
NATURAL KILLER CELLS TOT CNT
T CELLS; TOT CT
T CELLS; ABSOLUTE CD4-CD8 CNTRATIO
T CELLS; ABSOLUTE CD4 COUNT
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86367
86376
86378
86382
86384
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
86403
No
86406
86430
86431
No
No
No
86480
86485
86486
86490
86510
No
No
No
No
No
86580
86586
86590
86592
86593
86602
86603
86606
86609
86611
86612
No
No
No
No
No
No
No
No
No
No
No
Description
STEM CELLS TOT CNT
MICROSOMAL ANTIB EA
MIGRATION INHIBIT FACTOR TEST
NEUTRALIZATION TEST VIRAL
NITROBLUE TETRAZOLIUM DYE TEST
PARTICLE AGGLUTINATN; SCRN-EA
ANTIB
PARTICLE AGGLUTINATION; TITER EA AB
RHEUMATOID FACTOR; QUAL
RHEUMATOID FACTOR; QUAN
TUBERCULOSIS TST CELL MEDIATED
IMMUNITY
SKIN TEST; CANDIDA
SKIN TEST, NOS ANTIGEN
SKIN TEST; COCCIDIOIDOMYCOSIS
SKIN TEST; HISTOPLASMOSIS
SKIN TEST; TUBERCULOSIS
INTRADERMAL
UNLISTED ANTIGEN EACH
STREPTOKINASE ANTIB
SYPHILIS TEST; QUAL
SYPHILIS TEST; QUAN
ANTIB; ACTINOMYCES
ANTIB; ADENOVIRUS
ANTIB; ASPERGILLUS
ANTIB; BACTERIUM NES
ANTIB; BATONELLA
ANTIB; BLASTOMYCES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86615
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
86617
86618
86619
86622
86625
86628
86631
86632
86635
86638
86641
86644
86645
86648
86651
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
86652
86653
No
No
86654
86658
86663
86664
86665
86666
86668
Description
ANTIB; BORDETELLA
BORRELIA BURGDORFERI CONFIRM
TEST
ANTIB; BORRELIA BURGDORFERI
ANTIB; BORRELIA
ANTIB; BRUCELLA
ANTIB; CAMPYLOBACTER
ANTIB; CANDIDA
ANTIB; CHLAMYDIA
ANTIB; CHLAMYDIA IGM
ANTIB; COCCIDIOIDES
ANTIB; COXIELLA BRUNETII
ANTIB; CRYPTOCOCCUS
ANTIB; CYTOMEGALOVIRUS
ANTIB; CYTOMEGALOVIRUS IGM
ANTIB; DIPHTHERIA
ANTIB; ENCEPHALITIS CALIFORNIA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ANTIB; ENCEPHALITIS EASTERN EQUINE
ANTIB; ENCEPHALITIS ST. LOUIS
ANTIB; ENCEPHALITIS WESTERN
EQUINE
ANTIB; ENTEROVIRUS
ANTIB; EPSTEIN-BARR EARLY ANTIG
No
No
No
No
No
No
No
No
No
ANTIB; EPSTEIN-BARR NUCLEAR ANTIG
ANTIB; EPSTEIN-BARR VIRAL CAPSID
ANTIB; EHRLICHIA
ANTIB; FRANCISELLA TULARENSIS
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86671
86674
86677
86682
86684
86687
86688
86689
86692
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
86713
86717
86720
86723
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
ANTIB; FUNGUS NES
ANTIB; GIARDIA LAMBLIA
ANTIB; HELICOBACTER PYLORI
ANTIB; HELMINTH NES
ANTIBODY; HAEMOPHILUS INFLUENZA
ANTIB; HTLV I
ANTIB; HTLV-II
ANTIB; HTLV/HIV ANTIB CONFIRM TEST
ANTIB; HEPATITIS DELTA AGENT
ANTIB; HERPES SIMPLEX NON-SPEC
TYPE
ANTIB; HERPES SIMPLEX TYPE I
ANTIB; HERPES SIMPLEX, TYPE 2
ANTIB; HISTOPLASMA
ANTIB; HIV-1
ANTIB; HIV-2
ANTIB; HIV-1 & HIV-2 SNGL ASSAY
HEPATITIS B CORE ANTIB; IGG & IGM
HEPATITIS B CORE ANTIBODY; IGM AB
HEPATITIS B SURFACE ANTIBODY
HEPATITIS BE ANTIBODY
HEPATITIS A ANTIBODY; IGG & IGM
HEPATITIS A ANTIBODY; IGM ANTIBODY
ANTIB; INFLUENZA VIRUS
ANTIB; LEGIONELLA
ANTIB; LEISHMANIA
ANTIB; LEPTOSPIRA
ANTIB; LISTERIA MONOCYTOGENES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
86727
No
Description
ANTIB; LYMPHOCYTIC
CHORIOMENINGITIS
86729
86732
86735
86738
86741
86744
86747
86750
86753
No
No
No
No
No
No
No
No
No
ANTIB; LYMPHOGRANULOMA VENEREUM
ANTIB; MUCORMYCOSIS
ANTIB; MUMPS
ANTIB; MYCOPLASMA
ANTIB; NEISSERIA MENINGITIDIS
ANTIB; NOCARDIA
ANTIB; PARVOVIRUS
ANTIB; PLASMODIUM
ANTIB; PROTOZOA NES
No
No
No
No
No
No
No
No
No
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
No
No
No
No
No
No
No
No
No
No
ANTIB; RESPIRATORY SYNCYTIAL VIRUS
ANTIB; RICKETTSIA
ANTIB; ROTAVIRUS
ANTIB; RUBELLA
ANTIB; RUBEOLA
ANTIB; SALMONELLA
ANTIB; SHIGELLA
ANTIB; TETANUS
ANTIB; TOXOPLASMA
ANTIB; TOXOPLASMA IGM
No
No
No
No
No
No
No
No
No
No
86781
86784
86787
86788
86789
No
No
No
No
No
ANTIB; TREPONEMA PALLIDUM CONFIRM
ANTIB; TRICHINELLA
ANTIB; VARICELLA-ZOSTER
WEST NILE VIRUS AB, IGM
WEST NILE VIRUS ANTIBODY
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86790
86793
86800
86803
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
86804
No
86805
No
86806
No
86807
No
86808
86812
86813
86816
86817
No
No
No
No
No
86821
No
86822
86849
86850
86860
No
No
No
No
86870
No
86880
No
Description
ANTIB; VIRUS NES
ANTIB; YERSINIA
THYROGLOBULIN ANTIB
HEPATITIS C ANTIBODY;
HEPATITIS C ANTIBODY; CONFIRM TEST
LYMPHOCYTOTOXIC X-MATCH;
W/TITRAT
LYMPHOCYTOTOXIC X-MATCH;WO
TITRAT
SERUM SCREN CYTOTOXIC % REACT
ANTIB
SRM SCRN CYTOTOX % REACT
ANTIB;QUIK
HLA TYPING; A B/C SNGL ANTIG
HLA TYPING; A B/C MX ANTIG
HLA TYPING; DR/DQ SNGL ANTIG
HLA TYPING; DR/DQ MX ANTIG
HLA TYPING; LYMPHOCYTE CULTURE
MIX
HLA TYPING; LYMPHOCYTE CULT
PRIMED
UNLISTED IMMUNOLOGY PROC
ANTIB SCREEN RBC EA SERUM TECH
ANTIB ELUTION EA ELUTION
ANTIB ID RBC ANTIB EA PANEL EA SERM
ANTIHUMAN GLOB TEST; DIREC EA
ANTIS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
86885
86886
86890
No
No
No
86891
86900
86901
No
No
No
86903
No
Description
ANTIHUMAN GLOB TST; INDIREC QUAL
EA
ANTIHUMAN GLOB; INDIRECT TITER EA
AUTOLGUS BLD/COMP; PREDEPOSIT
AUTOLOGOUS BLD; INTRA/POSTOP
SALVAG
BLD TYPING; ABO
BLD TYPING; RH
BLD TYP; ANTIG SCRN REAGENT EA
UNIT
86904
No
BLD TYP; ANTIG SCRN PT SERM EA UNIT
No
86905
No
BLD TYPING; RBC ANTIG NOT ABO/RH EA
No
86906
86910
No
Not Reimbursable
BLD TYPING; RH PHENOTYPING COMPLT
BLD TYP PATERNITY-INDIV; ABO/RH/MN
No
Not Reimbursable
86911
86920
86921
Not Reimbursable
No
No
BLD TYP PATERN/INDIVI; EA ADD ANTIG
COMPAT TEST EA UNIT; IMMED SPIN
COMPAT TEST EA UNIT; INCUBATION
Not Reimbursable
No
No
86922
86923
86923
No
No
No
No
No
No
86927
86930
No
No
COMPAT TEST EA UNIT; ANTIGLOBULIN
COMPATIBILITY EA UNIT ELEC
COMPATIBILITY EA UNIT ELEC
FRESH FROZEN PLASMA THAWING EA
UNIT
FROZEN BLD PREP FREEZING EA UNIT
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
86931
No
86932
No
86940
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
FROZEN BLD PREP FREEZE EA; W/THAW
FROZN BLD PREP FREZ
EA;W/FREEZ/THAW
HEMOLYSINS & AGGLUTNS; AUTO SCRN
EA
No
No
86941
86945
86950
No
No
No
HEMOLYSINS & AGGLUTINS; INCUBATED
IRRADIATION BLD PRODUCT EA UNIT
LEUKOCYTE TRANSFUSION
No
No
No
86960
No
VOL RDCTJ BLD/BLD PRODUX EA UNIT
No
86960
No
No
86965
No
86970
No
VOL RDCTJ BLD/BLD PRODUX EA UNIT
POOLING PLATELETS/OTHER BLD
PRODUCT
PRETX RBC; INCUBATE W/AGENTS/DRG
EA
86971
No
No
86972
No
PRETX RBC; INCUBATE W/ENZYMES EA
PRETX RBC; DENSITY GRADIENT
SEPART
86975
No
PRETX SERUM-ANTIB ID; INCUBATION EA
No
86976
No
No
86977
No
PRETX SERUM-RBC ANTIB ID; DILUTION
PRETX SERM-RBC ANTIB; W/INHBITOR
EA
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
86978
No
PRETX SERM-ANTIB; DIFF RED CELL EA
No
86985
86999
87001
No
No
No
SPLITTING BLD/BLD PRODUCTS EA UNIT
UNLISTED TRANSFUSION MEDS PROC
ANIMAL INOCUL SM ANIMAL; W/OBSRV
No
No
No
87003
No
No
87015
No
87040
No
87045
No
87046
No
87070
No
87071
No
87073
No
87075
No
ANIMAL INOCUL SM; W/OBSRV/DISSECT
CONCNTR PARASITES OVA/TUBERCLE
BACI
CULT BACT;BLD AEROBIC
ISOLAT&PRESUMP ID ISOLATES
CULT BACT;STOOL AEROBIC
SALMONELLA&SHIGELLA SPEC
CULT BACT;STOOL AEROBIC ADD PATH
ISOLAT EA PLATE
CULT BACT; NO URINE/BLD/STOOL
AEROBIC W/ISOLAT
CULT BACTERIAL QUANTITATIVE,
AEROBIC W/ISOLATION
CULT BACTERIAL QUANTITATIVE
ANAEROBIC W/ISOLATION
CULT BACT; ANY SRC NO BLOOD
ANAEROB ISOLAT & ID
87076
87077
No
No
CULT BACT ANY; DEFIN ID EA ANAEROB
CULT BACT AEROBIC ISOLATE
No
No
87081
No
CULT BACT SCREEN ONLY SNGL ORGAN
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
87084
No
87086
87088
87101
No
No
No
87102
87103
No
No
Description
CULT PRSMPT SCRN ONLY KIT;COLNY
EST
CULT BACTERIAL URIN; QUAN COLONY
CT
CULT BACT URIN; ID ADD QUAN/KIT
CULTURE FUNGI ISOLATION; SKIN
CULTURE FUNGI ISOLAT; OTHER
SOURCE
CULTURE FUNGI ISOLATION; BLD
87106
87107
No
No
CULTURE FUNGI DEFINITIVE ID EA FUNG
CULTURE, MOLD
No
No
87109
87110
No
No
No
No
87116
No
87118
No
87140
No
87143
No
87147
No
87149
No
87152
No
CULTURE MYCOPLASMA ANY SOURCE
CULTURE CHLAMYDIA
CULT TB/AFB/MYCOBACT;ANY ISOLAT
ONL
CULT MYCOBACTERIA DEFFIN ID EA
ORGA
CULTURE TYPING; FLUORESC EA
ANTISER
CULTURE TYPING; GAS LIQ
CHROMATOGRA
CULT TYP; SEROLOG
AGGLUT/ANTISERUM
CULTURE IDENTIFICATION BY NUCLEIC
ACID PROBE
CULTURE IDENTIFICATION BY PULSE
FIELD GEL TYPE
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87158
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
87164
No
87166
87168
87169
87172
No
No
No
No
87176
No
87177
87181
No
No
87184
No
87185
87186
No
No
87187
No
87188
87190
87197
No
No
No
87205
No
87206
No
Description
CULTURE TYPING; OTHER METHD
DARK FIELD ANY SOURCE; W/SPEC
COLL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
DARK FIELD ANY SOURCE; WO COLLEC
MACROSCOPIC EXAM; ANTHROPOD
MACROSCOPIC EXAM; PARASITE
PINWORM EXAM
ENDOTOX BACT; HOMOGENIZAT TISS
CULT
OVA/PARASITS DIRECT SMEAR
CONCNT&ID
SENSIT ANTIBIOT; AGAR DIFF/ANTIBIOT
No
No
No
No
SENSIT ANTIBIOT; DISK METHOD/PLATE
SENSIT ANTIBIOT; ENZYME DETECTION,
PER ENZYME
SENSIT ANTIBIOT; MICRTITR MIC ANY #
No
SENSIT ANTIBIOT; MINI BACTRCDL CONC
SENSIT ANTIBIOT; MACROTUBE DILUT
EA
SENSIT ANTIBIOTIC; TB/AFB EA DRUG
SERUM BACTERICIDAL TITER
SMEAR PRIM W/INTERPT; ROUTINE
STAIN
SMEAR PRIM W/INTRPT; FLUOR/ACID
AFB
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
87207
No
87209
No
87210
87220
No
No
Description
SMEAR PRIM W/INTERPT; SPECIAL
STAIN
SMR PRIM SRC CPLX SPEC STAIN
OVA&PARASITS
SMEAR PRIM W/INTRPT; WET MNT
W/SIMP
TISS EXAM FUNGI
87230
87250
No
No
TOXIN/ANTITOXIN ASSAY TISS CULTURE
VIRUS ID; W/OBSRV & DISSECT
No
No
87252
87253
No
No
No
No
87254
No
87255
87260
No
No
87265
No
87267
No
87269
No
87270
No
87271
No
VIRUS ID; TISS CULT INOCULAT & OBSV
VIRUS ID; TISS CULT ADD STUDIES EA
VIRUS ID; SHELL VIAL, INCLUDES ID
W/IMMUNOFLURESCENCE STAIN
VIRUS ISOLAT; W/ID NON-IMMUOLOGIC
NOT CYTOPATHIC
AG-DIR FLUORES AB; ADENOVIRUS
AG-FLUORES AB; BORDATELLA
PERTUSSIS
INF AGT ANTIG DET IMMUOFLUORS
TECH; ENTRVRUS DFA
INF AGT ANTIG DETECT
IMMUNOFLUORES TECH; GIARDIA
AG-FLUORES AB; CHLAMYDIA
TRCHOMATIS
INF AGT ANTIG DET IMMUOFLUORES
TECH;CYTOMEGA DFA
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87272
No
87273
No
87274
87275
87276
No
No
No
87277
No
87278
No
87279
No
87280
No
87281
87283
No
No
87285
No
87290
87299
No
No
87300
No
87301
87305
No
No
Description
INF AGT IMMUNOFLUORRSCENT TECH;
CRYPTOSPORIDIUM
AG-FLOURES AB; HERPES SIMPLEX
VIRUS TYPE 2
AG-FLUORES AB; HERPES SIMPLEX
VIRUS
AG-FLOURES AB; INFLUENZA B VIRUS
AG-FLUORES AB; INFLUENZA A VIRUS
AG-FLOURES AB; LEGIONELLA
MICDADEL
AG-FLUORES AB; LEGIONELLA
PNEUMOPHL
AG-FLOURES AB; PARAINFLUENZA
VIRUS, EACH TYPE
AG-FLUORES AB; RESP SYNCYTIAL
VIRUS
AG-FLUORES AB; PNEUMOCYSTIS
CARINI
AG-FLOURES AB; RUBEOLA
AG-DIR FLUORES AB; TREPONEMA
PALLID
AG-DIR FLUORES AB; VARICELLA
ZOSTER
INFEC AG-DIR FLUORES AB; NOS
INFEC AG-ANTIGEN DETECT BY
IMMUNOFLUORESCENT
AG-IMMUNOASSAY; ADENOVIRUS
ENTERIC
ASPERGILLUS AG, EIA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87320
No
87324
No
87327
No
87328
No
87329
No
87332
No
87335
No
87336
No
87337
87338
No
No
87339
No
87340
No
87341
87350
No
No
AG-IMMUNOASSAY; CYTOMEGALOVIRUS
AG-IMMUNOASSAY; ESCHERICH COLI
0157
AG-IMMUNOASSAY; ENTAMOEBA
HISTOLYTICA DISPAR GRP
AG-IMMUNOASSAY; ENTAMOEBA
HISTOLYTICA GRP
INFEC AG-MX STEP; H PYLORI-STOOL
AG-IMMUNOASSAY; HELICOBACTER
PYLORI
AG-IMMUNOASSAY; HEP B SURFACE
ANTIG
AG-IMMUNOASSAY; HEPATITUS B
SURFACE ANTIGEN HBsAg
AG-IMMUNOASSAY; HEP BE ANTIG
87380
No
AG-IMMUNOASSAY; HEP DELTA AGENT
Description
AG-IMMUNOASSAY; CHLAMYDIA
TRCHOMATS
AG-IMMUNOASSAY; CLOSTRIDIUM-TOXIN
A
AG-IMMUNOASSAY; CRYPTOCOCCUS
NEOFORMANS
INF AGT ENZYME IMMUNOASSAY TECH;
CRYPTOSPORIDUM
INF AGT ANTIG EIA MX STEP METH;
GIARDIA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87385
87390
87391
No
No
No
87400
No
87420
87425
87427
87430
No
No
No
No
87449
No
87450
87451
No
No
87470
No
87471
No
87472
No
87475
No
87476
No
87477
No
Description
AG-IMMUNOASSAY; HISTOPLASMA
CAPSULA
AG-IMMUNOASSAY; HIV-1
AG-IMMUNOASSAY; HIV-2
AG-IMMUNOASSAY; INFLUENZA A OR B,
EACH
AG-IMMUNOASSAY; RESP SYNCYTIAL
VIR
AG-IMMUNOASSAY; ROTAVIRUS
AG-IMMUNOASSAY; SHIGA-LIKE TOXIN
AG-IMMUNOASSAY; STREP GROUP A
AG-IMMUNOASSAY; MX STEP METHDNOS
AG-IMMUNOASSAY; SNGL STEP METHDNOS
AG-IMMUNOASSAY; MULTI STEP METH
AGT-DNA/RNA; BARTONELLA-DIR PROBE
AGT-DNA/RNA; BARTONELLA-AMPLI
PROBE
AGT-DNA/RNA; BARTONELLA H & QQUAN
AGT-DNA/RNA; BORRELIA BURGDORFDIR
AGT-DNA/RNA; BORRELIA BURGDORAMPLI
AGT-DNA/RNA; BORRELIA BURGDORFQUAN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
87480
No
Description
AGT-DNA/RNA; CANDIDA SPECIESDIRECT
87481
No
AGT-DNA/RNA; CANDIDA SPECIES-AMPLI
No
87482
No
No
87485
No
87486
No
87487
No
87490
No
87491
No
87492
No
87495
No
87496
No
87497
87498
87500
No
No
No
87510
No
AGT-DNA/RNA; CANDIDA SPECIES-QUAN
AGT-DNA/RNA; CHLAMYDIA PNEUMONDIR
AGT-DNA/RNA; CHLAMYDIA PNEUMOAMPLI
AGT-DNA/RNA; CHLAMYDIA PNEUMONQUAN
AGT-DNA/RNA; CHLAMYDIA TRACHDIRECT
AGT-DNA/RNA; CHLAMYDIA TRACHAMPLI
AGT-DNA/RNA; CHLAMYDIA TRACHQUAN
AGT-DNA/RNA; CYTOMEGALOVIRUSDIRECT
AGT-DNA/RNA; CYTOMEGALOVIRUSAMPLI
AGT-DNA/RNA; CYTOMEGALOVIRUSQUAN
ENTEROVIRUS, DNA, AMP PROBE
VANOMYCIN, DNA, AMP PROBE
AGT-DNA/RNA; GARDNERELLA VAGDIRECT
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87511
No
87512
No
87515
No
87516
87517
87520
87521
87522
87525
87526
87527
No
No
No
No
No
No
No
No
87528
Description
AGT-DNA/RNA; GARDNERELLA VAGAMPLI
AGT-DNA/RNA; GARDNERELLA VAGQUAN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
AGT-DNA/RNA; HEP B VIRUS-DIR PROBE
AGT-DNA/RNA; HEP B VIRUS-AMPLI
PROB
AGT-DNA/RNA; HEP B VIRUS-QUAN
AGT-DNA/RNA; HEP C-DIRECT PROBE
AGT-DNA/RNA; HEP C-AMPLI PROBE
AGT-DNA/RNA; HEP C-QUAN
AGT-DNA/RNA; HEP G-DIRECT PROBE
AGT-DNA/RNA; HEP G-AMPLI PROBE
AGT-DNA/RNA; HEP G-QUAN
AGT-DNA/RNA; HERPES SIMPLEXDIRECT
No
87529
No
AGT-DNA/RNA; HERPES SIMPLEX-AMPLI
No
87530
No
AGT-DNA/RNA; HERPES SIMPLEX-QUAN
No
87531
No
AGT-DNA/RNA; HERPES VIRUS-6-DIRECT
No
87532
No
AGT-DNA/RNA; HERPES VIRUS-6-AMPLI
No
87533
87534
87535
No
No
No
AGT-DNA/RNA; HERPES VIRUS-6-QUAN
AGT-DNA/RNA; HIV-1-DIRECT PROBE
AGT-DNA/RNA; HIV-1-AMPLI PROBE
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87536
87537
87538
87539
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
87540
No
87541
No
87542
No
87550
No
87551
87552
No
No
87555
No
87556
No
87557
No
87560
No
87561
No
87562
No
87580
No
Description
AGT-DNA/RNA; HIV-1-QUAN
AGT-DNA/RNA; HIV-2-DIRECT PROBE
AGT-DNA/RNA; HIV-2-AMPLI PROBE
AGT-DNA/RNA; HIV-2-QUAN
AGT-DNA/RNA; LEGIONELLA PNEUMODIR
AGT-DNA/RNA; LEGIONELLA PNEUMOAMPL
AGT-DNA/RNA; LEGIONELLA PNEUMOQUAN
AGT-DNA/RNA; MYCOBACTERIA-DIR
PROBE
AGT-DNA/RNA; MYCOBACTERIA-AMPL
PROB
AGT-DNA/RNA; MYCOBACTERIA-QUAN
AGT-DNA/RNA; MYCOBACTERIA TBDIRECT
AGT-DNA/RNA; MYCOBACTERIA TBAMPLI
AGT-DNA/RNA; MYCOBACTERIA TBQUAN
AGT-DNA/RNA; MYCOBACTERIA AVIUMDIR
AGT-DNA/RNA; MYCOBACTERIA AVIUMAMP
AGT-DNA/RNA; MYCOBACTER AVIUMQUAN
AGT-DNA/RNA; MYCOPLASMA PNEUMONDIR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
87581
No
87582
No
87590
No
87591
No
87592
No
87620
No
Description
AGT-DNA/RNA; MYCOPLASMA PNEUMOAMPL
AGT-DNA/RNA; MYCOPLASMA PNEUMOQUAN
AGT-DNA/RNA; NEISSER GONORRHEADIR
AGT-DNA/RNA; NEISSER GONORRHEAAMPL
AGT-DNA/RNA; NEISSER GONORRHEAQUAN
AGT-DNA/RNA; PAPILLOMAVIRUSDIRECT
87621
No
AGT-DNA/RNA; PAPILLOMAVIRUS-AMPLI
No
87622
87640
87641
No
No
No
AGT-DNA/RNA; PAPILLOMAVIRUS-QUAN
STAPH A, DNA, AMP PROBE
MR-STAPH, DNA, AMP PROBE
No
No
No
87650
No
AGT-DNA/RNA; STREP GROUP A-DIRECT
No
87651
87652
87653
No
No
No
No
No
No
87660
No
87797
No
AGT-DNA/RNA; STREP GROUP A-AMPLI
AGT-DNA/RNA; STREP GROUP A-QUAN
STREP B, DNA, AMP PROBE
INF AGT DETECT NUCLEIC ACID; TRICH
VAG DIR PROBE
AGT-DNA/RNA; NOS-DIRECT PROBE
TECH
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87798
87799
87800
No
No
No
87801
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
AGT-DNA/RNA; NOS-AMPLIFIED PROBE
AGT-DNA/RNA; NOS-QUAN
AGT-DNA/RNA; MULTI ORGANISMS
AGT-DNA/RNA; AMPLIFIED PROBE
TECHNIQUE
87802
No
INF AGT ANTIG IMMUOAS; STREP GRP B
No
87803
No
INF AGT ANTIG IMMUNOAS;C-DIFF TOX A
No
87804
No
No
87807
87808
87809
No
No
No
87810
No
87850
No
87880
No
87899
No
INF AGT ANTIG DETECT IMMUNOAS; FLU
INF AGT ANTIG DETCT IMMUOASSY DIR
OPTICL OBS;RSV
TRICHOMONAS ASSAY W/OPTIC
ADENOVIRUS ASSAY W/OPTIC
AGT-IMMUNASSAY DIR OBSER;
CHLAMYDIA
AGT-IMMUNOASSAY DIR OBS;
GONORRHEA
AGT-IMMUNASSAY DIR OBS; STREP GRP
A
AGT-IMMUNOASSAY W/DIR OBSERV;
NOS
87900
No
87901
87902
No
No
NFCT AGT DRUG SC PHEXYP PREDICT
AGT-DNA/RNA; GENOTYPE ANALYSIS BY
NUCLEIC ACID
INF AGT GENOTYPE DNA/RNA; HCV
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
87903
No
87904
87999
No
No
88000
Not Reimbursable
88005
Not Reimbursable
88007
Not Reimbursable
88012
Not Reimbursable
88014
Not Reimbursable
88016
88020
88025
Not Reimbursable
Not Reimbursable
Not Reimbursable
88027
Not Reimbursable
88028
Not Reimbursable
88029
Not Reimbursable
88036
Not Reimbursable
88037
Not Reimbursable
Description
AGT-DNA/RNA; PHENOTYPE ANALYSIS
BY NUCLEIC ACID
AGT-DNA/RNA; ADD DRUG UP TO 5
DRUGS
UNLISTED MICROBIOLOGY PROC
NECROPSY GROSS EXAM ONLY; WO
CNS
NECROPSY GROSS EXAM ONLY;
W/BRAIN
NECROPSY GROSS ONLY; W/BRAINCORD
NECROPSY GROSS ONLY; INFANT
W/BRAIN
NECRPSY GRSS ONLY;STILB/NB
W/BRAIN
NECROPSY GROSS ONLY; MACERAT
STILLB
NECROPSY GROSS & MICRO; WO CNS
NECROPSY GROSS & MICRO; W/BRAIN
NECROPSY GROSS/MICRO;
W/BRAIN/CORD
NECRPSY GROSS/MICRO; INFANT
W/BRAIN
NECRPSY GRSS/MICRO;STILB/NB
W/BRAIN
NECROPSY LTD GROSS/MICRO;
REGIONAL
NECROPSY LTD GROSS/MICRO; 1
ORGAN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
88040
88045
88099
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
88104
No
88106
No
88107
No
88108
No
88112
88125
No
No
88130
No
88140
No
88141
No
88142
No
88143
No
88147
No
88148
No
Description
NECROPSY; FORENSIC EXAM
NECROPSY; CORONER'S CALL
UNLISTED NECROPSY PROC
CYTOPATH NO CERV/VAG; SMEARS
W/INTE
CYTPTH NO CERV/VAG;FLTR ONLY
W/INTE
CYTOPATH NO CERV/VAG; PREP
W/INTRPT
CYTOPATH CONCENTRA-SMEARS &
INTERP
CYTOPATH SELCTV CELLR ENHANCE
INTEPR NO CERV/VAG
CYTOPATHOLOGY FORENSIC
SEX CHROMATIN IDENT; BARR BODIES
SEX CHROMAT ID; PERIPHERL BLD
SMEAR
CYTOPATH CERV/VAG; REQ INTERPT
PHYS
CYTPTH CERV/VAG; THIN PREP; MAN
SCR
CYTOPATH CERV/VAG; W/MAN SCRNRESCR
CYTOPATH CERV/VAG; AUTO SCRNSUPRVS
CYTOPATH CERV; SCR-RESCRN-MD
SUPR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88150
No
88152
No
88153
No
88154
No
88155
88160
No
No
88161
No
88162
No
88164
No
88165
No
88166
No
88167
No
88172
No
88173
88174
88175
No
No
No
Description
CYTPTH SLIDE CERV/VAG; MANUALSUPRV
CYTPTH SLDE CERV/VAG; MANUALCMPUTR
CYTOPATH CERV/VAG; MAN SCRNRESCRN
CYTOPATH CERV/VAG; SCRN-RESCRNCELL
CYTPTH SLIDES CERV/VAG DEF
HORMONAL
CYTPATH SMEARS; SCREEN & INTRPT
CYTOPATH SMEAR;
PREP/SCREEN/INTERPT
CYTOPATH SMEARS; EXTEN STDY >5
SLDS
CYTOPATH SLIDES-CERV/VAG; MAN
SCRN
CYTOPATH SLIDES-CERV; MAN SCRN &
RE
CYTOPATH SLIDES-CERV; MAN-COMPU
SCR
CYTOPATH SLIDES-CERV/VAG; SCRN
CELL
EVAL FINE NEEDL ASPIRAT; IMMED STDY
EVAL FINE NEEDL
ASPIRAT;INTRPT/REPR
CYTOPATH, C/V AUTO, IN FLUID
CYPTOPATH, C/V AUTO FLUID REDO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88182
No
88184
No
88185
No
88187
No
88188
No
88189
88199
No
No
88230
88233
No
No
88235
No
88237
No
88239
88240
No
Not Reimbursable
88241
Not Reimbursable
88245
No
88248
No
Description
FLO CYTOMETRY; CELL CYCLE/DNA
ANALY
FLOW CYTOMETRY CELL SURF/NUCLR
TC ONLY; 1 MARKER
FLOW CYTOMETRY CELL SURF/NUCLR
TC ONLY; EA ADD
FLOW CYTOMETRY INTERPRETATION; 2
TO 8 MARKERS
FLOW CYTOMETRY INTERPRETATION; 9
TO 15 MARKERS
FLOW CYTOMETRY INTERPRETATION;
16/MORE MARKERS
UNLISTED CYTOPATHOLOGY PROC
TISS CULT NON-NEOPLASM;
LYMPHOCYTE
TISS CULT NON-NEOPLASM; SKIN
TISS CULT NON-NEOPLAS; AMNIOT
FLUID
TISS CULT NEOPLASM; MARROW/BLD
CELL
TISS CULTURE NEOPLASM; SOLID
TUMOR
CRYOPRESERV CELLS-EA CELL LINE
THAW & EXPANS FROZ CELLS EA
ALIQUOT
CHROMOS ANALY BREAK SYNDROM; 2025
CHROMOSOME ANALY; BASELINE
BREAKAGE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88249
No
88261
No
88262
No
88263
No
88264
No
88267
No
88269
88271
No
No
88272
No
88273
88274
No
No
88275
No
88280
No
88283
No
88285
No
Description
CHROMOSOME ANALY; CLASTOGEN
STRESS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
CHROMO ANALY; CT 5 CEL 1 KAROTYPE
CHROMO ANALY; CT 15-20 CELL 2
KARYO
No
CHROMO ANALY; CT 45 CEL MOSAICISM
CHROMOSOME ANALY; ANALY 20-25
CELLS
CHROMO ANALY AMNIO FLUID CT 15
CELL
CHROMO ANAL AMNIO FLD CT 6-12
COLNY
MOLEC CYTOGEN; DNA PROBE EA
MOLEC CYTOGEN; CHROMOSOM
HYBRID 3-5
CYTOGEN; CHROMOSOM HYBRID 10-3O
CEL
CYTOGEN; INTERPHASE HYBRID 25-99
No
CYTOGEN; INTERPHASE HYBRID 100-300
CHROMOSOME ANALY; ADD
KARYOTYPES EA
CHROMO ANALY; ADD SPECIALIZED
BAND
CHROMO ANALY; ADD CELLS COUNTED
EA
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88289
No
88291
88299
No
No
88300
No
88302
No
88304
No
88305
No
88307
No
88309
88311
No
No
88312
No
88313
No
88314
No
88318
No
88319
No
Description
CHROMO ANALY; ADD HIGH
RESOLUTION
CYTOGEN & MOLEC CYTOGEN INTER &
RPT
UNLISTED CYTOGENETIC STUDY
LEVEL I- SURG PATH GROSS EXAM ONLY
LEVEL II-SURG PATH GROSS/MICRO
EXAM
LEVEL III-SURG PATH GROS/MICRO
EXAM
LEVEL IV-SURG PATH GROSS/MICRO
EXAM
LEVEL V-SURG PATH GROSS/MICRO
EXAM
LEVEL VI-SURG PATH GROSS/MICRO
EXAM
DECALCIFICATION PROC
SPECIAL STAINS; GROUP I FOR
MICROORGANISMS EACH
SPCL STAINS; GRP II ALL BUT
ICYTOCHEM/IPEROX EA
SPCL STAINS; HISTOCHEM STAINING
W/FRZN SECTION
DETERM HISTOCHEM TO ID CHEM
COMPONT
DETERM HSTOCHEM/CYTCHEM ID
ENZYM EA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88321
No
88323
No
88325
88329
No
No
88331
No
88332
No
88333
No
88334
No
88342
No
88346
No
88347
88348
88349
No
No
No
88355
88356
88358
No
No
No
88360
No
Description
CONS & REPRT REF SLIDES PREP
ELSEWH
CONS & REPRT REF MAT REQ PREP
SLIDE
CONS COMP W/REVW
RECORD/SPECMN/REPT
PATH CONS DURING SURG
PATH CONS DURNG SURG; FROZEN 1
SPEC
PATH CONS DURING SURG; EA ADD
BLOCK
PATH CONSLTJ SURG CYTOLOGIC XM
1ST SIT
PATH CONSLTJ SURG CYTOLOGIC XM
EA SIT
IMMUNOHISTOCHEMISTRY EACH
ANTIBODY
IMMUNOFLUOR STUDY EA ANTIB;
DIRECT
IMMUNOFLUOR STUDY EA ANTIB;
INDIREC
ELECTRON MICRO; DX
ELECTRON MICRO; SCANNING
MORPHOMETRIC ANALY; SKELETAL
MUSCL
MORPHOMETRIC ANALY; NERV
MORPHOMETRIC ANALYSIS; TUMOR
MORPHOMTRIC ANALYSIS TUMR IHC EA
ANTIBDY; MANUAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
88361
88362
88365
No
No
No
88367
No
88368
No
88371
No
88372
88380
88381
No
No
No
88384
No
88385
No
88386
88399
88400
89049
89050
89051
No
No
No
No
No
No
89055
89060
No
No
Description
MORPHOMTRIC ANALY TUMR IHC EA
ANTIBDY; CMPT ASST
NERV TEASING PREP
IN SITU HYBRIDIZATION EA PROBE
MORPHOMTRIC ANALY IN SITU HYBRID
EA; CMPT ASST
MORPHOMTRIC ANALY IN SITU HYBRID
EA PROBE; MNL
PROT ANALY TISS W BLOT
W/INTRPT/REP
PROT ANALY W BLOT W/I & R; IMMUN EA
MICRODISSECTION
MICRODISSECTION, MANUAL
RA-BASED EVAL MLT MOLEC PRBS 11
THRU 50 PRBS
RA-BASED EVAL MLT MOLEC PRBS 51
THRU 250 PRBS
RA-BASED EVAL MLT MOLEC PRBS 251
THRU 500 PRBS
UNLISTED SURG PATH PROC
BILIRUBIN, TOTAL, TRANSCUTANEOUS
CAFFEINE HALOTHANE CONTRCURE
CELL CT MISC BODY FLUIDS EX BLD
CELL CT MISC FLUIDS EX BLD; W/DIFF
LEUKOCYTE ASSESSMENT FECAL
QUALITATIVE/SEMIQUAN
CRYSTAL ID LITE MICRO ANY FLUID
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
89100
No
89105
89125
No
No
89130
No
89132
No
89135
No
89136
89140
No
No
89141
89160
89190
No
No
No
89220
89225
No
No
89230
89235
No
No
89240
Not Reimbursable
89250
Not Reimbursable
Description
DUODENL INTUB/ASPIR;1 SPECMN +
TEST
DUODENL INTUB/ASPIR;COLCT MX F
SPEC
FAT STAIN FECES URIN/SPUTUM
GASTRIC INTUBAT & ASPIR DX EA
SPECM
GASTRIC INTUBAT/ASPIR DX; AFTR STIM
GASTRC INTUB/ASPIR/FRAC COLLEC;
1HR
GASTRC INTUB/ASPIR/FRAC COLLEC;
2HR
GASTRC INTUB/ASPIR/F COLLC; 2HR +
GASTRC INTUB/ASPIR/F COLLEC; 3HR +
MEAT FIBERS FECES
NASAL SMEAR EOSINOPHILS
SPUTUM OBTAINING SPECIMEN AROSL
INDUCD TECHNIQUE
STARCH GRANULES FECES
SWEAT COLLECTION BY
IONTOPHORESIS
WATER LOAD TEST
UNLISTED MISCELLANEOUS
PATHOLOGY TEST
CULTURE OOCYTE/EMBRYO LESS THAN
4 DAYS;
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
89251
Not Reimbursable
89253
89254
89255
Not Reimbursable
Not Reimbursable
Not Reimbursable
89257
89258
89259
Not Reimbursable
Not Reimbursable
Not Reimbursable
89260
Not Reimbursable
89261
Not Reimbursable
89264
89268
Not Reimbursable
Not Reimbursable
89272
Not Reimbursable
89280
Not Reimbursable
89281
Not Reimbursable
89290
Not Reimbursable
89291
Not Reimbursable
89300
Not Reimbursable
Description
CULT OOCYTE/EMBRYO <4 DAY; COCULT OOCYTE/EMBRYO
ASSISTED EMBRYO HATCHINGMICROTECH
OOCYTE ID FROM FOLLICULAR FLUID
PREP EMBRYO FOR TRANSFER
SPERM ID FROM ASPIR (NOT SEM FLUID)
CRYOPRESERVATION; EMBRYO
CRYOPRESERVATION; SPERM
SPERM ISOLA; SIMPL PREP W/SEMN
ANAL
SPERM ISOLA; CMPLX PREP W/SEMN
ANAL
SPERM ID TESTIS TISSFRESH/CRYOPRES
INSEMINATION OF OOCYTES
EXTENDED CULTURE OF
OOCYTE/EMBRYO 4-7 DAYS
ASSTD OOCYTE FERTILIZ MICROTECH;
</= 10 OOCYTES
ASSTD OOCYTE FERTILIZ MICROTECH; >
10 OOCYTES
BX OOCYTE POLAR BDY/EMBRYO
BLASTOMERE;</= 5 EMB
BX OOCYTE POLAR BDY/EMBRYO
BLASTOMERE; > 5 EMB
SEMEN; PRESENCE/MOTILITY INC
HUHNER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
89310
89320
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Not Reimbursable
89321
89322
89325
Bundled
Not Reimbursable
Not Reimbursable
89329
89330
89331
Not Reimbursable
Not Reimbursable
Not Reimbursable
89335
89342
89343
Not Reimbursable
Not Reimbursable
Not Reimbursable
89344
89346
Not Reimbursable
Not Reimbursable
89352
Not Reimbursable
89353
Not Reimbursable
89354
Not Reimbursable
89356
90281
90283
90284
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
SEMEN ANALY; MOTILITY & CT
SEMEN ANALY; COMPLT
SEMEN ANALY; PRESENCE &/OR
MOTILITY OF SPERM
SEMEN ANAL, STRICT CRITERIA
SPERM ANTIB
SPERM EVAL; HAMSTER PENETRATION
SPERM; CERV MUCOS PENETRAT
RETROGRADE EJACULATION ANAL
CRYOPRESERVATION REPRODUCTIVE
TISSUE TESTICULAR
STORAGE; EMBRYO
STORAGE; SPERM/SEMEN
STORAGE; REPRODUCTIVE TISSUE
TESTICULAR/OVARIAN
STORAGE PER YEAR; OOCYTES
THAWING OF CRYOPRESERVED;
EMBRYO
THAWING CRYOPRESERVED;
SPERM/SEMEN EACH ALIQUOT
THAWING CRYOPRES; TISS
TESTICULAR/OVARIAN
THAWING OF CRYOPRESERVED;
OOCYTES EACH ALIQUOT
IMMUNE GLOBULIN HUMAN-IM USE
IMMUNE GLOBULIN HUMAN-IV USE
HUMAN IG, SC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90287
Not Reimbursable
90288
Not Reimbursable
90291
Not Reimbursable
90296
Description
BOTULINUM ANTITOX-EQUINE-ANY
ROUTE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
BOTULISM IMMUNE GLOBULIN HUMAN-IV
CYTOMEGALOVIRUS IMMUNE GLOBULINIV
DIPHTHERIA ANTITOX EQUINE ANY
ROUTE
90371
Yes
HEPATITIS B IMMUNE GLOBULIN-IM USE
No
90375
No
RABIES IMMUNE GLOBULIN-IM &/SUBCUT
No
90376
No
No
90378
90379
Yes
Not Reimbursable
RABIES IG HEAT-TREATED IM &/SUBCUT
RESP SYNCYTIAL VIRUS IMMUN
GLOBULIN
RESP SYNCYTIAL VIR IMMUNE GLOB IV
Yes
Not Reimbursable
90384
90385
Not Reimbursable
Not Reimbursable
RHO IMMUNE GLOBULIN FULL DOSE-IM
RHO IMMUNE GLOBULIN MINI DOSE-IM
Not Reimbursable
Not Reimbursable
90386
Not Reimbursable
RHO IMMUNE GLOBULIN HUMAN-IV USE
Not Reimbursable
90389
Not Reimbursable
TETANUS IMMUNE GLOBULIN HUMAN-IM
Not Reimbursable
90393
Not Reimbursable
Not Reimbursable
90396
90399
No
Not Reimbursable
VACCINIA IMMUNE GLOBULIN HUMAN-IM
VARICELLA-ZOSTER IMMUNE GLOBULIN
IM
UNLISTED IMMUNE GLOBULIN
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90465
No
90466
No
90467
No
90468
No
90471
No
90472
90473
No
Not Reimbursable
90474
Not Reimbursable
90476
Not Reimbursable
90477
90581
Not Reimbursable
Not Reimbursable
90585
Yes
BCG VACCINE FOR TB LIVE-PERCUT USE
No
90586
Yes
BCG VACC BLADDER CA LIVE-INTRAVES
No
90632
No
HEPATITIS A VACCINE ADULT DOSE-IM
No
90633
No
HEP A VACCINE PED/ADOLES DOSE-2-IM
No
Description
IMM ADMIN < 8 YR PERQ INTDERM
SUBQ/IM; 1 INJ-DAY
IMM ADMIN < 8 YR PERQ INTDERM
SUBQ/IM; EA ADD DA
IMM ADMIN < 8 YR INTRANASL/ORL; 1
ADMIN-DAY
IMM ADMIN < 8 YR INTRANASL/ORL; EA
ADD ADMIN-DAY
IMMUNIZATION ADMINISTRATION ; ONE
VACCINE
IMMUNIZATION ADMINISTRATION; EA
ADD VACCINE
IMMU ADMN INTRANASAL/ORAL; 1 VAC
IMMU ADMN INTRANASAL/ORAL; ADD
VAC
ADENOVIRUS VACCINE TYPE 4 LIVEORAL
ADENOVIRUS VACCINE TYPE 7 LIVEORAL
ANTHRAX VACCINE-SUBCUT USE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
90634
Not Reimbursable
HEP A VACCINE PED/ADOLES DOSE-3-IM
Not Reimbursable
90636
No
No
90645
No
90646
No
90647
No
90648
No
90649
90650
Yes
Not Reimbursable
90655
No
90656
No
90657
No
90658
No
HEP A-HEP B VACCINE ADULT DOSE-IM
HEMOPHILUS FLU B VACC HBOC CONJUIM
HEMOPHIL FLU B VACC PRPD-D BOOST
IM
HEMOPHIL FLU B VACC PRP-OMP CONJIM
HEMOPHIL FLU B VACC PRP-T CONJUGIM
HPV TYP 6 11 16 18 QUADRIV 3 DOSE
SCHED IM
HPV TYP BIVAL 3 DOSE IM
FLU VIRUS VAC SPLIT PRES FREE 6-35
MO AGE IM
FLU VIRUS VAC SPLIT PRES FREE IND 3
YR AGE&> IM
INFLUENZA VIRUS VACC-SPLIT VIRUS 635 MO IM USE
INFLUENZA VIRUS VACC-SPLIT VIRUS 3
YR AGE & > IM
90660
90661
90662
90663
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
FLU VIRUS VACC-LIVE-INTRANASAL USE
FLU VACC CELL CULT PRSV FREE
FLU VACC PRSV FREE INC ANTIG
FLU VACC PANDEMIC
No
No
No
No
YES
Not Reimbursable
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90665
Yes
90669
90675
90676
No
No
No
90680
90681
90690
90691
Not Reimbursable
Not Reimbursable
Yes
Yes
90692
Yes
90693
90696
Not Reimbursable
Not Reimbursable
90698
Not Reimbursable
90700
No
90701
90702
No
No
90703
No
90704
No
90705
No
Description
LYME DISEASE VACC-ADULT DOSE-IM
USE
PNEUMOCOCCAL VACC-POLYVALENT-IM
USE
RABIES VACCINE-IM USE
RABIES VACCINE-INTRADERMAL USE
ROTAVIRUS VACC TETRAVLNT-LIVEORAL
ROTAVIRUS VACC 2 DOSE ORAL
TYPHOID VACCINE-LIVE-ORAL
TYPHOID VACCINE-VICPS-IM USE
TYPHOID VACC-HEAT INACTIVSUBQ/DERM
TYPHOID VACCINE ACETONE-KILLED
DRIED SUBQ USE
DTAP-IPV VACC 4-6 YR IM
DTAP-HIB-IPV FOR INTRAMUSCULAR
USE
DTAP INDIVIDUAL YOUNGER THAN 7 YRS
IM USE
DIPH/TET/WHOLE CELL PERTUSS VAC-IM
DIPHTH & TET TOX -PED USE-IM USE
TETANUS TOXOID ADSORBED FOR
INTRAMUSCULAR USE
MUMPS VIRUS VACCINE LIVE FOR
SUBCUTANEOUS USE
MEASLES VIRUS VACCINE LIVE
SUBCUTANEOUS USE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90706
No
90707
No
90708
No
90710
90712
90713
90714
Not Reimbursable
No
No
No
90715
No
90716
90717
No
No
90718
90719
No
Not Reimbursable
90720
No
90721
Not Reimbursable
90723
90725
90727
Description
RUBELLA VIRUS VACCINE LIVE
SUBCUTANEOUS USE
MEASLES MUMPS & RUBELLA VIRUS
VACC LIVE-SUBQ USE
MEASLES & RUBELLA VIRUS VACCINE
LIVE SUBQ USE
MEASLES/MUMPS/RUBELLA/VARCELLASUBQ
POLIOVIRUS VACCINE LIVE-ORAL USE
POLIOVIRUS VAC INACTIVATED-SUBQ
TD ADSORBED PRSRV FR 7 YR/> IM
TDAP VACCINE INDIVIDUAL 7
YEARS/OLDER IM USE
VARICELLA VIRUS VAC LIVE-SUBQ USE
YELLOW FEVER VAC LIVE-SUBQ USE
TD ADSORBED USE INDIVIDUALS 7
YRS/OLDER-IM USE
DIPHTHERIA TOXOID-IM USE
DIPTH/TET/WHLE CELL PERTUSS/INFLU
B
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
DIPTH/TET/ACELL PERTUSSIS/INFLU B V
DIPHTHERIA, TETANUS TOXOIDS,
ACELLULAR PERTUSSIS VACCINE, HE
CHOLERA VACCINE-INJ USE
Not Reimbursable
PLAGUE VACCINE INTRAMUSCULAR USE
Not Reimbursable
Not Reimbursable
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90732
No
90733
Yes
90734
Yes
90735
90736
No
Yes
90740
No
90743
Yes
90744
Yes
90746
Yes
90747
No
90748
90749
90760
90761
90765
90766
No
Not Reimbursable
No
No
No
No
90767
90768
No
No
Description
PNEUMOCOCCAL POLYSACCH VACADULT
MENINGOCOCCAL POLYSACCHARIDE
VACC SUBQ USE
MNINGOCOCCL CONJUGATE VAC
SEROGRP A C Y&W-135 IM
JAPANESE ENCEPHALITIS VAC-SUBQ
USE
ZOSTER VACC LIVE SUBQ NJX
HEPATITIS B VACCINE, DIALYSIS OR
IMMUNOSUPPRESSED PATIENT DO
HEPATITIS B VACCINE, ADOLESCENT (2
DOSAGE SCHEDULE) IM USE
HEP B VACCINE-PED/ADOLES DOS-IM
USE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
YES
No
No
No
No
No
No
HEPATITIS B VAC ADULT DOSE-IM USE
HEP B VAC DIALYSIS/IMMUNOSUPPRESIM
No
HEP B/HEMOPHILUS INFLU B VAC-IM USE
UNLIST VACCINE/TOXOID
IV NFS HYDRATION 1ST >1 HR
IV NFS HYDRATION EA HR >8 HR
IV NFS THER PROPH/DX 1ST >1 HR
IV NFS THER PROPH/DX EA HR >8 HR
IV NFS THER PROPH/DX ADDL SEQL NFS
>1 HR
IV NFS THER PROPH/DX CNCRNT NFS
No
Not Reimbursable
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90769
90770
90771
90772
90773
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
90774
No
90775
90776
90779
90801
No
Not Reimbursable
Yes
No
90802
Yes
90804
Yes
90805
Yes
90806
No
90807
No
90808
Not Reimbursable
90809
Not Reimbursable
90810
Yes
Description
SC THER INFUSION, UP TO 1 HR
SC THER INFUSION, ADDL HR
SC THER INFUSION, RESET PUMP
THER PROPH/DX NJX SUBQ/IM
THER PROPH/DX NJX IA
THER PROPH/DX NJX IV PUSH 1ST
SBST/DRUG
THER PROPH/DX NJX EA SEQL IV PUSH
SBST/DRUG
TX/PRO/DX INJ SAME DRUG ADON
UNLIS THER PROPH/DX IV/IA NJX/NFS
PSYCH DX INTERVIEW EXAM
INTERACT PSYCH DX INTERVIEW
W/EQUIP
PSYCHOTHER OV/OP-BEHV MOD 20-30
MN;
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
Not Reimbursable
Yes
No
Yes
Yes
PSYCHOTHER OP 20-30 MIN; W/MED E&M
PSYCHOTHER OV/OP-BEHV MOD 45-50
MN;
Yes
PSYCHOTHER OP 45-50 MIN; W/MED E&M
PSYCHOTHER OV/OP-BEHV MOD 75-80
MN;
No
PSYCHOTHER OP 75-80 MIN; W/MED E&M
PSYCHOTHER OV/OP-INTERACT 20-30
MN;
No
Not Reimbursable
Not Reimbursable
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90811
Yes
90812
No
90813
Yes
90814
Yes
90815
Yes
90816
Yes
90817
Yes
90818
Yes
90819
Yes
90821
Description
PSYCHOTHER OP-INTRAC 20-30 MIN;
E&M
PSYCHOTHER OV/OP-INTERACT 45-50
MN;
PSYCHOTHER OP-INTRAC 45-50 MIN;
E&M
PSYCHOTHER OV/OP-INTERACT 75-80
MN;
PSYCHOTHER OP-INTRAC 75-80 MIN;
E&M
PSYCHOTHER IP/PH/RCS-BEHV 20-30
MN;
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Yes
No
Yes
Yes
Yes
Yes
PSYCHOTHER IP-BEHV 20-30 MIN; W/E&M
PSYCHOTHER IP/PH/RCS-BEHV 45-50
MN;
Yes
Yes
Not Reimbursable
PSYCHOTHER IP-BEHV 45-50 MIN; W/E&M
PSYCHOTHER IP/PH/RCS-BEHV 75-80
MN;
Not Reimbursable
90822
Not Reimbursable
PSYCHOTHER IP-BEHV 75-80 MIN; W/E&M
Not Reimbursable
90823
Yes
PSYCHOTHER IP/RCS-INTRAC 20-30 MIN;
Yes
90824
Yes
PSYCHOTHER IP-INTRAC 20-30 MIN; E&M
Yes
90826
Yes
PSYCHOTHER IP/RCS-INTRAC 45-50 MIN;
Yes
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
90827
Yes
PSYCHOTHER IP-INTRAC 45-50 MIN; E&M
Yes
90828
Not Reimbursable
PSYCHOTHER IP/RCS-INTRAC 75-80 MIN;
Not Reimbursable
90829
90845
90846
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
90847
90849
No
Not Reimbursable
90853
Yes
PSYCHOTHER IP-INTRAC 75-80 MIN; E&M
PSYCHOANALYSIS
FAMILY PSYCHOTHERAPY (WO PT)
FAMILY PSYCHOTHER (CONJOINT)
(W/PT)
MX-FAMILY GROUP PSYCHOTHERAPY
GROUP PSYCHOTHERAPY (NOT MXFAMILY)
90857
Yes
INTERACTIVE GROUP PSYCHOTHERAPY
Yes
90862
No
No
90865
Yes
PHARM MGMT W/SCRIPT USE & REVIEW
NARCOSYNTHESIS FOR PSYCH DX &
THER
Yes
90870
90875
Yes
Not Reimbursable
ELEC-CONVULS THERAP; SNGL SEIZURE
INDIV PSYCHPHYSIOL THER; 20-30 MIN
No
Not Reimbursable
90876
90880
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
90882
Not Reimbursable
90885
Bundled
INDIV PSYCHOPHYSIOL THER; 45-50 MIN
HYPNOTHERAPY
ENVIRONM INTERVENW/AGENCIES/INSTIT
PSYCH EVAL HOSP RECRD-MED DX
PURPOS
No
Not Reimbursable
Yes
Not Reimbursable
Bundled
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
90887
Not Reimbursable
90889
90899
Bundled
Yes
90901
Not Reimbursable
90911
90918
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
INTERPT/EXPLAN RESULTS EXAM/DATA
PREP REPORT PT STATUS/TX FOR
OTHER
UNLISTED PSYCH SERV/PROC
Not Reimbursable
Not Reimbursable
Yes
No
BIOFEEDBACK TRAINING-ANY MODALITY
BIOFEEDBACK TRAIN-ANORECTAL
W/EMG
ESRD FULL MO <2 YR
90919
90920
90921
90922
Yes
Yes
Yes
Yes
ESRD SERV-FULL MO; 2 - 12 BIRTHDAYS
ESRD SERV-FULL MO; 12 - 19 YR
ESRD SERV-FULL MO; PTS 20 & OVER
ESRD RELAT SERV PER DA; PT < 2 YR
No
No
No
No
90923
Yes
ESRD RELAT SERV PER DA; PT 2-11 YR
No
90924
Yes
ESRD RELAT SERV PER DA; PT 12-19 YR
No
90925
Yes
No
90935
Yes
ESRD RELAT SERV PER DA; PT 20/> YR
HEMODIALYSIS PROC W/SNGL PHYS
EVAL
90937
90940
Yes
Yes
HEMODIALYSIS PROC W/REPEAT EVAL
HEMODIALYSIS ACCESS FLOW STUDY
No
No
90945
90947
Yes
Yes
DIALYSIS OTHER THAN HEMO W/1 EVAL
DIALYSIS NOT HEMO W/REPEAT EVAL
No
No
Bundled
Yes
Yes
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
90989
90993
90997
90999
Yes
Yes
Yes
Yes
DIALYSIS TRAIN-PT-INCL HELPR-COMPLT
DIALYSIS TRAIN-PT-PER SESSION
HEMOPERFUSION
UNLIST DIALYSIS PROC INPT/OUTPT
No
No
No
No
91000
91010
No
No
ESOPH INTUBAT & COLLEC-W/PREP (SP)
ESOPH MOTILITY STUDY;
No
No
91011
91012
91020
91022
No
No
No
No
ESOPH MOTILITY STUDY; W/MECHOLYL
ESOPH MOTILITY; W/ACID PERFUSION
GASTRIC MOTILITY STUDIES
DUOL MOTILITY STD
No
No
No
No
91030
No
No
91034
No
91035
No
91037
No
91038
No
91040
No
ESOPH ACID PERFUSION-ESOPHAGITIS
ESOPH GER TEST; W/NASAL CATH PH
ELEC PLCMT REC
ESOPH GER TEST; W/MUCOSL ATTCH
PH ELEC PLCMT REC
ESOPH FUNCT TST GER W/NASL CATH
ELEC PLCMT REC;
ESOPH FUNCT TST GER NASL CATH
ELEC PLCMT; PROLNG
ESOPHAGEAL BALLOON DISTENSION
PROVOCATION STUDY
91052
No
91055
No
GASTRIC ANALY W/INJ STIM SECRETION
GASTRIC INTUBAT WASH (SEPART
PROC)
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
91060
91065
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
91100
No
91105
No
91110
91111
Not Reimbursable
Not Reimbursable
91120
91122
No
No
91123
Bundled
91132
No
91133
No
91299
Yes
92002
No
92004
No
92012
No
92014
92015
No
No
Description
GASTRIC SALINE LOAD TEST
BREATH HYDROGEN TEST
INTEST BLEED TUBE-PASS POSIT &
MONI
GASTRIC INTUBAT & ASPIR/LAVAGE-TX
GI TRACT IMAG INTRALUM ESOPH THRU
ILEUM PHYS I&R
ESOPHAGEAL CAPSULE ENDOSCOPY
RECTAL SENSATION TONE AND
COMPLIANCE TEST
ANORECTAL MANOMETRY
PULSED IRRIGATION FECAL IMPACTION
ELECTROGASTROGRAPHY,
DIAGNOSTIC, TRANSCUTANEOUS
ELECTROGASTROGRAPHY,
W/PROVOCATIVE TESTING
UNLISTED DX GASTROENTEROLOGY
PROC
OPHTH SERV: EXAM-EVAL; INTERMED
NEW
OPHTH SERV: MED EXAM; COMP NEW PT
OPHTH SERV: MED EXAM; INTERM
ESTAB
OPHTH SERV: MED EXAM; COMP ESTAB
PT
DETERM REFRACTIVE STATE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92018
92019
92020
92025
Yes
Yes
No
No
92060
92065
92070
92081
92082
92083
92100
No
Not Reimbursable
Yes
No
No
No
No
92120
No
92130
No
92135
No
92136
No
92140
No
92225
No
92226
92230
92235
No
No
No
Description
OPHTH EXAM & EVAL-GEN ANES;
COMPLT
OPHTH EXAM & EVAL-GEN ANES; LTD
GONIOSCOPY (SEPART PROC)
CORNEAL TOPOGRAPHY
SENSORIMOTOR EXAM W/MEAS (SEP
PROC)
ORTHOPTIC &/OR PLEOPTIC TRAIN
FIT CONTACT LENS-TX INCL LENS
VISL FIELD EXAM UNI/BIL W/I&R; LTD
VISUAL FIELD EXAM W/I&R; INTERMED
VISUAL FIELD EXAM W/I&R; EXTEN
SERIAL TONOMETRY (SEP PRO) W/I&R
TONOGRAPHY W/I&R-RECORD INDEN
TONOM
TONOGRAPHY W/WATER PROVOCATION
SCAN COMPUTERIZ OPHTH DX IMAG
W/1&R
OPHTH BIOMET PART COHERNC
INTRFROMT
PROVOC TESTS-GLAU W/I&R WO
TONOGRPH
OPHTH EXTEN W/RET DRAW W/I&R; INIT
OPHTH EXTEN W/RET DRAW W/I&R;
SUBSQ
FLUORESCEIN ANGIOSCOPY W/I&R
FLUORESCEIN ANGIOGRAPHY W/I&R
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
Not Reimbursable
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
92240
92250
92260
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
92265
92270
92275
92283
92284
No
No
No
No
No
92285
No
92286
No
92287
92310
No
Yes
Description
INDOCYANINE-GREEN ANGIO W/I & R
FUNDUS PHOTOGRAPHY W/I&R
OPHTHALMODYNAMOMETRY
NEEDLE OCULOELECTROMYO 1/MORE
W/I&R
ELEC-OCULOGRAPHY W/I&R
ELECTRORETINOGRAPHY W/I&R
COLOR VISION EXAM EXTEN
DARK ADAPTATION EXAM W/I&R
EXT OCULAR PHOTO W/I&R DOCUMNT
PROG
SPEC ANT SEGMT PHOTO;
W/MICRO/CNT
SPECIAL ANT SEGMT PHOTO
W/FLUOROESC
SCRIPT & FIT CONTACT; EX APHAKIA
92311
Yes
SCRIPT & FIT CONTACT; APHAKIA-1 EYE
Yes
92312
Yes
Yes
92313
Yes
SCRIPT CONTACT LENS; APHAKIA-BOTH
SCRIPT CONTACT LENS;
CORNEOSCLERAL
Yes
92314
Not Reimbursable
SCRIPT W/FIT BY TECH; LENS-EX APHAK
Not Reimbursable
92315
Not Reimbursable
SCRIPT W/FIT BY TECH; APHAKIA-1 EYE
Not Reimbursable
92316
Not Reimbursable
SCRIPT W/FIT BY TECH; APHAKIA-BOTH
Not Reimbursable
No
No
No
No
No
No
No
No
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92317
Not Reimbursable
92325
92326
Not Reimbursable
Not Reimbursable
92340
No
92341
No
92342
No
92352
No
92353
92354
92355
92358
No
Yes
Not Reimbursable
Not Reimbursable
92370
No
92371
92499
No
Yes
92502
N0
92504
Yes
92506
Yes
Description
SCRIPT W/FIT BY TECH;
CORNEOSCLERAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
MODIFICAT LENS (SEP PRO) W/SUPERVS
REPLAC CONTACT LENS
FIT SPECTACLES EX APHAKIA;
MONOFOCL
Not Reimbursable
Not Reimbursable
FIT SPECTACLES EX APHAKIA; BIFOCAL
FIT SPECTACLE EX APHAKIA;
MULTIFOCL
FIT SPECTACL PROSTH-APHAK;
MONOFOCL
FIT SPECTACL PROSTH-APHAK;
MULTIFOC
FIT LO VISION AID; 1 ELEMNT SYST
FIT LO VISION AID; TELESCOP/OTHER
PROSTH SERV APHAKIA TEMPORARY
REPR & REFIT SPECTACLES; EX
APHAKIA
REPR & REFIT; SPECTACL PROSTHAPHAK
UNLISTED OPHTH SERV/PROC
OTOLARYNGOLOGIC EXAM UNDER GEN
ANES
No
BINOCULAR MICRO (SEPART DX PROC)
EVAL SPEECH/LANG/COMMUN/AUD
PROCESS
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92507
Yes
92508
Yes
92511
92512
92516
92520
Yes
Yes
Yes
Yes
92526
No
TX SPEECH/LANG/AUD DISORDER; INDIV
TX SPEECH/LANG/AUD DISORDER;
2/MORE
NASOPHARYNGOSCOPY W/ENDO (SEP
PRO)
NASAL FUNCT STUDIES
FACIAL NERV FUNCT STUDIES
LARYNGEAL FUNCT STUDIES
TX SWALLOW DYSFUNC &/OR ORAL
FUNCT
92531
92532
Bundled
Bundled
SPONTANEOUS NYSTAGMUS INCL GAZE
POSIT NYSTAGMUS
Bundled
Bundled
92533
Bundled
Bundled
92541
No
92542
92543
No
No
92544
No
92545
No
92546
92547
No
No
CALORIC VESTIBULAR TEST EA IRRIGA
SPONTANEOUS NYSTAGMUS TEST
W/RECORD
POSIT NYSTAGMS MIN 4 POSIT
W/RECORD
CALORIC VESTIB EA IRRIG W/RECORD
OPTOKINETIC NYSTAGMS
BIDIREC/FOVEAL
OSCILLATING TRACKING TEST
W/RECORD
SINUSOIDAL VERTCL AXIS ROTATNL
TEST
USE VERTICAL ELECTRODES
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92548
Not Reimbursable
92551
92552
92553
92555
No
No
No
No
92556
No
92557
92559
92560
92561
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
COMPUTERIZED DYNAMIC
POSTUROGRAPHY
SCREENING TEST PURE TONE AIR ONLY
PURE TONE AUDIOMETRY; AIR ONLY
PURE TONE AUDIOMETRY; AIR & BONE
SPEECH AUDIOMETRY THRESHOLD;
SPEECH AUDIOM THRESHLD;
W/RECOGNITN
COMP AUDIOMETRY THRESHOLD EVAL
AUDIOMETRIC TESTING GRP
BEKESY AUDIOMETRY; SCREENING
BEKESY AUDIOMETRY; DX
LOUD BALANC TEST ALTERN
BI/MONAURAL
TONE DECAY TEST
SHORT INCREMENT SENSITIVITY INDX
STENGER TEST PURE TONE
TYMPANOMETRY
ACOUSTIC REFLEX TESTING
ACOUSTIC REFLEX DECAY TEST
FILTERED SPEECH TEST
STAGGERED SPONDAIC WORD TEST
LOMBARD TEST
SENSORINEURAL ACUITY LEVEL TEST
SYNTHETIC SENTENCE IDENT TEST
STENGER TEST SPEECH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92579
92582
92583
92584
No
No
Not Reimbursable
No
92585
92586
No
No
92587
No
92588
No
92590
Not Reimbursable
92591
92592
92593
Not Reimbursable
Not Reimbursable
Not Reimbursable
92594
Not Reimbursable
92595
Not Reimbursable
92596
Not Reimbursable
92597
No
92601
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
VISUAL REINFORCEMENT AUDIOMETRY
CONDITIONING PLAY AUDIOMETRY
SELECT PICTURE AUDIOMETRY
ELECTROCOCHLEOGRAPHY
AUD EVOKED POTENTIALS &/OR TESTCNS
AUD EVOKED POTENTIAL, LIMITED
No
No
Not Reimbursable
No
EVOKED OTOACOUSTIC EMISSIONS; LTD
EVOKED OTOACOUSTIC EMISSNS;
COMP/DX
HEARING AID EXAM & SELECT;
MONAURAL
HEARING AID EXAM & SELECT;
BINAURAL
HEARING AID CHECK; MONAURAL
HEARING AID CHECK; BINAURAL
ELECTROACOUST EVAL H-AID;
MONAURAL
ELECTROACOUST EVAL H-AID;
BINAURAL
EAR PROTECTOR ATTENUATION
MEASUR
No
EVAL VOICE PROSTH/COMMUN DEVICE
DX ANALY COCHLEAR IMPL PT UND 7 YR
AGE; W/PROG
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92602
No
92603
No
92604
No
92605
Bundled
92606
Bundled
92607
No
92608
No
92609
No
92610
No
92611
No
92612
No
92613
Bundled
92614
No
92615
Bundled
Description
DX ANALY COCHLEAR IMPL PT >7 YR;
SUBSQT REPROG
DX ANALY COCHLEAR IMPL 7 YR/>;
W/PROG
DX ANALY COCHLEAR IMPL 7 YR/>;
SUBSQT REPROG
EVAL PRSC NON-SPCH-GEN AUG&ALT
CMNCT DEVICE
TX SRVC NON-SPCH-GEN DEVC INCL
PROGMMING&MOD
EVAL PRSC SPCH-GEN AUG&ALT DEVC
F/F W/PT; 1 HR
EVAL PRSC SPCH-GEN AUG&ALT DEVC
F/F PT;30 MIN
TX SRVC USE SPCH-GEN DEVICE INCL
PROGMMING&MOD
EVALUATION ORAL&PHARYNGEAL
SWALLOWING FUNCTION
MOT FLUORO EVAL SWALLWING FUNCT
CINE/VIDEO
FLX FIBEROPTIC ENDO EVAL
SWALLWING CINE/VIDEO;
FLX FO ENDO EVAL SWALLW
CINE/VIDEO; PHYS I&R
FLX FO ENDO EVAL LARYNG SENSY TST
CINE/VIDEO;
FLX ENDO LARYNG SENSY TST
CINE/VIDEO; PHYS I&R
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Bundled
Bundled
No
No
No
No
No
No
Bundled
No
Bundled
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92616
No
92617
Bundled
92620
No
92621
92625
92626
92627
92630
92630
No
No
No
No
Yes
Yes
Description
FLX FO ENDO SWALLW&LARYNG SENSY
TST CINE/VIDEO;
FLX ENDO SWALLW&LARYNG SENSY
CINE/VIDEO;PHYS I&R
EVAL CNTRL AUDITORY FUNCTION
W/RPT; INIT 60 MIN
EVAL CNTRL AUDITORY FUNCTION
W/RPT;EA ADD 15 MIN
ASSESSMENT OF TINNITUS
EVAL AUD RHAB STATUS 1ST HR
EVAL AUD RHAB STATUS EA 15 MIN
AUD RHAB PRELNG HEARING LOSS
AUD RHAB PRELNG HEARING LOSS
92633
92640
Yes
Yes
AUD RHAB POST-LNGL HEARING LOSS
AUD BRAINSTEM IMPLT PROGRAMG
92700
92950
Yes
Yes
92953
Yes
92960
Yes
92961
No
UNLISTED OTORHINOLARYNGOLOGICAL
SERVICE/PROC
CARDIOPULMONARY RESUSCITATION
TEMPORARY TRANSCUTANEOUS
PACING
CARDIOVERS ELEC-CONVER ARRHY;
EXT
CARDIOVERSION ELECT; INT (SEP
PROC)
92970
Yes
CARDIOASSIST-METHD CIRC ASSIST; INT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Bundled
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
92971
Yes
92973
92974
Yes
Yes
92975
Yes
92977
92978
92979
Yes
Yes
Yes
92980
Yes
92981
92982
92984
Yes
Yes
Yes
92986
Yes
92987
Yes
92990
Yes
92992
Yes
92993
Yes
92995
Yes
Description
CARDIOASSIST-METHD CIRC ASSIST;
EXT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
PERQ TRANSLUMINAL COR THROMBECT
TRNSCATH PLCMT RAD DEL DEVC
THROMBOLYSIS CORON; INTRACOR
INFUS
THROMBOLYSIS CORONARY; IV
INFUSION
VASC US (CORN) DX/TX-S/I&R; INIT
INVASC US (CORN/GFT)-S/I&R; EA ADD
TRNSCATH PLCMT INCORONARY STENT;
1
TRNSCATH PLC CORONARY STENT; EA
ADD
PTCA; 1 VESSEL
PTCA; EA ADD VESSEL
PERCUT BALLOON VALVULOPLSTY;
AORTIC
PERC BALLOON VALVULOPLASTY;
MITRAL
PERCUT BALLOON VALVULOPLASTY;
PULM
No
No
ATRIAL SEPTECT/SEPTOST; TRANSVEN
ATRIAL SEPTECT/SEPTOST; BLADE
METHD
PERQ TRNSLUM CORON ATHEREC; 1
VESSL
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
92996
Yes
92997
Yes
Description
PERQ TRNSLUM CORON ATHEREC; EA
ADD
PERC TRNSLUM PULM ART
ANGIOPLSTY; 1
92998
Yes
PERC PULM ART ANGIOPLSTY; EA ADD
No
93000
No
ECG-ROUTINE 12 LEAD; W/INTRPT & RPT
No
93005
No
ECG-ROUTINE 12 LEAD; TRACING ONLY
No
93010
No
No
93012
No
ECG-ROUTINE 12 LEAD; INTRPT & REPRT
TELEPHON POST-SX ECG/30 DA;
TRACING
93014
No
No
93015
93016
93017
93018
93024
No
No
No
No
No
93025
Not Reimbursable
93040
No
TELEPHONIC ECG/30 DA; INTERP & REPT
CV STRESS TST W/PHARM; INTRPT &
RPT
CV STRESS; PHYS SUPERVS ONLY
CV STRESS TEST; TRACING ONLY
CV STRESS; INTERPT & REPRT ONLY
ERGONOVINE PROVOCATION TEST
MICROVLT T-WAVE ALTRNANS VENT
ARRHY
RHYTHM ECG 1-3 LEAD; W/INTRPTREPRT
93041
No
RHYTHM ECG 1-3 LEADS; TRACING ONLY
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93042
No
93224
93225
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
RHYTHM ECG; INTERPT & REPORT ONLY
ECG-24 HR W/SCAN; REPRT-REVWINTRPT
ECG-24 HR W/SCAN; RECORDING
No
No
No
93226
No
ECG-24 HR W/SCAN; ANALY W/REPORT
No
93227
No
No
93230
93231
No
No
93232
No
ECG-24 HR W/SCAN; MD REVW & REPRT
ECG-24 HR W/PRINT; REPT-REVWINTRPT
ECG-24 HR W/PRINTOUT; RECORDING
ECG-24 HR; MICROPROCESS ANALY
W/RPT
93233
No
No
93235
No
93236
No
93237
No
93268
No
93270
No
93271
No
ECG-24 HR W/PRINT; MD REVW & INTRPT
ECG-24HR COMPUTR MONIT; W/ANALREPT
ECG-24 HR COMPUTR; ANALY
W/REPORT
ECG-24 HR COMPUTR; MD REVW &
INTRPT
PT DEMND RECRD/30 DA;
TRNSMIS/INTRP
PT DEMND RECRD/30 DA; HOOKUP/RECRD
PT DEMND RECRD/30 DA;
MONITOR/ANALY
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93272
No
93278
No
93303
No
93304
No
93307
No
93308
No
93312
No
93313
No
93314
No
93315
No
93316
No
93317
Description
PT DEMND RECRD/30 DA;
REVIEW/INTERP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
SIGNAL-AVG ELECTROCARDIOGRAPHY
TRANSTHOR ECHO-CONG CARD ANOM;
COMP
TRANSTHOR ECHO-CONG CARD ANOM;
LTD
ECHO TRNSTHORAC REAL-TIME;
COMPLT
No
No
No
ECHO TRNSTHORAC REAL-TIME; F/U-LTD
ECHO TRNSESOPH; W/PROBE PLCMTREPRT
ECHO TRANSESOPH; PLCMT PROBE
ONLY
ECHO TRANSESOPH; INTERPT &
REPORT
TRANSESOPH ECHO-CONG CARD ANOM;
TOT
TRANSESOPH ECHO-CONG CARD; PLC
PROB
TRNSESOPH ECHO-CONG CARD; IMAGEI&R
93318
No
ECHO TEE FOR MONITORING PURPOSES
No
93320
93321
No
No
DOPPLER ECHO CONT WAVE; COMPLT
DOPPLER ECHO CONT WAVE; F/U-LTD
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93325
No
93350
93501
No
No
93503
93505
No
No
93508
No
93510
No
93511
No
93514
No
93524
No
93526
No
93527
No
93528
No
93529
No
93530
No
Description
DOPPLR ECHO COLOR FLOW VELOCITY
MAP
ECHO W/REST & STRESS-INTERP &
REPRT
RT HEART CATH
INSRT & PLCMT FLO DIREC CATHMONITR
ENDOMYOCARDIAL BX
CATH PLC-CORON ANGIO-NO LT HRT
CATH
LT HRT CATH RETRO-BRACH/FEM;
PERCUT
LT HRT CATH RETRO-BRACH/FEM;
CUTDN
LT HRT CATH BY LT VENTRICULAR
PUNCT
COMBO TRNSSEPTL & RETRO LT HRT
CATH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
COMBO RT HRT & RETRO LT HRT CATH
COMBO RT HRT-LT HRT CATH THRU
SEPTM
No
COMBO RT HRT CATH W/LT VENT PUNCT
COMBO RT & LT HRT CATH VIA SEP
OPEN
RT HEART CATH-CONGEN CARD
ANOMALIES
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
93531
No
93532
No
93533
No
93539
No
93540
No
Description
RT & RETRO LT HRT CATH-CONGEN
ANOM
RT-LT TRNSSEPT-INTACT-HRT CATHCONG
RT-LT TRNSSEP-EXIST OP-HRT CTHCONG
INJ PROC CARDIAC CATH; ART
CONDUITS
INJ PROC CARDIAC CATH;
AORTOCORON
93541
No
INJ PROC CARDIAC CATH; PULM ANGIO
No
93542
No
INJ PROC-CATH; RT VENT/ATRIAL ANGIO
No
93543
No
No
93544
No
93545
No
INJ PROC-CATH; LT VENT/ATRIAL ANGIO
INJ PROC CARDIAC CATH;
AORTOGRAPHY
INJ PROC-CATH; SELECT CORONRY
ANGIO
93555
No
No
93556
No
IMAG SUPERVS I&R-CATH; VENT/ATRIAL
IMAG SUPERVS I&R-CATH; PULM
ANGIOGR
93561
No
INDICA DIL STDY; W/CARD OUTPUT (SP)
No
93562
No
INDICAT DILUT; SUBSQT CARD OUTPUT
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
93571
No
INTRAVASC DOPPLER DURING SCA; INIT
No
93572
No
No
93580
Yes
93581
93600
93602
93603
93609
93610
93612
93613
93615
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
93616
93618
Yes
Yes
93619
Yes
93620
Yes
93621
Yes
INTRAVASC DOPPLER DUR SCA; EA ADD
PERQ TRNSCATH CLO CONGN
INTERATRIAL CMNCT W/IMPL
PERQ TRNSCATH CLO CONGN VENT
SEPTAL DEFEC W/IMPL
BUNDLE HIS RECORDING
INTRA-ATRIAL RECORDING
RT VENTRICULAR RECORDING
INTRAVENT/-ATRIAL MAP TACHY SITE
INTRA-ATRIAL PACING
INTRAVENTRICULAR PACING
INTRACARD EP 3-D MAPPING
ESOPH RECORD ATRIAL ELECTROGM
ESOPH RECORD ATRIAL ELECGM;
W/PACNG
INDUCTION ARRHY BY ELEC PACING
COMP ELECTROPHYS EVAL; WO INDUC
ARR
COMP ELECTROPHYS EVAL; W/INDUCT
ARR
COMP ELECTROPHYS; LT ATRIAL
RECORD
93622
Yes
COMP ELECTROPHYS; LT VENT RECORD
No
93623
Yes
PROGRAM STIM & PACE AFTER IV DRUG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
93624
Yes
ELECTROPHYSIOL F/U W/INDUCT ARRHY
No
93631
Yes
INTRA-OP PACING/MAP-SITE OF TACHY
No
93640
93641
Yes
Yes
No
No
93642
Yes
93650
Yes
93651
Yes
93652
Yes
93660
Yes
93662
No
EVAL CARDIOVERTER-DEFIB LEADS-INIT;
EVAL DEFIB LEADS-INIT; W/GEN TEST
EVAL 1/2 CHAMBER CARDIOVERTERDEFIB
INTRACARD CATH ABLAT-AV NODE
FUNCT
INTRACARD CATH ABLAT ARRHY; TX
TACH
INTRACARD CATH ABLAT; TX VENT
TACHY
EVAL CARDIOVASC FUNCT W/TILT
TABLE
INTRACARDIAC ECHO DURING
THERAPEUTIC/DIAGNOST
INTERVENTION
93668
Not Reimbursable
PERIPHERAL ARTERIAL DISEASE REHAB
Not Reimbursable
93701
Not Reimbursable
Not Reimbursable
93720
No
93721
No
BIOIMPEDANCE THORACIC ELECTRICAL
PLETHYSMOG BODY; W/INTERPT &
REPORT
PLETHYSMOGRAPHY TOT BODY;
TRACING
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93722
No
93724
No
93727
No
93731
No
93732
No
93733
No
93734
No
93735
No
93736
93740
No
Bundled
93741
No
93742
No
93743
No
93744
No
93745
No
Description
PLETHYSMOG BODY; INTRPT & REPT
ONLY
ELECT ANALY ANTITACHY PACEMAKR
SYST
ELEC ANALY IMPLNT LOOP RECORDER
SYS
ELECT ANALY INT PACMKR;
W/PROGRAM
ELECT ANALY INT PACMKR;
W/REPROGRAM
ELECT ANALY INT PACMKR;
TELEPHONIC
ELECT ANALY 1-CHMBR PAC; WO
REPROGM
ELECT ANALY 1-CHMBR PAC;
W/REPROGM
ELECT ANALY 1-CHMBR PAC;
TELEPHONIC
TEMP GRADIENT STUDIES
ELEC ANALY CARDIOVERT-DEFIB; 1
CHMBR W/O REPROG
ELEC ANALY CARDIOVERT-DEFIB; 1
CHMBR W/REPROG
ANALY CARDIOVERT; 2 CHMBR WO
REPROG
ANALY CARDIOVERT; 2 CHMBR
W/REPROGM
INIT SETUP&PROG BY PHYS WEARBLE
CARDIOVERT-DEFIB
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Bundled
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93760
93762
93770
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Not Reimbursable
Bundled
93784
93786
No
No
93788
No
93790
No
93797
93798
Not Reimbursable
No/Not covered for Basic Health
Plan
93799
Yes
93875
No
93880
No
93882
No
93886
No
93888
No
93890
No
Description
THERMOGRAM; CEPHALIC
THERMOGRAM; PERIPHERAL
DETERM VENOUS PRESS
AMB BP MONIT; RECORD-INTERPTREPORT
AMB BP MONITOR; RECORDING ONLY
AMB BP MONITOR; SCAN ANALY
W/REPRT
AMB BP MONITOR; REVW-INTERPTREPRT
PHYS SERV-OUTPT CARD REHAB; WO
ECG
PHYS SERV-OUTPT CARD REHAB;
W/MONIT
UNLISTED CARDIOVASCULAR
SERV/PROC
NONINVASIV STDIES EXTRACRAN ART
BIL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Bundled
No
No
No
No
Not Reimbursable
NA
No
No
DUPLEX SCAN EXTRACRAN ART; BILAT
DUPLEX SCAN EXTRACRAN ART;
UNI/LTD
TRANSCRAN DOPPLER STDY ART;
COMPLT
No
TRANSCRAN DOPPLER STDY ART; LTD
TRANSCRANIL DOPPLR INTRACRAN
ART;VASOREACTV STDY
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93892
No
93893
No
93922
No
93923
No
93924
No
93925
No
93926
No
93930
Description
TRANSCRANIL DOPPLR; EMBOLI NO IV
MICROBUBBLE INJ
TRANSCRANIL DOPPLR; EMBOLI W/IV
MICROBUBBLE INJ
NONINVASV STDY-UP/LO EXTM ART 1
LEV
NONINVAS STDY-UP/LO EXTM ART MX
LEV
NONINVASIV PHYSIOL STDY-LO EXTM
ART
DUPLEX SCAN LOWR EXTREM ART;
COMPLT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
DUPLEX SCAN LOWR EXT ART; UNI/LTD
DUPLEX SCAN UPPR EXTREM ART;
COMPLT
93931
93965
No
No
DUPLEX SCAN UPPR EXT ART; UNI/LTD
NON-INVAS STDY EXTREM VEIN; BILAT
No
No
93970
No
DUPLEX SCAN-EXTREM VEINS; COMPLT
No
93971
No
No
93975
No
93976
93978
No
No
DUPLEX SCAN-EXTREM VEINS; UNI/LTD
DUPLEX SCAN FLO ABD ORGANS;
COMPLT
DUPLEX SCAN FLO ABD/PEL ORGANS;
LTD
DUPLEX SCAN AORTA/GFTS; COMPLT
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
93979
No
93980
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
DUPLEX SCAN AORTA/IVC/GFTS; UNI/LTD
DUPLEX SCAN PENILE VESSELS;
COMPLT
93981
93982
No
No
DUPLEX SCAN PENILE VESSELS; F/U-LTD
ANEURYSM PRESSURE SENS STUDY
No
No
93990
94002
94003
94004
94005
No
No
No
No
Not Reimbursable
94010
94014
No
No
94015
94016
No
No
94060
No
94070
94150
No
Bundled
94200
94240
No
No
94250
No
DUPLEX SCAN HEMODIALYSIS ACCESS
VENT MGMT INPAT, INIT DAY
VENT MGMT INPAT, SUBQ DAY
VENT MGMT NF PER DAY
HOME VENT MGMT SUPERVISION
SPIROMTRY W/RECRD-VC-EXPIR FLO
RATE
PT INIT SPIROM/30 DA; INCL ANAL-1&R
PT INIT SPIROM RECRD/30 DA; RECRDNG
PT INIT SPIROM RECRD/30 DA; 1&R
BRONCHODILAT RESPN PRE&POST
BRONCHODILAT ADMIN
BRONCHOSPASM EVAL MX SPIROMETRC
DETRM W/AGTS
VITAL CAPACITY TOT (SEPART PROC)
MAX BREATH CAPACITY MAX VOLUN
VENT
FUNCT RESIDUAL CAPACITY/VOLUM
EXPIRED GAS COLLEC QUAN 1 (SEP
PRO)
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
Bundled
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
94260
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
94350
No
Description
THORACIC GAS VOLUM
DETERM MALDISTRIBUTION INSPIRED
GAS
94360
No
DETERM RESIST AIRFLO-OSCILLATORY
No
94370
94375
94400
94450
No
No
No
No
No
No
No
No
94452
Not Reimbursable
94453
94610
94620
94621
Not Reimbursable
No
No
No
94640
No
94642
94644
94645
94656
No
No
No
No
DETERM AIRWAY CLO VOLUM 1 BREATH
RESPIRATORY FLOW VOLUM LOOP
BREATHING RESPONSE TO CO2
BREATHING RESPONSE TO HYPOXIA
HAST WITH PHYSICIAN
INTERPRETATION&REPORT;
HAST W/PHYS INTERP&RPT;
W/SUPLMNTL O2 TITRATION
SURFACTANT ADMIN THRU TUBE
PULM STRESS TESTING; SIMPL
PULM STRESS TEST; COMPLEX
NONPRESS INHALA TX ACUTE AIRWAY
OBS
AEROSOL INHALA PENTAMIDINE PC
PNEUM
CBT, 1ST HOUR
CBT, EACH ADDL HOUR
VENTILATION ASSIST & MGMT; 1ST DA
No
No
No
No
94657
94660
94662
No
No
No
VENTILAT ASSIST & MGMT; SUBSQT DA
CPAP VENTILAT INIT & MGMT
CNP VENTILAT INIT & MGMT
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
94664
94667
94668
No
No
No
94680
No
94681
No
94690
No
94720
94725
No
No
94750
No
94760
Bundled
94761
Description
AEROSOL/VAPOR INHALA; 1ST
DEMO/EVAL
MANIP CHEST WALL; 1ST DEMO/EVAL
MANIP CHEST WALL; SUBSQT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
O2 UPTAKE EXPIRED GAS; DIREC SIMPL
O2 UPTAKE EXPIRED GAS; W/CO2
OUTPUT
No
O2 UPTAKE EXPIRED GAS; REST (SEP)
CO MONOXD DIFFUS CAPACITY ANY
METHD
MEMBRN DIFFUS CAPACITY
No
No
No
No
Bundled
Bundled
PULM COMPLIANCE STUDY ANY METHD
NONINVAS OXIMETRY-O2 SAT; 1
DETERM
NONINVAS OXIMETRY-O2 SAT; MX
DETERM
No
94762
No
NONINVAS OXIMETRY; OVERNITE (SEP)
No
94770
No
No
94772
94774
94775
94776
94777
No
No
No
No
No
CO2 EXPIRED GAS DETERM-INFRARED
CIRCADN RESP PATTRN 12-24 HRINFANT
PED HOME APNEA REC, COMPL
PED HOME APNEA REC, HK-UP
PED HOME APNEA REC, DOWNLD
PED HOME APNEA REC, REPORT
Bundled
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
94799
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Yes
95004
No
95010
95012
No
Not Reimbursable
95015
No
95024
95027
No
No
PERQ SEQUENT/INCREM-SPEC # TEST
EXHALED NITRIC OXIDE MEAS
INTRACUT SEQUENT/INCREM-SPEC #
TEST
INTRACUT W/ALLERG EXTRCT-SPEC #
TES
SKIN END POINT TITRATION
95028
95044
95052
95056
95060
No
No
No
No
No
INTRACUT W/ALLERG DELAYED-# TESTS
PATCH/APPLIC TEST(S)
PHOTO PATCH TEST(S)
PHOTO TESTS
OPHTH MUCOS MEMBRN TESTS
No
No
No
No
No
95065
No
No
95070
No
95071
95075
95078
95115
No
No
Not Reimbursable
No
DIRECT NASAL MUCOS MEMBRN TEST
INHALA BRONCH CHALLENG;
W/HISTAMINE
INHALA BRONCHIAL CHALLENGE;
W/ANTIG
INGESTION CHALLENGE TEST
PROVOCATIVE TESTING
PROF IMMUNOTX WO EXTRCT; 1 INJ
No
No
Not Reimbursable
No
95117
95120
No
Not Reimbursable
PROF IMMUNOTX WO EXTRACT; 2/> INJ
PROF IMMUNOTX INCL EXTRACT; 1 INJ
No
Not Reimbursable
Description
UNLISTED PULM SERV/PROC
PERQ W/ALLERG EXTRACT-SPEC # TEST
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
95125
Not Reimbursable
PROF IMMUNOTX INCL EXTRACT; 2/> INJ
Not Reimbursable
95130
Not Reimbursable
PROF IMMUNOTX W/EXTRACT; 1 INSECT
Not Reimbursable
95131
95132
95133
95134
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
PROF IMMUNOTX W/EXTRACT; 2 INSECT
PROF IMMUNOTX W/EXTRCT; 3 INSECT
PROF IMMUNOTX W/EXTRCT; 4 INSECT
PROF IMMUNOTX W/EXTRCT; 5 INSECT
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
95144
95145
95146
95147
95148
95149
95165
No
No
No
No
No
No
No
No
No
No
No
No
No
No
95170
95180
No
No
PRO SERV-IMMUNTX; 1/MX ANTIG 1 VIAL
PRO-SUPERVS/PROVIS; 1 VENOM
PRO-SUPERVS/PROVIS; 2 VENOMS
PRO-SUPERVS/PROVIS; 3 VENOMS
PRO-SUPERVS/PROVIS; 4 VENOMS
PRO-SUPERVS/PROVIS; 5 VENOMS
PRO SERV-IMMUNOTX; 1/MX ANTIG
PRO-IMMUNOTX;WHOLE BOD EXTRCTINSEC
RAPID DESENZT PROC EA HR
95199
Yes
95250
Not Reimbursable
95251
No
95805
Yes
UNLIST ALLERG/CLINIC IMMUNOL SERV
GLU MON TO 72 HR CONT
RECORD&STOR
GLUC MNTR CONT REC FROM NTRSTL
TISS FLU PHYS I&R
MX SLEEP LATENCY-MX TRIALSLEEPINES
No
No
No
Not Reimbursable
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
95806
Not Reimbursable
95807
Yes
95808
Yes
95810
Yes
95811
95812
95813
95816
95819
95822
95824
95827
Yes
No
No
No
No
No
No
No
95829
No
95830
No
95831
No
95832
No
95833
No
95834
No
Description
SLEEP STUDY RESP-ECG-02
UNATTENDED TECH
SLEEP STUDY RESP-ECG-O2-ATTEND
TECH
POLYSOMNOGRAPHY; W/1-3 ADD
PARAMETR
POLYSOMNOGRAPHY; W/4-MORE ADD
PARAM
POLYSOMNOG; W/4/> ADD PARAM
W/CPAP
EEG EXTEND MONITOR; UP TO 1 HR
EEG EXTEND MONITOR; >1 HR
EEG AWAKE & DROWSY
EEG AWAKE & ASLEEP
EEG; SLEEP ONLY
EEG; CEREBRAL DEATH EVAL ONLY
EEG; ALL NIGHT SLEEP ONLY
ELECTROCORTICOGM AT SURG (SEP
PRO)
INSRT-PHYS SPHENOIDAL ELECTRODEEG
MUSC TEST (SEP PROC); EXTREM/TRNK
MUSC TEST MAN (SEP PRO) W/RPT;
HAND
MUSC TEST (SEP PROC) W/RPT; TOT
BOD
MUSC TEST (SEP PRO); TOT BOD
W/HAND
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
95851
No
95852
95857
No
No
95860
No
95861
No
95863
No
95864
95865
95866
No
No
No
95867
No
95868
No
95869
No
95870
No
95872
No
95873
No
95874
No
Description
ROM REPRT (SP);EA EXTREM/TRUNK
SEC
ROM-REPORT (SP); HAND W/WO
COMPAR
TENSILON TEST MYASTHENIA GRAVIS
NEEDLE EMG; 1 EXTREM W/WO
PARASPIN
NEEDLE EMG; 2 EXTREM W/WO
PARASPIN
NEEDLE EMG; 3 EXTREM W/WO
PARASPIN
NEEDLE EMG; 4 EXTREME W/WO
PARASPIN
NDL EMG LARX
NDL EMG HEMIDPHRM
NEEDLE EMG CRAN NERV-MUSCL;
UNILAT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
NEEDLE EMG CRAN NERV-MUSCL; BILAT
NEEDLE EMG; THORACIC PARASPIN
MUSC
NEEDL EMG; LTD-1 MUS EXTREM/NONLIM
NEEDLE EMG W/QUAN MEAS EA MUSC
STDY
No
ESTIM GDN CONJUNCT CHEMODNRVTJ
NDL EMG GDN CONJUNCT
CHEMODNRVTJ
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
95875
No
95900
No
95903
No
95904
No
95920
No
95921
No
95922
No
95923
No
95925
No
95926
No
95927
No
95928
No
95929
No
95930
No
Description
ISCHEM LIMB EXER W/NEEDLE EMGLACTC
NRV CONDUC STDY EA ; MOTOR WO FWAV
NRV CONDUC STDY EA ; MOTOR W/FWAVE
NERVE CONDUC STUDY EA NRV;
SENSORY
INTRAOPER NEUROPHYSIOL TEST PER
HR
AUTO NERV SYS FUNC TEST;
CARDIOVAGL
AUTO NERV SYS FUNC TEST;
VASOMOTOR
AUTO NERV SYS FUNC TEST;
SUDOMOTOR
SOMATOSENS STUDY 1/ > NERV; UP
LIMB
SOMATOSEN STUDY 1/> NERV; LOW
LIMBS
SOMATOSEN STUDY 1/> NERV;
TRNK/HEAD
CENTRAL MOTOR EVOKED POTENTIAL
STUDY; UPR LIMBS
CENTRAL MOTOR EVOKED POTENTIAL
STUDY; LWER LIMBS
VEP TESTING CNSCHECKERBOARD/FLASH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
95933
No
95934
No
95936
No
95937
No
Description
ORBICULARIS OCULI REFLEX BY ELECDX
H-REFLEX AMP STUDY;
GASTNEM/SOLEUS
H-REFLEX STUDY; NOT
GASTNEM/SOLEUS
NEUROMUSCL JUNCT TST EA NERV 1
METH
95950
Yes
MONITOR-CEREBRAL SEIZ-EEG EA 24 HR
No
95951
Yes
MONITOR CEREBRAL SEIZ-CABLE/RADIO
No
95953
Yes
No
95954
Yes
MONITOR SEIZ FOC-PORT EEG; EA 24 HR
PHARM/PHYS ACTIV-MD ATTND-EEG
RECRD
No
95955
Yes
EEG DURING NONINTRACRANIAL SURG
No
95956
95957
Yes
Yes
No
No
95958
Yes
95961
Yes
95962
Yes
95965
Yes
MONIT CEREB SEIZ-TELEMET EEG-24 HR
DIGITAL ANALY EEG
WADA ACTIVAT HEMISPHER FUNCT
W/EEG
FUNCT CORTIC MAP; INIT HR MD
ATTEND
FUNC CORTIC MAP; EA AD HR MD
ATTEND
MEG REC&ANALY;BRAIN MAGNETIC
ACTV
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
95966
95967
95970
Yes
Yes
Yes
95971
No
95972
No
95973
No
95974
Yes
95975
Yes
95978
No
95979
95980
95981
95982
No
No
No
No
95990
Yes
95991
Yes
95999
Yes
96000
Not Reimbursable
Description
MEG REC&ANALY; EVOKED 1 MODALITY
MEG REC&ANALY; EA ADD MODALITY
ANALY NEUROSTIM; WO REPROGRM
ELEC ANALY NEUROSTIM; SMPL SP
CRD/PERIPH W/PROG
ELEC ANALY NEUROSTIM; CMPLX
SC/PERIPH PROG 1 HR
ELEC ANALY NEUROSTIM;CMPLX SC
PROG EA ADD 30 MIN
ANAL NEUROSTIM; CRAN NERV W/PROG1
ANALY NEUROSTIM; CRAN NRV W/PROGRX
ELEC ANALY NEUROSTIM CMPLX BRAIN
W/PROG; 1 HR
ELEC ANALY NEUROSTIM CMPLX
BRAIN;EA ADD 30 MIN
IO ANAL GAST N-STIM INIT
IO ANAL GAST N-STIM SUBSQ
IO GA N-STIM SUBSQ W/REPROG
REFIL&MNT IMPL PUMP/RESRVR DRUG
DEL SP/BRAIN;
REFIL&MNT IMPL PUMP/RESRVR RX DEL
SP/BRAIN;BY MD
UNLIST NEUROLOGIC/NEUROMUSCL DX
PRO
COMP CMPT-BASD MOT ANALY VIDEOTAP;
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
96001
Not Reimbursable
96002
Not Reimbursable
96003
Not Reimbursable
96004
96020
96040
96101
Not Reimbursable
Not Reimbursable
Yes
Yes
96102
Yes
96103
96105
Yes
Not Reimbursable
96110
Not Reimbursable
96111
Not Reimbursable
96116
Yes
96118
Yes
96119
Yes
96120
96125
Yes
YES
Description
COMP CMPT-BSD MOT ANALY; PLNTR
PRSS
DYN SURF EMG WLK/OTH ACTV 1-12
MUSC
DYN FINE WIRE EMG WALK/OTH 1 MUSC
PHYS REV COMP CMPT BASD MOT
ANALY
FUNCTIONAL BRAIN MAPPING
GENETIC COUNSELING, 30 MIN
PSYCL TSTG PR HR F2F TIME W/PT
PSYCL TSTG PR HR ADMN BY TECH PR
HR
PSYCL TSTG PR HR ADMN BY CPTR
W/PROF I&R
ASSESS APHASIA W/I&R PER HR
DEVELOPMENTAL TESTING; LTD W/I&R
DEVELOPMENTAL TESTING; EXTENDED
W/INTERP&REPORT
NUBHVL STATUS XM PR HR F2F W/PT
INTERPJ&PREPJ
NUROPSYC TSTG PR HR F2F W/PT +
INTERPJ TIME
NUROPSYC TSTG WPROF I&R ADMN BY
TECH PR HR
NUROPSYC TSTG ADMN BY CPTR
W/PROF I&R
COGNITIVE TEST BY HC PRO
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
Yes
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
96150
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
96151
96152
Not Reimbursable
Not Reimbursable
HLTH&BHV ASSESS 15 MIN; RE-ASSESS
HLTH&BHV INTRVN EA 15 MIN; IND
Not Reimbursable
Not Reimbursable
96153
96154
96155
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
96401
No
96402
No
HEALTH&BHV INTRVN EA 15 MIN; GROUP
HEALTH&BHV INTRVN EA 15 MIN; FAM
HEALTH&BHV INTRVN EA 15 MIN; FAM
CHEMOTX ADMN SUBQ/IM NONHORMONAL ANTI-NEO
CHEMOTX ADMN SUBQ/IM HORMONAL
ANTI-NEO
96405
96406
No
No
No
No
96409
No
96411
No
96413
No
CHEMOTX ADMIN INTRALES; TO & INCL 7
CHEMOTX ADMIN INTRALES; > 7 LES
CHEMOTX ADMN IV PUSH TQ 1/1ST
SBST/DRUG
CHEMOTX ADMN IV PUSH TQ EA
SBST/DRUG
CHEMOTX ADMN IV NFS TQ UP 1 HR
1/1ST SBST/DRUG
96415
No
No
96416
No
96417
No
96420
No
CHEMOTX ADMN IV NFS TQ EA HR 1 8 HR
CHEMOTX ADMN TQ INIT PROLNG
CHEMOTX NFUS PMP
CHEMOTX ADMN IV NFS TQ EA SEQL
NFS TO 1 HR
CHEMOTX ADMIN INTRA-ART; PUSH
TECH
Description
HLTH&BHV ASSESS 15 MIN W/PT; INIT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
96422
No
CHEMOTX INTRA-ART; INFUSION TO 1 HR
No
96423
No
No
96425
No
96440
No
96445
No
96450
96521
No
No
96522
No
96523
No
CHEMOTX INTRA-ART; 1-8 HR EA ADD HR
CHEMOTX INTRA-ART; PROLONGED
W/PUMP
CHEMOTX-PLEURAL CAVITYW/THORACENTE
CHEMOTX-PERITONEALW/PERITONEOCENTE
CHEMOTX-CNS-REQ & INCL LUMBAR
PUNCT
RFL/MAIN PORTABLE PMP
RFL/MAIN IMPLTABLE PMP/RSVR F/DRUG
DLVR SYSIC
IRRIGATION IMPLTED VAD F/DRUG DLVR
SYSS
96542
96549
No
No
No
No
96567
Not Reimbursable
CHEMOTX INJ SUBARACH-1/MX AGENTS
UNLISTED CHEMOTX PROC
PHOTODYN TX EXT APPL LGHT EA
EXPOS
Not Reimbursable
96570
Not Reimbursable
PHOTODYNAM THER-LIGHT; 1ST 30 MIN
Not Reimbursable
96571
96900
Not Reimbursable
No
Not Reimbursable
No
96902
Bundled
PHOTODYNAM TX-LIGHT; EA ADD 15 MIN
ACTINOTHERAPY
MICRO EXAM HAIRS-TELOGEN-ANAGEN
CNT
No
No
No
No
No
No
No
Bundled
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
96904
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
96910
No
Description
WHOLE BODY PHOTOGRAPHY
PHOTOCHEMOTX; TAR-UV B/PETROL-UV
B
96912
No
PHOTOCHEMOTX; PSORALENS & UV A
No
96913
No
No
96920
Yes
96921
Yes
96922
Yes
PHOTOCHEMOTX 4-8 HR CARE BY PHYS
LASER TX INFLAM SKIN DZ; TOT AREA <
250 SQ CM
LASER TX INFLAMMATORY SKIN DZ; 250500 SQ CM
LASER TX INFLAMMATORY SKIN DZ;
OVER 500 SQ CM
96999
97001
97002
97003
97004
97005
97006
Yes
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Not Reimbursable
Not Reimbursable
97010
Bundled
97012
97014
No - unless over 24 visits
No - unless over 24 visits
97016
No - unless over 24 visits
UNLISTED SPECIAL DERM SERV/PROC
PHYS THERAP EVAL
PHYS THERAP RE-EVAL
OCCUPATIONAL THERAP EVAL
OCCUPATIONAL THERAP RE-EVAL
ATHLETIC TRAINING EVALUATION
ATHLETIC TRAINING RE-EVALUATION
APPLIC MODAL 1/> AREAS; HOT/CLD PKS
APPLIC MODAL 1/> AREAS; TRACTNMECH
APPLIC MODAL 1/> AREAS; ELEC STIM
APPLIC MODAL 1/> AREAS; VASPNEU
DEV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Not Reimbursable
Not Reimbursable
Bundled
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
97018
No - unless over 24 visits
Description
APPLIC MODAL 1/> AREAS; PARAFN
BATH
97022
No - unless over 24 visits
APPLIC MODAL 1/> AREAS; WHIRLPOOL
No - unless over 24 visits
97024
97026
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
97028
97032
No - unless over 24 visits
No - unless over 24 visits
97033
No - unless over 24 visits
97034
No - unless over 24 visits
97035
No - unless over 24 visits
97036
No - unless over 24 visits
97039
No - unless over 24 visits
APPLIC MODAL 1/> AREAS; DIATHERMY
APPLIC MODAL 1/> AREAS; INFRARED
APPLIC MODAL 1/> AREAS;
ULTRAVIOLET
APPLIC MODAL 1/> AREAS; ELEC STIM
APPLIC MODAL 1/> AREAS;
IONTOPHORES
APPLIC MODAL 1/> AREAS; CNTRST
BATH
APPLIC MODAL 1/> AREAS;
ULTRASOUND
APPLIC MODAL 1/> AREAS; HUBBRD
TANK
UNLIST MODAL (SPEC TYP/TIMEATTEND)
97110
No - unless over 24 visits
THERAP 1/> AREAS/15 MIN; EXERCISES
No - unless over 24 visits
97112
97113
97116
97124
97139
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
THERAP 1/> AREA/15 MIN; BALNC/COORD
THERAP 1/> AREAS/15 MIN; AQUATIC
THERAP 1/> AREAS/15 MIN; GAIT TRAIN
THERAP 1/> AREAS/15 MIN; MASSAGE
THERAP 1/> AREAS/15 MIN; UNLISTED
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
97140
97150
97530
97532
97533
97535
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
97537
97542
No - unless over 24 visits
No - unless over 24 visits
97545
Not Reimbursable
97546
Not Reimbursable
97597
No
97598
No
97602
No
97605
No - unless over 24 visits
97606
No - unless over 24 visits
97750
No - unless over 24 visits
97755
No - unless over 24 visits
Description
MAN THER TECH-1/> REGIONS-EA 15 MIN
THERAP PROC(S)-GROUP
THERAP ACTIVITIES 1-ON-1 EA 15 MIN
DEVELOPMENT OF COGNITIVE SKILLS
SENSORY INTEGRATIVE TECHNIQUES
SELF CARE TRAIN-1 ON 1-EA 15 MIN
COMMUNITY/WORK REINTEGRAT TRAIN1 ON 1-EA 15 MIN
WHEELCHAIR MGMT TRAIN-EA 15 MIN
WORK HARDENING/CONDITION; INIT 2
HR
WORK HARDENING/CONDITION; EA ADD
HR
REMV DEVITLZ TISS SELCTV DEBRID; </=
20 SQ CM
REMV DEVITLZ TISS SELCTV DEBRID;
>20 SQ CM
REMV DEVITLZ TISS NONSELCTV
DEBRID W/O ANES SESS
NEG PRESS WND TX PER SESS; TOT
SURF </= 50 SQ CM
NEG PRESS WND TX PER SESS; TOT
SURF > 50 SQ CM
PHYS PERFMNCE TEST/MEASUR
W/REPORT
ASSTIV TECH ASSESS DIR 1:1 CNTC
W/RPT EA 15 MIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Not Reimbursable
Not Reimbursable
No
No
No
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
97760
97761
No - unless over 24 visits
No - unless over 24 visits
97762
No - unless over 24 visits
97799
Yes
97802
No
97803
No
97804
No
97810
Yes
97811
Yes
97813
Yes
97814
Yes
98925
No
98926
No
98927
No
98928
No
Description
ORTHOTIC MGMT&TRAINJ UXTR
LXTR&/TRNK EA 15 MIN
PROSTC TRAINJ UPR&/LXTR EA 15 MIN
CHECKOUT F/ORTHOTIC/PROSTC USE
EST PT EA 15 MIN
UNLISTED PHYS MEDS/REHAB
SERV/PROC
MED NUTRI THERAPY, INITIAL
ASSESSMENT
MED NUTRI THERAPY, RE-ASSESSMENT
MED NUTRI THERAPY, GRP (2 OR MORE
INDIVID) 30 MIN EA
ACUPUNCT 1/> NDLES W/O E-STIM; INIT
15 MIN 1-1
ACUP 1/> NDLS W/O ELEC STIMJ EA 15
MIN
ACUP 1/> NDLS W/ELEC STIMJ 1ST 15
MIN
ACUPUNCT 1/> NDLES WITH E-STIM;EA
ADD 15 MIN 1-1
OSTEOPATH MANIP TX; 1-2 BOD
REGIONS
OSTEOPATH MANIP TX; 3-4 BOD
REGIONS
OSTEOPATH MANIP TX; 5-6 BOD
REGIONS
OSTEOPATH MANIP TX; 7-8 BOD
REGIONS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Yes
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
98929
98940
98941
98942
No
Yes
Yes
Yes
98943
Not Reimbursable
98960
Yes
98961
Yes
98962
98966
98967
98968
98969
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
99000
Bundled
99001
Bundled
99002
Bundled
99024
Bundled
99026
Not Reimbursable
99027
Not Reimbursable
Description
OSTEOPATH MANIP TX; 9-10 BOD
REGION
CHIRO MANIP TX; SPINAL 1-2 REGIONS
CHIRO MANIP TX; SPINAL 3-4 REGIONS
CHIRO MANIP TX; SPINAL 5 REGIONS
CHIRO MANIP TX; EXTRASPIN 1/> AREAS
EDUCAJ&TRAINJ F/PT SELF-MGMT BY
NONPHYS 1 PT
EDUCAJ&TRAINJ F/PT SELF-MGMT BY
NONPHYS 2-4 PT
EDUCAJ&TRAINJ F/PT SELF-MGMT BY
NONPHYS 5-8 PTS
HC PRO PHONE CALL 5-10 MIN
HC PRO PHONE CALL 11-20 MIN
HC PRO PHONE CALL 21-30 MIN
ONLINE SERVICE BY HC PRO
HANDL/CONVEY SPECMN-OFFIC TO LAB
HANDL/CONVEY SPECMN-FRON PT TO
LAB
HANDL/CONVEY/OTHER SERV
W/DEVICES
POSTOP F/U VST E&M DUR POSTOP PRD
REL ORIG PROC
HOSP MANDATED CALL SERVICE; INHOSP EA HOUR
HOSP MANDATED CALL SERVICE; OUTOF-HOSP EA HOUR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Bundled
Bundled
Bundled
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99050
No
99051
Bundled
99053
No
99056
99058
Bundled
Bundled
99060
Description
SRVC REQUEST AFTER POSTED OFFICE
HR ADD BASIC
SVC PRV OFFICE REG SCHEDD EVN
WKEND/HOLIDAY HRS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Bundled
Bundled
Bundled
Bundled
SVC PRV BTW 10 PM&8 AM AT 24-HR FAC
SERV @ REQ OF PT @ LOCAT NOT
OFFIC
OFFIC SERV PROVID-EMER BASIS
SVC PRV EMER OUT OFFICE DISRUPTS
OFFICE SVC
99070
99071
99075
Bundled
Bundled
No
SUPPL/MAT PROVID-PHYS NOT W/VISIT
EDUCAT SUPPL @ COST TO PHYS
MED TESTIMONY
Bundled
Bundled
No
99078
No
No
99080
99082
Bundled
No
99090
Bundled
99091
Not Reimbursable
PHYS EDUCAT SERV RENDERED IN GRP
SPEC REPORT >INFO IN USUAL MED
FORM
UNUSUAL TRAVEL
ANALYS INFORM DATA STOREDCOMPUTERS
CLCT&INTEPR PHYSIOLOGIC DATA 30
MIN
99100
Bundled
99116
Bundled
ANES PT EXTREM AGE <1 YR & OVER 70
ANES COMPLIC BY UTILIZ BODY
HYPOTHE
No
Bundled
Bundled
No
Bundled
Not Reimbursable
Bundled
Bundled
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99135
99140
Bundled
Bundled
99143
Bundled
99144
Bundled
99145
Bundled
99148
Bundled
99149
Bundled
99150
Bundled
99170
No
99172
Not Reimbursable
99173
99174
99175
Bundled
Yes
No
99183
99185
99186
99190
99191
Yes
Yes
Yes
No
No
Description
ANES COMPLIC BY UTILIZ HYPOTENSION
ANES COMPLIC BY EMER CONDITIONS
M-SEDATJ BY SM PHYS PERFRMG SVC
<5 YR
M-SEDAJ BY SM PHYS PERFRMG SVC 5+
YR
M-SEDAJ BY SM PHYS PERFRMG SVC EA
15 MIN
M-SEDAJ BY PHYS OTH/THN HC PROF
PERFRMG <5 YR
M-SEDAJ BY PHYS OTH/THN HC PROF
PERFRMG 5+ YRS
M-SEDAJ PHYS OTH/THN HC PROF
PERFRMG EA 15 MIN
ANOGENITAL EXAM W/COLPOSCOPCHILD
VISUAL FUNCT SCREENING,
AUTOMAT/SEMI BILAT QUANITATIVE
SCREEN TEST VISUAL ACUITY-QUAN-BIL
OCULAR PHOTOSCREENING
IPECAC ADMIN FOR EMESIS & OBSRV
PHYS ATTEND/SUPERVS HYPERBARIC
O2
HYPOTHERMIA; REGIONAL
HYPOTHERMIA; TOT BODY
ASSEMBLY & OPERAT-PUMP; EA HR
ASSEMBLY & OPERAT-PUMP; 3/4 HR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
No
Not Reimbursable
Bundled
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
99192
No
ASSEMBLY &/OR PUMP W/OXYGENATOR
No
99195
99199
99201
No
Not Reimbursable
No
No
Not Reimbursable
No
99202
No
99203
No
PHLEBOTOMY THERAP (SEPART PROC)
UNLISTED SPECIAL SERV/PROC/RPT
OFFIC/OUTPT E&M NEW MINOR 10MIN
OFFIC/OUTPT E&M NEW LOW-MOD
20MIN
OFFIC/OUTPT E&M NEW MOD SEVER
30MIN
99204
No
OFFIC/OUTPT E&M NEW MOD-HI 45 MIN
No
99205
99211
No
No
OFFIC/OUTPT E&M NEW MOD-HI 60 MIN
OFFIC/OUTPT E&M ESTAB 5 MIN
No
No
99212
No
No
99213
No
OFFIC/OUTPT E&M ESTAB MINOR 10MIN
OFFIC/OUTPT E&M ESTAB LOW-MOD
15MIN
No
99214
No
OFFIC/OUTPT E&M ESTAB MOD-HI 25 MIN
No
99215
99217
No
No
No
No
99218
No
99219
No
OFFIC/OUTPT E&M ESTAB MOD-HI 40 MIN
OBSRV CARE D/C DA MGMT
INIT OBSRV CARE-DA E&M LOW
SEVERITY
INIT OBSRV CARE-DA E&M MOD
SEVERITY
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99220
No
99221
No
99222
99223
No
No
99231
No
99232
No
99233
No
99234
No
99235
No
99236
99238
Description
INIT OBSRV CARE-DA E&M HI SEVERITY
INIT HOSP-DA E&M LOW SEVERITY
30MIN
INIT HOSP-DA E&M MOD SEVERITY
50MIN
INIT HOSP-DA E&M HI SEVERITY 70 MIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
SUBSQT HOSP-DA E&M STABLE 15 MIN
SUBSQT HOSP-DA E&M MINR COMPL
25MIN
SUBSQT HOSP-DA E&M SIG COMPL 35
MIN
OBSRV/INPT HOSP CARE E&M LOW
SEVER
OBSRV/INPT HOSP CARE E&M MOD
SEVER
OBSRV/INPT HOSP CARE E&M HIGH
SEVER
HOSP D/C DA MGMT; 30 MIN/LESS
99239
No
HOSP D/C DA MGMT; MORE THAN 30 MIN
No
99241
No
No
99242
99243
No
No
OFFIC CONS NEW/ESTAB MINOR 15 MIN
OFFICE CONS NEW/EST LO SEVER 30
MIN
OFFIC CONS NEW/ESTAB MOD 40 MIN
No
No
99244
No
OFFIC CONS NEW/ESTAB MOD-HI 60 MIN
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
99245
No
OFFIC CONS NEW/ESTAB MOD-HI 80 MIN
No
99251
No
INIT INPT CONS NEW/ESTAB MINR 20MIN
No
99252
No
INIT INPT CONS NEW/ESTAB LOW 40MIN
No
99253
No
INIT INPT CONS NEW/ESTAB MOD 55MIN
No
99254
99255
99281
No
No
No
No
No
No
99282
No
99283
No
99284
No
INIT INPT CONS NEW/EST MOD-HI 80MIN
INIT INPT CONS N/E MOD-HI 110MIN
EMER VISIT E&M SELF LIMITED/MINOR
EMER VISIT E&M LOW-MODERAT
SEVERITY
EMER DEPT VISIT E&M MODERATE
SEVER
EMER VISIT E&M HI SEVER URGENT
EVAL
99285
99288
99289
99290
99291
99292
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
99293
No
99294
No
ER E&M-HIGH SEVERITY SIGNIF THREAT
PHYS DIRECT EMS/EMER CARE/ALS
PHYS ATTN CRTLLY ILL/INJR;30-74 MIN
PHYS ATTN CRTL ILL/INJR; ADD 30 MIN
CRITICAL CARE E&M; 1ST 30-74 MIN
CRITICAL CARE E&M; EA ADD 30 MIN
INIT IP PED CRTL CARE E/M 29 DAYS TO
24 MOS AGE
SUBSQT IP PED CRTL CARE E/M 29 DAY
TO 24 MOS AGE
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
99295
No
99296
No
99298
No
99299
No
Description
INIT IP NEONAT CRTL CARE PER DAY
E/M 28 DA AGE/<
SUBSQT IP NEONAT CRTL CARE DAY E/M
28 DAY AGE/<
SUBSQT IC-DA E&M RECOVR VERY LBW
INFNT <1500 GMS
SUBSQT IC-DA E&M RECOVR LBW INFNT
1500-2500 GMS
99300
99304
No
No
SBSQ IC PR D F/E/M RECOVERING INFT
1ST NF CARE PR D E/M LW SEVERITY
No
No
99305
99306
99307
No
No
No
No
No
No
99308
No
1ST NF CARE PR D E/M MOD SEVERITY
1ST NF CARE PR D E/M HI SEVERITY
SBSQ NF CARE PR D E/M STABLE
SBSQ NF CARE PR D E/M MINOR
COMPLCTJ
99309
No
No
99310
No
SBSQ NF CARE PR D E/M NEW PROBLEM
SBSQ NF CARE PR D E/M
UNSTABLE/NEW PROBLEM
99315
99316
99324
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
99325
No
99326
No
NURS FACIL D/C DA MGMT; 30 MIN/LESS
NURS FACIL D/C DA MGMT; > 30 MIN
DOM/R-HOME LW SEVERITY
DOM/R-HOME E/M NEW PT MOD
SEVERITY
DOM/R-HOME E/M NEW PT MOD HI
SEVERITY
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99327
No
99328
No
99334
No
99335
No
99336
No
99337
No
99339
No
99340
No
99341
No
99342
Description
DOM/R-HOME E/M NEW PT HI SEVERITY
DOM/R-HOME E/M NEW PT SIGNIFICANT
NEW PROBLEM
DOM/R-HOME E/M EST PT SELFLMTD/MINOR
DOM/R-HOME E/M EST PT LW MOD
SEVERITY
DOM/R-HOME E/M EST PT MOD HI
SEVERITY
DOM/R-HOME E/M EST PT SIGNIFICANT
NEW PROBLEM
INDIV PHYS SUPVJ HOME/DOM/R-HOME
MO 15-29 MIN
INDIV PHYS SUPVJ HOME/DOM/R-HOME
MO 30 MIN/>
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
HOME VISIT E&M NEW PT LO SEV-20 MIN
HOME VISIT E&M NEW PT MOD SEV-30
MN
No
No
99343
No
HOME VISIT E&M NEW PT MOD-HI-45 MIN
No
99344
No
No
99345
99347
No
No
99348
No
HOME VISIT E&M NEW PT HI SEV-60 MIN
HOME VISIT E&M NEW PT UNSTBL-75
MIN
HOME VISIT E&M ESTAB MINOR-15 MIN
HOME VISIT E&M ESTAB LOW-MOD 25
MIN
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99349
No
HOME VISIT E&M ESTAB MOD-HI 40 MIN
No
99350
No
No
99354
No
99355
No
No
99356
No
99357
No
HOME VISIT E&M ESTAB MOD-HI 60 MIN
PROLONG MD SERV OUTPT W/PT; 1ST
HR
PROLONG MD SERV OUTPT W/PT; EA
30MN
PROLONG PHYS SERV INPT W/PT; 1ST
HR
PROLONG MD SERV INPT W/PT; ADD
30MN
99361
No
MED CONFRNCE PHYS W/TEAM; 30 MIN
No
99362
99363
99364
99366
99367
99368
No
No
No
Not Reimbursable
No
Not Reimbursable
No
No
No
Not Reimbursable
No
Not Reimbursable
99371
No
MED CONFRNCE PHYS W/TEAM; 60 MIN
ANTICOAG MGMT, INIT
ANTICOAG MGMT, SUBSEQ
TEAM CONF W/PAT BY HC PRO
TEAM CONF W/O PAT BY PHYS
TEAM CONF W/O PAT BY HC PRO
PHONE CALL PHYS-PT/OTHR;
SIMPL/BRIF
99358
99359
99360
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No - Reimbursed FOR WMIP
No - Reimbursed FOR WMIP ONLY PROLONG E/M WO PT CONTACT; 1ST HR
ONLY
PROLONG E/M WO PT CONTCT; ADD
No - Reimbursed FOR WMIP
No - Reimbursed FOR WMIP ONLY 30MIN
ONLY
PHYS STANDBY W/PROLONG ATTEND EA
No
30
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99372
No
99373
No
99374
Bundled
99375
No
99377
99378
Bundled
No
PHYS SUPERVS HOSPICE PT; 15-29 MIN
PHYS SUPERVS HOSPICE PT; 30 MIN/>
Bundled
No
99379
Bundled
PHYS SUPERVS NURS FAC PT; 15-29 MIN
Bundled
99380
No
No
99381
No
PHYS SUPERVS NURS FAC PT; 30 MIN/>
INIT PREVEN MEDS E&M NEW PT;
INFANT
99382
99383
No
No
INIT PREVEN MEDS E&M NEW PT; 1-4 YR
INIT PREVEN MEDS E&M NEW PT; 5-11
No
No
99384
No
INIT PREVEN MEDS E&M NEW PT; 12-17
No
99385
No
INIT PREVEN MEDS E&M NEW PT; 18-39
No
99386
99387
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
99391
No
INIT PREVEN MEDS E&M NEW PT; 40-64
INIT PREVEN MEDS E&M NEW PT; 65/>
PREVEN MEDS E&M ESTAB PT; INFANT
<1
Description
PHONE CALL PHYS-PT/OTHER;
INTERMED
PHONE CALL PHYS-PT/OTHR;
COMPLX/LEN
PHYS SUPERVS PT-HOME HLTH; 15-29
MN
PHYS SUPERVS PT-HOME HLTH; 30/>
MIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Bundled
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99392
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Description
PREVEN MEDS E&M ESTAB PT; 1-4 YR
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
99393
No
PREVEN MEDS E&M ESTAB PT; 5-11 YR
No
99394
No
PREVEN MEDS E&M ESTAB PT; 12-17 YR
No
99395
No
PREVEN MEDS E&M ESTAB PT; 18-39 YR
No
99396
Not Reimbursable
PREVEN MEDS E&M ESTAB PT; 40-64 YR
Not Reimbursable
99397
Not Reimbursable
Not Reimbursable
99401
No
99402
No
99403
Not Reimbursable
99404
99406
99407
99408
99409
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
99411
Not Reimbursable
99412
99420
99429
Not Reimbursable
Not Reimbursable
Not Reimbursable
PREVEN MEDS E&M ESTAB PT; 65/> YR
PREVEN MED COUNSL (SEP PRO); 15
MIN
PREVEN MED COUNSL (SEP PRO); 30
MIN
PREVEN MED COUNSL (SEP PRO); 45
MIN
PREVEN MED COUNSL (SEP PRO); 60
MIN
BEHAV CHNG SMOKING 3-10 MIN
BEHAV CHNG SMOKING < 10 MIN
AUDIT/DAST, 15-30 MIN
AUDIT/DAST, OVER 30 MIN
PREVEN MED COUNSL GRP (SEP PRO);
30
PREVEN MED COUNSL GRP (SEP PRO);
60
ADMIN/INTRPT HEALTH RISK ASSESS
UNLISTED PREVEN MEDS SERV
No
No
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99431
No
99432
No
99433
99435
No
No
99436
No
99440
99441
99442
99443
99444
99450
No
No
No
No
Not Reimbursable
Not Reimbursable
99455
Not Reimbursable
99456
99477
99499
Not Reimbursable
No
Yes
99500
Not Reimbursable
99501
Not Reimbursable
99502
Not Reimbursable
Description
HX/EXAM NORM NB INIT DX/TX/PREP
REC
NORM NB CARE NOT HOSP/BRTH RM +
PHY
SUBSQT HOSP CARE E&M NORM NB-DA
HX & EXAM NORMAL NB-D/C SAME DA
ATTEND DELIV-INIT STABILIZE
NEWBORN
NB RESUSC: VENT &/OR CHEST
COMPRESS
PHONE E/M BY PHYS 5-10 MIN
PHONE E/M BY PHYS 11-20 MIN
PHONE E/M BY PHYS 21-30 MIN
ONLINE E/M BY PHYS
BASIC LIFE &/OR DISABILITY EXAM
WORK RELAT/DISABL EXAM-TREATING
MD
WORK RELAT/DISABL EXAM-NOT TRTNG
MD
INIT DAY HOSP NEONATE CARE
UNLISTED EVAL & MGMT SERV
ER 15-20 MIN EG MED REFILLS
LACERATION NO SUTURES
HOME VISIT POSTNATL ASSESS&F/U
CARE
HOME VISIT NEWBORN
CARE&ASSESSMENT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
99503
Not Reimbursable
99504
Not Reimbursable
99505
Not Reimbursable
99506
99507
Not Reimbursable
Not Reimbursable
99509
Not Reimbursable
99510
Not Reimbursable
99511
99512
Not Reimbursable
Not Reimbursable
99600
Not Reimbursable
99601
Not Reimbursable
99602
99605
99606
99607
0003T
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
0008T
Not Reimbursable
Description
HOME VISIT RESPIRATORY THERAPY
CARE
HOME VISIT PTS RECEIVING MECH VENT
HOME VISIT STOMA
CARE&MAINTENANCE
HOME VISIT INTRAMUSCULAR
INJECTIONS
HOME VISIT CARE&MAINT CATHETER
HOME VST ASST W/DAILY LIV&PERS
CARE
HOME VISIT FOR INDIVIDUAL, FAMILY OR
MARRIAGE COUNSELING
HOME VISIT FOR FECAL IMPACTION
MANAGEMENT AND ENEMA ADMIN
HOME VISIT FOR HEMODIALYSIS
UNLISTED HOME VISIT SERVICE OR
PROCEDURE
HOME INFUSION/SPECIALTY DRUG
ADMIN PER VISIT
HOME INFUS/SPEC DRUG ADMIN PER
VISIT; EA ADD HR
MTMS BY PHARM, NP, 15 MIN
MTMS BY PHARM, EST, 15 MIN
MTMS BY PHARM, ADDL 15 MIN
CERVICOGRAPHY
UP GI ENDO;W/SUT ESOPHAGOGASTR
JUNC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
0016T
Not Reimbursable
0017T
Not Reimbursable
0018T
Not Reimbursable
0019T
Not Reimbursable
0021T
Not Reimbursable
0024T
Not Reimbursable
0026T
Not Reimbursable
0027T
Not Reimbursable
0028T
Not Reimbursable
0029T
Not Reimbursable
0030T
0031T
Not Reimbursable
Not Reimbursable
0032T
Not Reimbursable
0041T
Not Reimbursable
0042T
Not Reimbursable
Description
DESTRC LES CHOROID TRNSPUP
THERMOTX
DESTRUC MACULAR DRUSEN
PHOTOCOAG
DEL HI PWR FOCL MAGNET PULS
NEURONS
XTRACORP SHOCK WAVE TX; INVLV
MUSCU
INSRT TRNSCERV/VAG FETL OXIMTR
SENS
NONSURG SEPTL RDUC TX;COR
ARTERIGRM
LIPOPROTEIN DIRECT MEASUREMENT
IDL
ENDO LYSIS EPIDURL ADHES W/DIR
VISLIZATION
DEXA BODY COMPOSITION STUDY
1/MORE SITES
TX INCONT PULSED MAGNET
NEUROMODULATION- PER DAY
ANTIPROTHROMBIN ANTIBODY EACH IG
CLASS
SPECULOSCOPY
SPECULOSCOPY; WITH DIRECTED
SAMPLING
UA INF AGT DETECT SEMI-QUAN ANALY
VOLATIL COMPND
CERBRL PERFUS ANALY CT W/CONTRST
W/PARAMETRC MAP
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
0043T
Not Reimbursable
0044T
Not Reimbursable
0045T
Not Reimbursable
0046T
Not Reimbursable
0047T
Not Reimbursable
0048T
Not Reimbursable
0049T
Not Reimbursable
0050T
Not Reimbursable
0051T
Not Reimbursable
0052T
Not Reimbursable
0053T
Not Reimbursable
0054T
Not Reimbursable
0055T
Not Reimbursable
0056T
Not Reimbursable
Description
CARBON MONOXIDE EXPIRED GAS
ANALYSIS
WHOLE BDY INTEG PHOTGRPH HI-RSK
PT;NEVUS/MELNOMA
WHOLE BDY INTEG PHOTO HX
DYSPLASTC NEVI/MELANOMA
CATH LAVAGE MAMM DUCT HI RSK IND
EA BRST; 1 DUCT
CATH LAVAGE MAMM DUCT HI RSK EA
BRST;EA ADD DUCT
IMPL VAD XTRACORP PERQ
TRANSSEPTAL 1/2 CANNULAT
PROLONG XTRACORP PERQ
TRANSSEPTAL VAD>24 HR EA
REMV VAD XTRACORP PERQ
TRNSSEPTL ACSS 1/2 CANNUL
IMPL TOTAL REPL HEART SYS
W/RECIPIENT CARDIECT
REPL/REPR THORACIC UNIT TOTAL
REPL HEART SYSTEM
REPL/REPR IMPL CMPNT TOT REPL
HEART SYS NOT THOR
CMPT ASST MS SURG NAVIGATNL
ORTHO PROC W/FLUORO
CMPT-ASST MS SURG NAVIGATNL
ORTHO PROC W/CT&MRI
CMPT ASST MS SURG NAVIGATNL
ORTHO PROC IMAG-LESS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
0058T
0059T
Not Reimbursable
Not Reimbursable
0060T
Not Reimbursable
0061T
Not Reimbursable
0062T
Not Reimbursable
0063T
Not Reimbursable
0064T
Not Reimbursable
0065T
Not Reimbursable
0066T
Not Reimbursable
0067T
Not Reimbursable
0068T
Not Reimbursable
0069T
Not Reimbursable
0070T
Not Reimbursable
0071T
Not Reimbursable
0072T
Not Reimbursable
Description
CRYOPRESERVATION; REPRODUCTIVE
TISSUE OVARIAN
CRYOPRESERVATION; OOCYTE
ELECTRICAL IMPEDANCE SCAN THE
BREAST BILATERAL
DESTRUC/RDUC MAL BRST TUMR
MICROWAVE PA THERMOTX
PERQ INTRADISCL ANNULPLSTY UNI/BIL
FLUORO; 1 LVL
PERQ INTRADISCL ANNULPLSTY UNI/BIL
FLUORO;1/>LVL
SPECTROSCOPY EXPIRED GAS
ANALYSIS
OCULAR PHOTOSCREENING W/INTEPR &
RPT BILATERAL
COMPUTED TOMOGRAPHIC
COLONOGRAPHY; SCREENING
COMPUTED TOMOGRAPHIC
COLONOGRAPHY; DIAGNOSTIC
ACOUSTIC HRT SOUND
RECORDING&CMPT ANALY; W/I&R
ACOUSTIC HRT SOUND RECORD &
COMPUTER ANALY ONLY
ACOUSTIC HRT SOUND RECORD & CMPT
ANALY; I&R ONLY
FOC US ABLAT UTERN LEIOMYOMA;TOT
VOL<200 CC TISS
FOC US ABLAT UTRN LEIOMYOMATA;
TOT>/=200 CC TISS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
0073T
Not Reimbursable
0074T
Not Reimbursable
0075T
Not Reimbursable
0076T
Not Reimbursable
0077T
Not Reimbursable
0078T
Not Reimbursable
0079T
Not Reimbursable
0080T
Not Reimbursable
0081T
Not Reimbursable
0082T
Not Reimbursable
0083T
Not Reimbursable
0084T
Not Reimbursable
0086T
Not Reimbursable
0087T
Not Reimbursable
Description
COMP-BASD BEAM MODULATD TX DEL
TX 3/> FIELDS-TX
ONLINE E&M SRVC BY PHYS PT
REQUEST; EST PT
TRNSCATH PLCMT VERT/CAROTID ART
STENT PREQ;1 VES
TRNSCATH PLCMT VERT/CAROTID ART
STNT PREQ;EA ADD
IMPL&SECUR CERBRL THRML PERFUS
PROBE TWIST DRILL
ENDOVASC REPR AAA FENESTRATED
PROS 2 DOCK LIMBS
PLCMT VISCERAL EXTENSION PROSTH
EA VISCERAL BR
ENDOVSC REP AAA FNSTRATD PROS 2
DOCK LMB RAD S&I
PLCMT VISCERAL EXT PROS EA
VISCERAL BR RAD S&I
STEREOTACTIC BODY RAD TX TR DEL
1/> TR AREAS DAY
STEREOTACTIC BODY RAD TX TR
MANAGEMENT PER DAY
INSERTION OF A TEMPORARY
PROSTATIC URETH STENT
LT VENT FIL PRSSURE INDIR MSR
CMPTIZED CALIBRATN
SPERM EVALUATION HYALURONAN
BINDING ASSAY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
0088T
Not Reimbursable
0120T
0123T
Yes
Yes
0124T
Yes
0126T
Yes
0137T
0140T
0141T
0142T
0143T
0144T
0145T
0146T
0147T
0148T
0149T
0150T
0151T
0152T
0153T
0154T
0162T
0163T
0164T
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Description
SUBMUC RADFREQ TISS VOL RDUC
TONGUE 1/>SITE-SESS
ABLTJ CRYOSURG W/US GDN EA
FIBROADENOMA
FSTLJ SCL GLC THRU CILIARY BDY
CJNCL INC W/PST JUXTASCLL PLMT RX
AGT
COMMON CRTD IMT RISK FACTOR
ASSMT
BX PRST8 NDL SATURATION SAMPLING
PRST8 MAPG
EXHALED BRTH CONDENSATE PH
PERQ ISLET TRANSPLANT
OPEN ISLET TRANSPLANT
LAPAROSCOPIC ISLET TRANSPLNT
CT HEART WO DYE; QUAL CALC
CT HEART W/WO DYE FUNCT
CCTA W/WO DYE
CCTA W/WO, QUAN CALCIUM
CCTA W/WO, STRXR
CCTA W/WO, STRXR QUAN CALC
CCTA W/WO, DISEASE STRXR
CT HEART FUNCT ADD-ON
COMPUTER CHEST ADD-ON
IMPLANT ANEUR SENSOR ADD-ON
IMPLANT ANEUR SENSOR STUDY
ANAL PROGRAM GAST NEUROSTIM
LUMB ARTIF DISKECTOMY ADDL
REMOVE LUMB ARTIF DISC ADDL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
0165T
0166T
0167T
0168T
0169T
0170T
0171T
0172T
0173T
0174T
0175T
0176T
0177T
0183T
0184T
0185T
0186T
0187T
A4250
A4261
A4262
A4267
A4268
A4269
A4561
A4562
A4565
A4570
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
Description
REVISE LUMB ARTIF DISC ADDL
TCATH VSD CLOSE W/O BYPASS
TCATH VSD CLOSE W BYPASS
RHINOPHOTOTX LIGHT APP BILAT
PLACE STEREO CATH BRAIN
ANORECTAL FISTULA PLUG RPR
LUMBAR SPINE PROCES DISTRACT
LUMBAR SPINE PROCES ADDL
IOP MONIT IO PRESSURE
CAD CXR WITH INTERP
CAD CXR REMOTE
AQU CANAL DILAT W/O RETENT
AQU CANAL DILAT W RETENT
WOUND ULTRASOUND
EXC RECTAL TUMOR ENDOSCOPIC
COMPTR PROBABILITY ANALYSIS
SUPRACHOROIDAL DRUG DELIVERY
OPHTHALMIC DX IMAGE ANTERIOR
URIN TEST REAG STR/TAB (100)
CERV CAP CONTRACEPTIVE USE
HCPCS - No Auth
HCPCS - No Auth
HCPCS - No Auth
HCPCS - No Auth
PESSARY RUBBER ANY TYPE
PESSARY NON RUBBER ANY TYPE
SLINGS
SPLINTS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
A4601
No
A4614
No
A4627
No
A4641
No
A4642
A5507
Yes
No
A9500
No
A9502
No
A9503
A9504
A9505
No
No
No
A9507
Yes
A9508
Yes
A9510
A9512
A9513
A9514
Description
LITHIUM ION BATTERY NONPROSTHETIC
USE REPLACMENT
PEAK EXPIR FLOW METER HAND HELD
SPAC/BG/RESVR W/WO MASK USE
W/INHAL
SUPP RADIOPHARM DX IMAG AGENT
NOS
SUPP SATUMOMAB PENDETIDE PER
DOSE
HCPCS - No Auth
TECHNETIUM TC 99M SESTAMIBI/DOSE
TECHNETIUM TC 99M TETROFOSMIN EA
UD
TECHNETIUM TC 99/MEDRONATE <=
30MCI
TECHNETIUM TC 99M APCITIDE
THALLOUS CHLORIDE TL 201/MCI
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No, under $200
No, under $200
No, under $200
No
No
No
No
No
No
No
No
No
No
RP DX INDIUM IN 111 CAPROMABPENDET
SUPP RADIOPHARMACEUTICAL DIAG
IMAGING AGENT-IOBENGUANE SULFA
SUPP RADIOPHARMACEUTICAL DIAG
IMAGING AGENT-TECHNETIUM TC99M
No
No
No
TECHNETIUM TC 99M PER TECHNETATE
HCPCS - No Auth
HCPCS - No Auth
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
A9515
A9516
A9517
A9519
A9520
A9521
A9522
A9523
A9524
A9525
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
A9526
No
A9527
No
A9528
No
A9529
No
A9530
No
A9531
No
A9532
A9533
A9534
A9535
No
No
No
No
A9568
No
Description
HCPCS - No Auth
I-123 SODIUM IODIDE CAPSULE
I-131 SODIUM IODIDE CAPSULE
HCPCS - No Auth
HCPCS - No Auth
TECHNETIUM TC 99M EXAMETAZINE
HCPCS - No Auth
HCPCS - No Auth
IODINATED I-131 SERUM ALBUMIN
HCPCS - No Auth
SUPPLY RADOPHRM DX IMAG AGT
AMMONIA N-13-DOSE
IODINE I-125 SODIUM IODIDE SOL TX
PER MCI
SPL RADOPHRM DX AGT I-131 SODIM
IODIDE CAP-MCI
SPL RADOPHRM DX AGT I-131 SODIM
IODIDE SOL-MCI
SPL RADOPHRM TX AGT I-131 SODIM
IODIDE SOL-MCI
SPL RADOPHRM DX AGT I-131 SODIM
IODIDE-MICROCURI
SPL RADOPHRM TX AGT IODINATED I125 SERUM ALBUMI
HCPCS - No Auth
HCPCS - No Auth
INJECTION METHYLENE BLUE 1 ML
TECHTM TC-99M ARCITUMOMAB DX
STDY DOSE TO 45 MCI
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
A9600
A9603
Yes
No
A9605
No
A9699
Not Reimbursable
A9700
A9900
No
No
D1203
No
G0008
No
G0009
No
G0010
No
G0027
G0030
G0031
G0032
G0033
G0034
G0035
G0036
G0037
G0038
Not Reimbursable
No
No
No
No
No
No
No
No
No
Description
SUPP THERAP STRONTIUM-89 CL PER
MCI
HCPCS - No Auth
RP SAMARIUM SM 153 LEXIDRNMM 50
MCL
SUPPLY RADOPHRM THERAPEUTIC
IMAGING AGT NOC
SUPP INJECT CONTRAST MATERIALECHOCARDIOGRAPHY
MISC SUPP/ACCES/SERV
TOP FLUORIDE (PROPHYL NOT INCL)
CHD
ADMIN FLU VIRUS VAC-NO PHYS
SRV/DAY
ADMIN PNEUMOCOC VAC-NO PHYS
SRV/DAY
ADMIN HEPAT B VAC-NO PHYS SRV/DAY
SEMEN ANALY; PRES/MOT EXCLD
HUHNER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0039
G0040
G0041
G0042
G0043
G0044
G0045
G0046
G0047
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
G0101
No
CERV/VAG CA SCREEN PELVIC/BREAST
No
G0102
G0103
Bundled
No
PROSTATE CA SCRN DIG RECTAL EXAM
PROSTATE CA SCRN (PSA) TOTAL
Bundled
No
G0104
G0105
G0106
No
No
No
No
No
No
G0107
No
COLORECTAL CA SCREEN FLEX SCOPE
COLORECTAL CA SCREEN HI RISK IND
COLON CA SCREEN BARIUM ENEMA
CA SCREEN FECAL BLD TEST 1-3
DETERM
G0108
No
DIAB OUTPT SELF-MGMT INDIV /SESSION
No
G0109
No
No
G0117
G0118
Bundled
Bundled
G0120
No
DIAB SELF-MGMT GRP TRAIN PER INDIV
GLAUC SCR HI RISK BY
OPT/OPHTHLGIST
GLAUC SCR HI RISK UND DIR SUP DR
COLORECT CA SCRN ALT G0105 SCOPE
BE
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
Bundled
Bundled
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0121
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
G0122
No
G0123
Not Reimbursable
G0124
Description
COLORECTAL CA SCRN NOT HI RISK
COLORECTAL CA SCREEN BARIUM
ENEMA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Not Reimbursable
Not Reimbursable
SCRN CERV/VAG THIN LAY W/MD SUPER
SCREEN CERV/VAG THIN LAY PHYS
INTRP
G0127
Not Reimbursable
TRIM DYSTROPHIC NAILS ANY NUMBER
Not Reimbursable
G0128
Not Reimbursable
DIR SKILL NSG RN OUTPT REHAB EA 10
Not Reimbursable
G0129
No
No
G0130
No
G0141
Not Reimbursable
SKILLS OCCUP THERAP PT HOSP TX QD
SEXA BONE DENS STUD APPEND >=1
SITE
SCR CERV/VAG CYTO/AUTOSYS MAN
RESCR
G0143
Not Reimbursable
G0144
G0145
G0147
Not Reimbursable
Not Reimbursable
Not Reimbursable
G0148
Not Reimbursable
G0151
Not Reimbursable
G0152
Not Reimbursable
SCR CERV/VAG THIN-SCRN/RESCR-TECH
SCR CYTO CERV/VAG SCRN-COMP
RESCRN
SCR CERV/VAG THIN MAN SCR COMP
SCR SMEARS CERV/VAG AUTO-MD
SCR SMEAR CERV/VAG AUTO MAN
RESCR
SERV PHYS THERAP/HOME HEALTH/15
MIN
SERV OCCUP THERAP/HOME HLTH/15
MIN
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
G0153
Not Reimbursable
SERV SPEECH/LANG PATH/HOME/15 MIN
Not Reimbursable
G0154
Not Reimbursable
Not Reimbursable
G0155
Not Reimbursable
SERV SKL NURS/HOME HLTH SET/15 MIN
SERV CSW/HOME HEALTH SET/EA 15
MIN
G0156
Not Reimbursable
SERV HOME HLTH AIDE/HOME/EA 15 MIN
Not Reimbursable
G0166
G0168
Not Reimbursable
No
Not Reimbursable
No
G0173
No
G0179
No
EXT COUNTERPULSATION PER TX SES
WOUND CLO UTILIZ TISS ADHES ONLY
LINR ACCELERATOR STEREOTAC
RADIOSURG CMPL 1 SESS
INTENSITY MODULATED RAD THERAP
PLAN
G0180
No
G0181
No
G0182
G0186
No
No
G0202
No
G0204
No
G0206
G0210
No
No
PHY SERV-MC-HHA PROV/CERT PERIOD
PHYS SUPVSN HAA PT-CMPLX/MO30/>MIN
PHYS SUPV HOSPIC PT-CMPLX/MO30/>MI
PHOTOCOAG FDR VES TECH->=1SES
SCR MAMMOGRAPHY PRODUCING
DIRECT DIGITAL IMAGE
DIAG MAMMOGRAPHY, DIRECT DIGITAL
IMAGE, BILAT, ALL VIEWS
DIAG MAMMOGRAPHY, DIRECT DIGITAL
IMAGE, UNILAT, ALL VIEWS
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0211
G0212
G0213
G0214
G0215
G0216
G0217
G0218
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
G0219
G0220
G0221
G0222
G0223
G0224
G0225
G0226
G0227
G0228
G0229
G0230
G0231
G0232
G0233
G0234
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
G0237
Not Reimbursable
Description
PET IMAGING WHOLE BODY; MELANOMA
FOR NON-COVERED INIDICATION
MUSCLES FACE FACE 1 ON 1 EA 15 MIN
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G0238
Not Reimbursable
G0239
Not Reimbursable
G0243
No
G0245
Not Reimbursable
G0246
Not Reimbursable
G0247
Not Reimbursable
G0248
Not Reimbursable
G0249
Not Reimbursable
G0250
Not Reimbursable
G0251
G0252
G0253
G0254
Not Reimbursable
Not Reimbursable
No
No
G0255
Not Reimbursable
G0257
Not Reimbursable
G0259
Not Reimbursable
Description
TX PROC IMPRV RESP NOT G0237 15 MIN
TX PROC IMPRV RESP NOT G0237
2/MORE
MX-SRC PHOTON STEREO RADIOSURG
DEL
INITIAL PHYS E&M DIABETIC
NEUROPATHY W/LOPS
FOLLOWUP EVAL DIABETIC PT
NEUROPATHY W/LOPS
ROUTINE FOOT CARE BY PHYS OF
DIABETIC PT W/LOPS
DEM USE HOME INR MON PT W/MECH
HEART VALVE
PRVS TEST MATL & EQUIP HOME INR
MON; PER 8 TESTS
PHYS REV INTEPR & PT MGMT HOME INR
MON; 8 TESTS
LINR STEREOTAC RADIOSURG TX ALL
LES MAX 5 SESS
PET IMAGING, FULL & PARTIAL-RING
CURRNT PERCEPT THRESHOLD/SNCT
PER LIMB ANY NERVE
UNSCHD/EMERG DIALYSIS TX ESRD PT
HOS OP NOT CERT
INJECTION PROCEDURE FOR SI JNT;
ARTHROGRAPY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0260
G0265
G0266
G0267
G0268
G0269
G0270
G0271
G0275
G0278
G0281
G0282
G0283
G0288
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
NO PA in ASC ASC POS 24
Grouper 1; Not Reimbursable other INJ PROC SI JNT;ANES STEROID&/TX
POS.
AGT&ARTHROGRPH
CRYOPRES FREEZING&STOR CELLS TX
Not Reimbursable
USE EA CELL LINE
THAWING&EXPAN FRZN CELLS TX USE
Not Reimbursable
EA ALIQUOT
BN MARROW/STEM CELL HARV MOD/TX
Not Reimbursable
ELIMIN CELL TYPE
REMV IMP CERUMEN PHYS SAME DATE
Not Reimbursable
AUDIO FUNCT TST
PLCMT OCCL DEVC VENUS/ART POST
Bundled
SURG/INTRVNL PROC
MED NUT TX; REASSESS FLW 2 REF YR
Not Reimbursable
W/PT EA 15 MIN
MED NUT TX REASSESS FLW 2 REF YR
Not Reimbursable
GRP EA 30 MIN
RENL ART ANGIO PRFRM AT CARD CATH
Not Reimbursable
RAD SUP&INTEPR
ILIAC ART ANGIO PRFRM W/CARD CATH
Not Reimbursable
RAD SUP&INTEPR
E-STIM 1/> AREAS CHRONIC STAGE III&IV
Not Reimbursable
ULCERS
E-STIM 1/MORE AREAS WND CARE OTH
Not Reimbursable
THAN DESC G0281
E-STIM 1/> AREAS OTH THAN WND CARE
Not Reimbursable
PART TX PLAN
RECON CT ANGIO AORTA SURG
Not Reimbursable
PLANNING VASC SURG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G0289
Not Reimbursable
G0290
Not Reimbursable
G0291
Not Reimbursable
G0293
Not Reimbursable
G0294
Not Reimbursable
G0295
G0296
Not Reimbursable
No
G0297
No
G0298
No
G0299
No
G0300
No
G0302
No
G0303
No
G0304
No
G0305
No
Description
SCOPE KNEE REMV FB/SHAV TM OTH
SURG DIFF CMPRTMT
TRNSCATH PLCMT RX ELUTING
INTRACOR STNT; 1 VES
TRNSCATH PLCMT RX ELUTING
INTRACOR STNT; EA ADD
NONCOVR SURG CONSC SEDAT ANESMCR QUAL TRIAL-DAY
NONCOVR PROC NO ANES/LOC ANESMCR QUAL TRIAL-DAY
ELECMAGNET TX 1/>AREA WND CARE
NOT G0329/OTH USE
INSRT 1 CHAMB PACE CARDIOVRT DFIB
PULSE GENERATR
INSRT 2 CHAMB PACE CARDIOVRT DFIB
PULSE GENERATR
INSRT/REPSTN LEAD 1 CHAMB
DFIB&INSRT PULSE GEN
INSRT/REPSTN LEAD 2 CHAMB
DFIB&INSRT PULSE GEN
PRE-OP PULM SURG SRVC PREP LVRS
CMPL COURSE SRVC
PRE-OP PULM SURG SRVC PREP LVRS
10 15 DA SRVC
PRE-OP PULM SURG SRVC PREP LVRS 1
9 DA SRVC
POST-DISCHRG PULM SURG SRVC
AFTER LVRS MINI 6 DA
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G0306
G0307
No
No
G0308
Not Reimbursable
G0309
Not Reimbursable
G0310
Not Reimbursable
G0311
Not Reimbursable
G0312
Not Reimbursable
G0313
Not Reimbursable
G0314
Not Reimbursable
G0315
Not Reimbursable
G0316
Not Reimbursable
G0317
Not Reimbursable
G0318
Not Reimbursable
G0319
Not Reimbursable
Description
COMPLETE CBC
AUTOMATED&AUTOMATED WBC DIFF
COUNT
COMPLETE AUTOMATED
ESRD REL SRVC DUR TX PTS UND 2 YRS;
4/> VSTS MO
ESRD REL SRVC DUR TX PTS UND 2 YRS;
2/3 VSTS MO
ESRD REL SRVC DUR TX PTS UND 2 YRS
AGE; 1 VST MO
ESRD REL SRVC DUR TX PT BETWN
2&11 YR; 4/>VST MO
ESRD REL SRVC DUR TX PT BETWN
2&11; 2/3 VSTS MO
ESRD REL SRVC DUR TX PT BETWN
2&11 YR; 1 VST MO
ESRD REL SRVC DUR TX PT BETWN
12&19; 4/> VSTS MO
ESRD REL SRVC DUR TX PT BETWN
12&19; 2/3 VSTS MO
ESRD REL SRVC DUR TX PT BETWN
12&19 YR; 1 VST MO
ESRD REL SRVC DUR TX PTS 20
YRS&OVR; 4/> VSTS MO
ESRD REL SRVC DUR TX PTS 20
YRS&OVR; 2/3 VSTS MO
ESRD REL SRVC DUR TX PTS 20
YRS&OVR; 1 VST MONTH
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G0320
Not Reimbursable
G0321
Not Reimbursable
G0322
Not Reimbursable
G0323
Not Reimbursable
G0324
Not Reimbursable
G0325
Not Reimbursable
G0326
Not Reimbursable
G0327
Not Reimbursable
G0328
No
G0329
Not Reimbursable
G0332
Yes
G0337
No
G0339
Not Reimbursable
G0340
Not Reimbursable
Description
ESRD REL SRVC HOM DIALYSIS FULL
MO; UND 2 YR AGE
ESRD REL SRVC HOM DIALYSIS FULL
MO; 2-11 YRS AGE
ESRD REL SRVC HOM DIALYSIS FULL
MO; 12-19 YR AGE
ESRD REL SRVC HOM DIALYSIS FULL
MO; 20 YRS&OLDER
ESRD REL SRVC < FULL MO DAY; PTS
UND 2 YR AGE
ESRD REL SRVC < FULL MO DAY; PT
BETWN 2&11 YR
ESRD REL SRVC < FULL MO DAY; PT
BETWN 12&19 YR
ESRD REL SRVC < FULL MO DAY; PT 20
YR & OVER
COLOREC CA SCR; FOB TST IMMUNO 1-3
SIMULTANEOUS
ELECMAGNET TX ULCERS NOT HEALING
30 DAYS CARE
PREADMIN REL SRVC IV INFUS OF IG
INFUS ENCOUNTER
HOSPICE EVALUATION & CNSL
SERVICES PREELECTION
IMAG GUID ROBOT SRS CMPL TX 1
SESS/1ST FRACT TX
IMAG GUID ROBOT SRS FRACT TX 2-5
SESS MAX 5 SESS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G0341
No
G0342
No
G0343
No
G0344
No
G0364
No
G0365
No
G0366
No
G0367
No
G0368
No
G0375
No
G0376
No
G0389
No
G0390
Bundled
G0392
Not Reimbursable
Description
PERQ ISLET CELL TPLNT INCL PORTL
VEIN CATH&INFUS
LAP ISLET CELL TPLNT INCL PORTAL
VEIN CATH&INFUS
LAPAROT ISLET CELL TPLNT W/PORTL
VEIN CATH&INFUS
INIT PREV PE; FCE-FCE NEW BENEFICRY
1ST 6 MO MCR
BN MARROW ASPIR PRFRM W/BX SAME
INCI SAME DOS
VESSEL MAPPING OF VESSELS FOR
HEMODIALYSIS ACESS
ECG AT LEAST 12 LEADS; I&R CMPNT
INIT PREV PE
ECG =/>12 LEADS;TRACING ONLY
CMPNT INIT PREV PE
ECG =/> 12 LEADS; I&R ONLY CMPNT INIT
PREV PE
SMOKING&TOB CESSATION CNSL;
INTERMED 3-10 MINS
SMOKING&TOB CESSATION CNSL;
INTENSIVE > 10 MINS
US B-SCAN &/OR REAL TIME W/IMAG
DOC; AAA SCREEN
TRAUMA RESPONSE TEAM ASSOC
W/HOSP CC SERVICE
TRNSLUM BLLN ANGIO PERQ; MNT HD
AV FIST/GFT; ART
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
G0393
Not Reimbursable
G0394
Not Reimbursable
G3001
G9001
No
Not Reimbursable
Description
TRNSLUM BLLN ANGIO PERQ; MNT HD
AV FIST/GFT; VEN
BLOOD OCCULT TEST 1 DETERM
COLORECTAL NEOPLASM
ADMINISTRATION AND SUPPLY OF
TOSITUMOMAB 450MG
COORDINATED CARE FEE INIT RATE
G9002
Not Reimbursable
COORDINATED CARE FEE MAINT RATE
Not Reimbursable
G9003
Not Reimbursable
Not Reimbursable
G9004
G9005
G9006
Not Reimbursable
Not Reimbursable
Not Reimbursable
G9007
Not Reimbursable
G9008
Not Reimbursable
G9009
Not Reimbursable
G9010
Not Reimbursable
G9011
Not Reimbursable
G9012
G9013
Not Reimbursable
No
COORD CARE FEE RISK ADJUST-HI-INIT
COORD CARE FEE RISK ADJUST-LOWINIT
COORD CARE FEE RISK ADJST MAINT
COORD CARE FEE-HOME MONITOR
COORD CARE FEE-SCHED TEAM
CONFER
COORD CARE FEE-PHYS OVRSIGHT
SERV
COORD CARE FEE RSK ADJST MNT LEVL
3
COORD CARE FEE RSK ADJST MNT LEVL
3
COORD CARE FEE RSK ADJST MNT LEVL
3
COORD CARE FEE RSK ADJST MNT LEVL
3
ESRD DEMO BASIC BUNDLE LEVEL I
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
G9014
No
G9016
Not Reimbursable
G9017
No
G9018
No
G9019
No
G9020
No
G9034
No
G9035
No
G9036
H0009
J0120
J0130
J0132
J0133
J0140
No
No
No
No
No
No
No
J0150
J0151
J0152
No
No
No
Description
ESRD DEMO EXPND BUNDLE INCL
VENOUS ACSS&REL SRVC
SMOKNG CESS CNSLG-W/WO OTH
E&M/SESS
AMANTADINE HYDROCHLORIDE ORAL
GENRIC NAME 100 MG
ZANAMIVIR INHAL POWDR ADMIN INHAL
GENRIC 10 MG
OSELTAMIVIR PHOSPHATE ORAL
GENERIC 75 MG
RIMANTADINE HYDROCHLORIDE ORAL
GENERIC 100 MG
ZANAMIVIR INHAL POWDR ADMIN INHAL
BRAND 10 MG
OSELTAMIVIR PHOSPHATE ORAL BRAND
NAME 75 MG
RIMANTADINE HYDROCHLORIDE ORAL
BRAND NAME 100 MG
AL &/OR DRG SRV;ACUTE DETOX-IP
INJ TETRACYCLINE TO 250 MG
INJ ABCIXIMAB 10 MG
INJECTION ACETYLCYSTEINE 100 MG
INJECTION ACYCLOVIR 5 MG
INJECTION ADENOSINE THERAPEUTIC
USE 6 MG
INJECTION ADENOSINE DIAGNOSTIC
USE 30 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0160
J0170
J0180
J0190
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
J0200
J0205
J0207
J0210
J0215
J0220
J0256
J0270
No
No
No
No
No
Yes
No
No
J0275
J0278
J0280
No
No
No
J0282
J0285
J0286
No
No
No
J0287
No
J0288
No
J0289
J0290
J0295
No
No
No
Description
INJ ADRENALINE EPINEPHRINE <=1 ML
INJ BIPERIDEN LACTATE, PER 5 MG
INJ ALATROFLOXACIN MESYLATE 100
MG
INJ ALGLUCERASE/10 U (CEREDASE)
INJ AMIFOSTINE 500 MG
INJ METHYLDOPATE HCL TO 250 MG
INJECTION ALEFACEPT 0.5 MG
INJ ALGLUCOSIDASE ALFA 10 MG
INJ ALPHA 1 PROTEINASE INHIB/10 MG
INJ ALPROSTADIL 1.25 MCG DIR PHYS
ALPROSTADIL URETHRAL SUPP ADMIN
MD
INJECTION AMIKACIN SULFATE 100 MG
INJ AMINOPHYLLIN TO 250 MG
INJ AMIODARONE HYDROCHLORIDE 30
MG
INJ AMPHOTERICIN B 50 MG
INJECTION AMPHOTERICIN B LIPID
COMPLEX 10 MG
INJ AMPHOTERICIN B CHOLESTRYL
SULFAT CMPLX 10 MG
INJECTION AMPHOTERICIN B LIPOSOME
10 MG
INJ AMPICILLIN SODIUM 500 MG
INJ AMPICILLIN SODIUM 1.5 GM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0300
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
J0330
J0340
J0350
J0360
J0365
J0380
J0390
J0395
J0400
J0456
J0460
J0470
J0475
J0476
J0480
J0500
J0510
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
SUCCINYLCHOLINE CHLORIDE TO 20 MG
J0515
No
INJ BENZTROPINE MESYLATE, PER 1 MG
No
J0520
J0530
J0540
J0550
J0560
J0570
J0580
No
No
No
No
No
No
No
INJ BETHANECHOL CHLORIDE, <= 5 MG
INJ PEN G BENZ/PRO TO 600,000 U
INJ PEN G BENZ/PRO TO 1,200,000 U
INJ PEN G BENZ/PRO TO 2,400,000 U
INJ PEN G BENZATHINE TO 600,000 U
INJ PEN G BENZATHINE TO 1,200,000 U
INJ PEN G BENZATHINE TO 2,400,000 U
No
No
No
No
No
No
No
Description
INJ AMOBARBITAL TO 125 MG
INJ ANISTREPLASE PER 30 UNITS
INJ HYDRALAZINE HCL TO 20 MG
INJECTION APROTONIN 10000 KIU
INJ METARAMINOL BITARTRATE/10 MG
INJ CHLOROQUINE HCL TO 250 MG
INJ ARBUTAMINE HCL 1 MG
INJ AZITHROMYCIN 500 MG
INJ ATROPINE SULFATE TO 0.3 MG
INJ DIMECAPROL PER 100 MG
INJ BACLOFEN 10 MG
INJ BACLOFEN 50 MCG IT TRIAL
INJECTION BASILIXIMAB 20 MG
INJ DICYCLOMINE HCL UP TO 20 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0583
J0585
J0587
J0590
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Yes
Yes
No
J0592
No
J0595
No
J0600
J0610
No
No
J0620
J0630
J0635
J0636
J0637
J0640
J0670
J0690
No
No
No
No
No
No
No
No
J0692
J0694
J0695
No
No
No
INJ CEFEPIME HYDROCHLORID 500 MG
INJ CEFOXITIN SODIUM 1 GM
No
No
No
J0696
No
INJ CEFTRIAXONE SODIUM PER 250 MG
No
J0697
No
INJ STER CEFUROXIME SODIUM/750 MG
No
Description
INJECTION BIVALIRUDIN 1 MG
BOTULINUM TOXIN TYPE A /PER UNIT
BOTULINUM TOXIN TYPE B-100 UNITS
INJECTION BUPRENORPHINE
HYDROCHLORIDE 0.1 MG
INJECTION BUTORPHANOL TARTRATE 1
MG
EDETATE CALCIUM DISODIUM TO 1000
MG
INJ CALCIUM GLUCONATE PER 10 ML
CA GLYCEROPHOSPHATE/LACTATE/10
ML
INJ CALCITONIN SALMON TO 400 UNITS
INJECTION CALCITRIOL 0.1 MCG
CASPOFUNGIN ACETATE
INJ LEUCOVORIN CALCIUM PER 50 MG
INJ MEPIVACAINE HCL, PER 10 ML
INJ CEFAZOLIN SODIUM 500 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0698
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
J0702
No
J0704
J0706
J0710
J0713
J0715
No
No
No
No
No
J0720
No
J0725
J0730
J0735
J0740
J0743
J0744
J0745
J0760
No
No
No
No
No
No
No
No
J0770
J0780
No
No
J0795
J0800
J0810
J0835
J0850
No
No
No
No
Yes
Description
CEFOTAXIME SODIUM PER GM
BETAMETHASONE ACETATE-NA PHOS/3
MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
BETAMETHASONE NA PHOSPHATE/4 MG
INJECTION, CAFFEINE CITRATE, 5MG
INJ CEPHAPIRIN SODIUM TO 1 GM
INJECTION, CEFTAZIDIME, PER 500 MG
INJ CEFTIZOXIME SODIUM PER 500 MG
CHLORAMPHENICOL NA SUCCINATE-1
GM
No
No
No
No
No
CHORIONIC GONADOTROPIN/1000 USP U
No
No
No
No
No
No
No
No
INS CLONIDINE HYDROCHLORIDE 1 MG
INJ CIDOFOVIR 375 MG
IMIPENEM-CILASTATIN SODIUM/250MG
INJ CIPROFLOXACIN IV INFUS 200 MG
INJ CODEINE PHOSPHATE PER 30 MG
INJ COLCHICINE PER 1 MG
INJ COLISTIMETHATE SODIUM TO 150
MG
INJ PROCHLORPERAZINE TO 10 MG
INJ CORTICORELIN OVINE TRIFLUTATE 1
MICROGM
INJ CORTICOTROPIN TO 40 UNITS
INJ COSYNTROPIN PER 0.25 MG
INJ CMV IMMUNE GLOBULIN IV/VIAL
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J0881
No
J0882
No
J0885
No
J0886
No
Description
INJECTION DARBEPOETIN ALFA 1 MCG
NON-ESRD USE
INJ DARBEPOETIN ALFA 1 MCG FOR
ESRD DIALYSIS
INJECTION EPOETIN ALFA FOR NONESRD 1000 UNITS
INJ EPOETIN ALFA 1000 UNITS FOR
ESRD DIALYSIS
J0895
No
DEFEROXAMINE MESYLATE 500 MG/5 CC
No
J0900
No
TESTOS ENANTH/ESTRA VALERATE-1CC
No
J0945
J0970
No
No
INJ BROMPHENIRAMINE MALEATE/10 MG
INJ ESTRADIOL VALERATE TO 40 MG
No
No
J1000
No
No
J1020
No
J1030
No
J1040
J1050
No
No
DEPO-ESTRADIOL CYPIONATE TO 5 MG
METHYLPREDNISOLONE ACETATE-20
MG
METHYLPREDNISOLONE ACETATE-40
MG
METHYLPREDNISOLONE ACETATE-80
MG
J1051
No
J1055
No
INJECTION MEDROXYPROGESTERONE
ACETATE 50 MG
MEDROXYPRO ACETATE-CONTRA-150
MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J1056
J1060
No
No
J1070
No
J1080
J1090
No
No
J1094
J1095
No
No
J1100
No
J1110
No
J1120
J1160
No
No
J1162
J1165
J1170
J1180
J1190
J1200
Description
INJ MDRXYPRGESTRON/ESTRDIOL
5/25MG
TESTOS/ESTRADIOL CYPIONATE-1 ML
TESTOSTERONE CYPIONATE TO 100 MG
TESTOSTERONE CYPIONATE-1 CC-200
MG
INJECTION DEXAMETHASONE ACETATE
1 MG
DEXAMETHASONE NA PHOSPATE-4
MG/ML
INJ DIHYDROERGOTAMINE MESYLATE/1
MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
INJ ACETAZOLAMIDE SODIUM TO 500 MG
INJ DIGOXIN TO 0.5 MG
INJECTION DIGOXIN IMMUNE FAB OVINE
PER VIAL
INJ PHENYTOIN SODIUM, PER 50 MG
INJ HYDROMORPHONE TO 4 MG
INJ DYPHYLLINE TO 500 MG
INJ DEXRAZOXANE HCL PER 250 MG
INJ DIPHENHYDRAMINE HCL TO 50 MG
No
No
No
No
No
No
No
No
J1205
No
CHLOROTHIAZIDE SODIUM, PER 500 MG
No
J1212
No
DMSO DIMETHYL SULFOXIDE 50%-50 ML
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J1230
J1240
J1245
J1250
J1260
J1265
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
J1270
J1320
J1325
J1327
J1330
No
No
Yes
No
No
INJECTION, DUOVAL 2X-P.A., UP TO 1 ML
INJ AMITRIPTYLINE HCL TO 20 MG
INJ EPOPROSTENOL 0.5 MG
INJ EPTIFIBATIDE 5 MG
INJ ERGONOVINE MALEATE TO 0.2 MG
No
No
Yes
No
No
J1335
J1362
No
No
INJECTION ERTAPENEM SODIUM 500 MG
No
No
J1364
J1380
J1390
No
No
No
No
No
No
J1410
No
J1430
J1435
J1436
No
No
No
J1438
J1440
J1441
No
No
No
ERYTHROMYCIN LACTOBIONATE/500 MG
INJ ESTRADIOL VALERATE TO 10 MG
INJ ESTRADIOL VALERATE TO 20 MG
INJ ESTROGEN CONJUGATED PER 25
MG
INJECTION ETHANOLAMINE OLEATE 100
MG
INJ ESTRONE PER 1 MG
INJ ETIDRONATE DISODIUM TO 300 MG
INJ ETANERCEPT 25 MG-NOT SELF
ADMIN
INJ FILGRASTIM 300 MCG
INJ FILGRASTIM 480 MCG
Description
INJ METHADONE HCL UP TO 10 MG
INJ DIMENHYDRINATE TO 50 MG
INJ DIPYRIDAMOLE PER 10MG
INJ, DOBUTAMINE HCL, PER 250 MG
INJ DOLASETRON MESYLATE 10 MG
INJECTION DOPAMINE HCL 40 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J1450
J1451
J1452
J1455
J1460
J1470
J1480
J1490
J1500
J1510
J1520
J1530
J1540
J1550
J1560
J1561
J1562
J1563
J1565
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J1566
No
J1567
J1570
J1580
J1590
No
No
No
No
J1595
J1600
No
No
Description
INJ FLUCONAZOLE 200 MG
INJECTION FOMEPIZOLE 15 MG
INJ FOMIVIRSEN SODIUM IO 1.65MG
INJ FOSCARNET SODIUM PER 1000MG
INJ GAMMA GLOBULIN IM 1 CC
INJ GAMMA GLOBULIN IM 2 CC
INJ GAMMA GLOBULIN IM 3 CC
INJ GAMMA GLOBULIN IM 4 CC
INJ GAMMA GLOBULIN IM 5 CC
INJ GAMMA GLOBULIN IM 6 CC
INJ GAMMA GLOBULIN IM 7 CC
INJ GAMMA GLOBULIN IM 8 CC
INJ GAMMA GLOBULIN IM 9 CC
INJ GAMMA GLOBULIN IM 10 CC
INJ GAMMA GLOBULIN IM OVER 10 CC
INJ RESP SYNCYTIAL VIRUS IVIG 50 MG
INJECTION IG IV LYOPHILIZED POWDER
500 MG
INJ IG IV NONLYOPHILIZED LIQUID 500
MG
INJ GANCICLOVIR SODIUM 500 MG
INJ GARAMYCIN GENTAMICIN TO 80 MG
INJECTION, GLUKOR, UP TO 1 ML
INJECTION GLATIRAMER ACETATE 20
MG
GOLD SODIUM THIOMALATE-50 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J1610
No
J1620
J1626
J1630
No
No
No
J1631
J1640
No
No
Description
INJ GLUCAGON HYDROCHLORIDE PER 1
MG
GONADORELIN HYDROCHLORIDE/100
MCG
INJ GRANISETRON HCL 100 MCG
INJ HALOPERIDOL TO 5 MG
INJ HALOPERIDOL DECANOATE PER 50
MG
INJECTION HEMIN 1 MG
J1642
J1644
J1645
No
No
No
HEPARIN SODIUM-HEP LOCK FLUSH-10 U
INJ HEPARIN SODIUM PER 1000 UNITS
INJ DALTEPARIN SODIUM PER 2500 IU
No
No
No
J1650
No
No
J1652
No
INJECTION ENOXAPARIN SODIUM 10 MG
INJECTION FONDAPARINUX SODIUM 0.5
MG
J1655
No
No
J1670
No
J1675
J1690
No
No
INJECTION TINZAPARIN SODIUM 1000 IU
TETANUS IMMUNE GLOBULIN HUMAN250 U
INJECTION HISTRELIN ACETATE 10
MICROGRAMS
J1700
No
J1710
No
INJ HYDROCORTISONE ACETATE TO 25
MG
HYDROCORTISONE NA PHOSPHATE-50
MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J1720
J1730
J1739
J1741
J1742
J1745
J1750
J1751
J1752
J1756
J1760
J1770
J1780
J1785
J1790
J1800
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J1810
J1815
Not Reimbursable
No
J1817
J1820
No
No
J1825
No
J1830
J1835
J1840
No
No
No
Description
HYDROCORTISONE NA SUCCINATE-100
MG
INJ DIAZOXIDE TO 300 MG
INJ IBUTILIDE FUMARATE 1 MG
INJ INFLIXIMAB 10 MG
INJECTION IRON DEXTRAN 165 50 MG
INJECTION IRON DEXTRAN 267 50 MG
IRON SUCROSE INJECTION
INJ IMIGLUCERASE PER UNIT
INJ DROPERIDOL TO 5 MG
INJ PROPRANOLOL HCL TO 1 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
DROPERIDOL-FENTANYL CITRATE-2 ML
INJECTION INSULIN PER 5 UNITS
INSULIN ADMINISTRATION THROUGH
DME PER 50 UNITS
Not Reimbursable
No
INJ INTERFERON BETA-1A 33 MCG/PHYS
INTERFERON BETA-1B PER 0.25
MG/PHYS
INJECTION, ITRACONAZOLE, 50 MG
INJ KANAMYCIN SULFATE TO 500 MG
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J1850
No
J1885
J1890
J1910
J1930
J1940
J1945
No
No
No
No
No
No
J1950
J1955
J1956
Description
INJ KANAMYCIN SULFATE UP TO 500 MG
INJ KETOROLAC TROMETHAMINE PER
15MG
INJ CEPHALOTHIN SODIUM TO 1 GM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
INJ FUROSEMIDE TO 20 MG
INJECTION LEPIRUDIN 50 MG
No
No
No
No
No
No
No
No
No
INJ LEUPROLIDE ACETATE PER 3.75 MG
INJ LEVOCARNITINE PER 1 GM
INJ LEVOFLOXACIN 250 MG
No
No
No
J1960
J1970
J1980
No
No
No
INJ LEVORPHANOL TARTRATE TO 2 MG
No
No
No
J1990
J2000
No
No
INJ CHLORDIAZEPOXIDE HCL TO 100 MG
INJ HYOSCYAMINE SULFATE TO .25 MG
J2001
J2010
J2020
J2060
J2150
No
No
No
No
No
INJECTION LIDOCAINE HCL
INTRAVENOUS INFUS 10 MG
INJ LINCOMYCIN HCL TO 300 MG
INJECTION, LIPO-HEPIN
INJ LORAZEPAM 2MG
INJ MANNITOL 25% IN 50 ML
J2175
No
MEPERIDINE HYDROCHLORIDE/100 MG
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J2180
J2185
No
No
J2210
J2240
J2250
J2260
J2270
J2271
J2275
J2278
J2280
J2300
J2310
No
No
No
No
No
No
No
No
No
No
No
J2320
No
J2321
No
J2322
J2325
J2330
J2350
J2352
No
No
No
No
No
J2353
No
J2354
No
Description
MEPERIDINE & PROMETHAZINE HCL-50
MG
INJECTION MEROPENEM 100 MG
METHYLERGONOVINE MALEATE TO 0.2
MG
INJ, MIDAZOLAM HCL, PER 1 MG
MILRINONE LACTATE PER 5 ML
INJ MORPHINE SULFATE TO 10 MG
INJ MORPHINE SULFATE 100MG
INJ MORPHINE SULFATE UP TO 10MG
INJECTION ZICONOTIDE 1 MICROGRAM
INJECTION, MYCHEL-S, UP TO 250MG
INJ, NALBUPHINE HCL, PER 10 MG
INJ, NALOXONE HCL, PER 1 MG
INJ NANDROLONE DECANOATE TO 50
MG
INJ NANDROLONE DECANOATE TO 100
MG
INJ NANDROLONE DECANOATE TO 200
MG
INJECTION NESIRITIDE 0.1 MG
INJ OCTREOTIDE DEPOT FORM IM INJ 1
MG
INJ OCTREOTIDE NON-DEPOT FORM
SUBQ/IV INJ 25 MCG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J2355
J2357
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
Yes
J2360
J2370
No
No
J2400
J2405
J2410
No
No
No
J2425
No
J2430
J2440
J2460
J2480
J2500
J2501
Description
INJ OPRELVEKIN 5 MG
INJ OMALIZUMAB 5 MG
INJ ORPHENADRINE CITRATE UP TO
60MG
INJ PHENYLEPHRINE HCL TO 1 ML
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
Yes
No
No
INJ CHLOROPROCAINE HCL, PER 30 ML
INJ ONDANSETRON HCL PER 1 MG
INJ OXYMORPHONE HCL TO 1 MG
INJECTION PALIFERMIN 50
MICROGRAMS
No
No
No
No
No
No
No
No
No
INJ PAMIDRONATE DISODIUM PER 30 MG
INJ PAPAVERINE HCL TO 60 MG
INJ OXYTETRACYCLINE HCL TO 50 MG
PARICALCITOL
No
No
No
No
No
No
J2503
Yes
INJECTION PEGAPTANIB SODIUM 0.3 MG
No
J2504
J2505
No
No
INJECTION PEGADEMASE BOVINE 25 IU
INJECTION PEGFILGRASTIM 6 MG
No
No
J2510
J2512
No
No
PEN G PROCAINE AQUEOUS-600,000 U
No
No
J2513
No
INJECTION PENTASTARCH 10%
SOLUTION 100 ML
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J2515
J2540
J2543
No
No
No
J2545
J2550
No
No
J2560
J2590
J2597
J2640
J2650
J2670
J2675
No
No
No
No
No
No
No
J2680
J2690
J2700
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
INJ PENTOBARBITAL SODIUM PER 50 MG
PEN G POTASSIUM-600,000 U
INJ PIPERACILLIN NA/TAZOBACTAM NA
PENTAM ISETH INHAL SOLN/300
MG(DME)
INJ PROMETHAZINE HCL TO 50 MG
No
No
No
INJ PHENOBARBITAL SODIUM TO 120 MG
INJ OXYTOCIN TO 10 UNITS
INJ, DESMOPRESSIN ACETATE/1 MCG
No
No
No
No
No
No
No
No
No
No
No
No
INJ PREDNISOLONE ACETATE TO 1 ML
INJ TOLAZOLINE HCL TO 25 MG
INJ PROGESTERONE PER 50 MG
INJ FLUPHENAZINE DECANOATE TO 25
MG
INJ PROCAINAMIDE HCL TO 1 GM
INJ OXACILLIN SODIUM TO 250 MG
No
No
No
J2710
J2720
J2725
J2730
No
No
No
No
NEOSTIGMINE METHYLSULFATE-0.5 MG
INJ PROTAMINE SULFATE PER 10 MG
INJ PROTIRELIN PER 250 MCG
INJ PRALIDOXIME CHLORIDE TO 1 GM
No
No
No
No
J2760
J2765
No
No
No
No
J2770
No
INJ PHENTOLAMINE MESYLATE TO 5 MG
INJ METOCLOPRAMIDE HCL TO 10 MG
INJECTION
QUINUPRISTIN/DALFOPRISTIN 500 MG
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J2780
J2783
No
No
J2788
J2790
J2792
No
No
No
J2795
J2800
J2805
J2810
J2820
No
No
No
No
No
J2850
J2860
J2910
No
No
No
J2912
J2915
J2916
J2920
No
No
No
No
INJ SODIUM CHLORIDE, 0.9 % PER 2 ML
NA FERRIC GLUCONATE COMPLEX
METHYLPRED NA SUCCINATE-40 MG
No
No
No
No
J2930
No
METHYLPRED NA SUCCINATE TO 125MG
No
J2940
J2941
J2950
J2970
No
No
No
No
INJECTION, SPANESTRIN P, UP TO 1 ML
INJECTION, SOMATROPIN, 1 MG
INJ PROMAZINE HCL TO 25 MG
No
No
No
No
Description
INJ RANITIDINE HYDROCHLORIDE 25 MG
INJECTION RASBURICASE 0.5 MG
INJECTION RHO D IG HUMAN MINIDOSE
50 MCG
RHO D IG HUMAN 1 DOSE PKG
INJ RHO D IMMUNE GLOBULIN IV 100 IU
INJ ROPIVACAINE HYDROCHLORIDE 1
MG
INJ METHOCARBAMOL TO 10 ML
INJECTION SINCALIDE 5 MICROGRAMS
INJ THEOPHYLLINE PER 40 MG
INJ SARGRAMOSTIN (GM-CSF)/50MCG
INJECTION SECRETIN SYNTHETIC
HUMAN 1 MICROGRAM
INJ AUROTHIOGLUCOSE TO 50 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J2993
J2994
J2995
J2996
J2997
J3000
J3010
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
J3030
J3070
J3080
J3100
J3105
No
No
No
Yes
No
J3120
No
J3130
No
J3140
No
J3150
J3230
J3240
J3245
No
No
Yes
No
J3250
J3260
J3265
J3270
No
No
No
No
Description
INJ RETEPLASE 18.8 MG
INJ STREPTOKINASE PER 250,000 IU
INJ ALTEPLASE RECOMBINANT 1 MG
INJ STREPTOMYCIN TO 1 GM
INJ FENTANYL CITRATE TO 2 ML
INJ SUMATRIPTAN SUCCINATE 6
MG/PHYS
INJ PENTAZOCINE HCL TO 30 MG
INJECTION, TERRAMYCIN, UP TO 50 MG
INJ TERBUTALINE SULFATE TO 1 MG
TESTOSTERONE ENANTHATE TO 100 MG
TESTOSTERONE ENANTHATE TO 20O
MG
TESTOSTERONE SUSPENSION TO 50 MG
TESTOSTERONE PROPIONATE TO 100
MG
INJ CHLORPROMAZINE HCL TO 50 MG
INJ THYROTROPIN ALFA 0.9MG
INJ TRIMETHOBENZAMIDE HCL TO 200
MG
INJ TOBRAMYCIN SULFATE TO 80 MG
INJECTION, TORSEMIDE, 10 MG/ML
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
J3280
J3285
J3301
J3302
No
Yes
No
No
THIETHYLPERAZINE MALEATE TO 10 MG
INJECTION TREPROSTINIL 1 MG
TRIAMCINOLONE ACETONIDE/10 MG
TRIAMCINOLONE DIACETATE/5 MG
No
Yes
No
No
J3303
No
No
J3305
J3310
No
No
J3315
J3320
J3350
J3355
J3360
J3364
J3365
J3370
J3390
J3400
J3410
J3411
J3415
J3420
J3430
J3450
J3465
J3470
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
TRIAMCINOLONE HEXACETONIDE/5 MG
INJ, TRIMETREXATE GLUCORONATE/25
MG
INJ PERPHENAZINE TO 5 MG
INJECTION TRIPTORELIN PAMOATE 3.75
MG
SPECTINOMYCIN HCL, 2GM
INJ UREA TO 40 GM
INJECTION UROFOLLITROPIN 75 IU
INJ DIAZEPAM TO 5 MG
INJ UROKINASE 5000 IU VIAL
INJ IV UROKINASE 250,000 IU VIAL
INJ VANCOMYCIN HCL 500MG
INJ TRIFLUPROMAZINE HCL TO 20 MG
INJ HYDROXYZINE HCL TO 25 MG
INJECTION THIAMINE HCL 100 MG
INJECTION PYRIDOXINE HCL 100 MG
VIT B-12 CYANOCOBALAMIN-1000 MCG
INJ PHYTONADIONE (VIT K) PER 1 MG
INJECTION VORICONAZOLE 10 MG
INJ HYALURONIDASE TO 150 UNITS
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J3471
No
J3472
J3475
J3480
J3485
No
No
No
No
J3486
J3487
J3490
J3520
J3530
No
No
No
Not Reimbursable
No
J3535
J3570
J3590
J7030
J7040
J7042
J7050
J7051
No
Not Reimbursable
No
No
No
No
No
No
J7060
J7070
J7100
J7110
No
No
No
No
J7120
No
Description
INE HYALURONIDASE OVINE PRES FREE
1 USP UNIT
INJ HYALURONIDASE OVINE PRES FREE1000 USP UNITS
INJ, MAGNESIUM SULFATE/500 MG
INJ, POTASSUIM CHLORIDE/2 MEQ
INJ ZIDOVUDINE 10 MG
INJECTION ZIPRASIDONE MESYLATE 10
MG
ZOLEDRONIC ACID
UNCLASSIFIED DRUGS
EDETATE DISODIUM PER 150 MG
NASAL VACCINE INHALATION
DRUG ADMIN THRU METERED DOSE
INHAL
LAETRILE AMYGDALIN VITAMIN B17
UNCLASSIFIED BIOLOGICS
INFUS NORMAL SALINE SOLN 1000 CC
INFUS NS SOLN STER 500 ML
D5NS 500 ML = 1 UNIT
INFUS NORMAL SALINE SOLN 250 CC
5% DEXTROSE/WATER 500 ML = 1 UNIT
INFUSION D5W 1000 CC
INFUSION DEXTRAN 40, 500 ML
INFUSION DEXTRAN 75, 500 ML
RINGERS LACTATE INFUSION TO 1000
CC
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J7130
No
J7188
J7189
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
HYPERTON SAL SOLN 50-100 MEQ, 20 CC
INJECTION VON WILLEBRAND FACTOR
COMPLEX HUMAN IU
FACTOR VIIA 1 MICROGRAM
J7190
No
FACT VIII(ANTI-HEMOPHI HUMAN)PER IU
No
J7191
No
FACT VIII/ANTIHEMOPH/PORCINE PER IU
No
J7192
J7193
J7194
J7195
J7197
J7198
J7199
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J7300
No
J7302
No
J7303
No
J7306
Yes
J7308
Not Reimbursable
J7310
No
FACTOR VIII (ANTIHEMO RECOMB)PER IU
FACTOR IX PER I.U.
FACTOR IX COMPLX PER IU
FACTOR IX PER I.U.
ANTITHROMBIN III (HUMAN) PER IU
ANTI-INHIBITOR PER I.U.
HEMOPHILIA CLOT FACT NOC
INTRAUTERINE COPPER
CONTRACEPTIVE
LEVONORGESTREL INTRAUTERN
CNTRACPT
CONTRACEPT SUPPLY HORMONE
CONTAINING VAG RING EA
LEVONORGESTREL CNTRACPTV IMPL
SYS INCL IMPL&SPL
AMINOLEVULINIC ACID HCL TOP ADMN
20% 1 U DOSE
GANCICLOVIR 4.5 MG LONG-ACT
IMPLANT
No
No
No
No
No
No
Not Reimbursable
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7315
J7316
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
J7317
J7320
No
No
J7330
J7340
Not Reimbursable
No
J7341
No
J7342
No
J7350
J7500
J7501
J7502
No
Not Reimbursable
No
Not Reimbursable
J7504
J7505
J7506
J7507
J7508
J7509
J7510
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
J7511
J7513
J7515
No
No
No
Description
SODIUM HYALURONATE 20-25MG
(HYALGAN) [1 UNIT=20-25MG]
AUTOLOGOUS CULTURED
CHONDROCYTES, IMPLANT
MIXED VESPID VENOM PROTEIN
DERM TISS NH ORIGIN W/METABL
ACTIVE ELEM SQ CM
DERM TISS HUMN ORIGIN W/METABOL
ACTV ELEM-SQ CM
DERM TISS HUMN ORIG INJ NO METAB
ACTV ELEM-10 MG
AZATHIOPRINE ORAL 50 MG
AZATHIOPRINE PARENTERAL 100 MG
CYCLOSPORINE ORAL 100 MG
LYMPH IG/ANTITHYMOCYTE GLOB 250
MG
MONOCLONAL ANTIBODIES PAR/5MG
PREDNISONE/ORAL/PER 5 MG
TACROLIMUS ORAL PER 1 MG
METHYLPREDNISOLONE PO/4 MG
PREDNISOLONE ORAL, PER 5 MG
LYMPHCYT GLOB RABBIT PARNTRAL
25MG
DACLIZUMAB PARENTERAL 25 MG
CYCLOSPORINE ORAL 25 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Not Reimbursable
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7516
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
J7517
J7520
J7525
J7599
No
No
No
No
J7608
J7610
J7615
J7617
No
No
No
No
Description
CYCLOSPORIN PARENTERAL 250 MG
MYCOPHENOLATE MOFETIL ORAL 250
MG
SIROLIMUS ORAL 1 MG
TACROLIMUS PARENTERAL 5 MG
IMMUNOSUPPRESSIVE DRUG, NOC
ACETYLCYSTEINE INHAL SOL UD PER
GM
ALBUTEROL TO 2.5 MG & IPRATROPIUM
BR TO 0.5 MG
BETHAMETHASONE INHAL SOL DME U
MG
BETHAMETHASONE INHAL SOL DME U
MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
J7620
No
J7622
No
J7624
J7625
J7626
No
No
No
J7627
No
BUDESONIDE INHAL SOL DME .25 MG
BUDESONIDE PWDR CMPND INHAL SOL
U DOSE TO 0.5 MG
J7628
No
BITOLTEROL MESYLATE INHAL SOL CON
No
J7629
J7630
No
No
BITOLTEROL MESYLATE INHAL SOL/MG
No
No
J7631
No
CROMOLYN NA INHAL SOL UD PER 10
MGS
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
J7633
No
J7635
J7636
No
No
J7637
No
J7638
No
J7639
No
J7640
No
J7641
No
J7642
No
J7643
No
J7644
J7645
J7648
No
No
No
J7649
J7650
J7651
J7652
J7653
No
No
No
No
No
Description
BUDESONIDE INHAL SOL ADMND THRU
DME CONC-0.25 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
ATROPINE INHAL SOL/CONCEN PER MG
ATROPINE INHAL SOL UD PER MG
DEXAMETHASONE INHAL SOL/CON PER
MG
DEXAMETHASONE INHAL SOL UD PER
MG
No
No
DORNASE ALPHA INHAL SOL UD PER MG
FORMOTEROL INHAL SOL UNIT DOSE 12
MICROGRAMS
FLUNISOLIDE INHAL SOL ADMNED DMEMG
GLYCOPYRROLATE INHAL SOL CON PER
MG
GLYCOPYRROLATE INHAL SOL UD PER
MG
IPRATROPIUM BROMIDE INHAL SOL
UD/MG
No
ISOETHARINE HCL INHAL SOL CON/MG
ISOETHARINE HCL INHAL SOL UD PER
MG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7654
J7655
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
J7658
No
J7659
J7660
J7665
No
No
No
J7668
No
J7669
J7670
J7672
J7675
No
No
No
No
J7680
No
J7681
J7682
No
No
J7683
No
J7684
J7699
J7799
No
No
No
J8498
J8499
No
Not Reimbursable
Description
ISOPROTERENOL HCL INHAL SOL
CON/MG
ISOPROTERENOL HCL INHAL SOL UD/
MG
METAPROTERENOL INHAL SOL CON/10
MGS
METAPROTERENOL INHAL SOL UD/10
MGS
TERBUTALINE SO4 INHAL SOL CON/MG
TERBUTALINE SO4 INHAL SOL UD/PER
MG
TOBRAMYCIN UD 300 MG INHAL SOL
TRIAMCINOLONE INHAL SOL CONC/PER
MG
TRIAMCINOLONE INHAL SOL CON PER
MG
NOC DRUGS, INHAL SOLN ADMIN-DME
NOC DRUGS, OTH THAN INHAL
ANTIEMETIC DRUG
RECTAL/SUPPOSITORY NOS
RX DRUG/ORAL/NON-CHEMO/NOS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J8510
J8515
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
J8520
J8521
J8530
J8540
J8560
No
No
No
No
No
J8597
J8600
J8610
J8700
J8999
J9000
J9001
J9010
J9015
J9017
J9020
J9025
J9027
J9031
J9040
J9045
J9050
J9060
J9062
Description
BUSULFAN ORAL 2 MG
CABERGOLINE ORAL 0.25 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
TRIAMCINOLONE INHAL SOL/DME UD/MG
CAPECITABINE ORAL 500 MG
CYCLOPHOSPHAMIDE ORAL 25 MG
DEXAMETHASONE ORAL 0.25 MG
ETOPOSIDE ORAL 50 MG
ANTIEMETIC DRUG ORAL NOT
OTHERWISE SPECIFIED
MELPHALEN ORAL 2 MG
METHOTREXATE ORAL 2.5 MG
TEMOZOLOmIDE ORAL 5 MG
RX DRUGORALCHEMONOS
DOXORUBICIN HCL 10 MG
DOXORUBICIN HCL/ALL LIPID/10 MG
ALEMTUZUMAB 10 MG
ALDESLEUKIN, PER SINGLE USE VIAL
ARSENIC TRIOXIDE, 1MG
ASPARAGINASE 10,000 UNITS
INJECTION AZACITIDINE 1 MG
INJECTION CLOFARABINE 1 MG
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
BCG (INTRAVESICAL) PER INSTALLATION
BLEOMYCIN SULFATE 15 UNITS
CARBOPLATIN, 50 MG
CARMUSTINE, 100MG
CISPLATIN, POW/SOLN/10 MG
CISPLATIN 50 MG
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9065
J9070
J9080
J9090
J9091
J9092
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
J9093
No
J9094
No
J9095
No
Description
INJ CLADRIBINE PER 1 MG
CYCLOPHOSPHAMIDE 100MG
CYCLOPHOSPHAMIDE 200 MG
CYCLOPHOSPHAMIDE 500 MG
CYCLOPHOSPHAMIDE 1 G
CYCLOPHOSPHAMIDE 2 G
CYCLOPHOSPHAMIDE LYOPHILIZED 100
MG
CYCLOPHOSPHAMIDE LYOPHILIZED 200
MG
CYCLOPHOSPHAMIDE LYOPHILIZED 500
MG
J9096
No
CYCLOPHOSPHAMIDE LYOPHILIZED 1 G
No
J9097
J9098
J9100
J9110
J9120
J9130
J9140
J9150
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
J9151
J9160
J9165
J9170
J9175
No
No
No
No
No
CYCLOPHOSPHAMIDE LYOPHILIZED 2 G
CYTARABINE LIPOSOME 10 MG
CYTARABINE 100 MG
CYTARABINE 500 MG
DACTINOMYCIN 0.5 MG
DACARBAZINE 100 MG
DACARBAZINE 200 MG
DAUNORUBICIN HCL 10 MG
DAUNORUBICN CITRATE LIPOSOML 10
MG
DENILEUKIN DIFTITOX 300 MCG
DIETHYLSTILBESTROL DIPHOS/250 MG
DOCETAXEL 20 MG
INJECTION ELLIOTTS B SOLUTION 1 ML
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9178
J9180
J9181
J9182
J9185
J9190
J9200
J9201
J9202
J9206
J9208
J9209
J9211
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
J9212
No
INJ INTERFERN ALFAC-1 RECOMB 1 MCG
No
J9213
No
INTERFERON,ALFA-2A,RECOMB/3 MIL U
No
J9214
J9215
J9216
No
No
No
INTERFERON,ALFA-2B,RECOMB,1 MIL U
INTERFERON, ALFA-N3, 250,000 IU
INTERFERON, GAMMA-1B, 3 MIL U
No
No
No
J9217
J9218
No
No
LEUPROLIDE ACET/DEPOT SUSP 7.5 MG
LEUPROLIDE ACETATE PER 1 MG
No
No
J9219
J9225
J9226
J9230
Yes
Yes
Yes
No
LEUPROLIDE ACETATE IMPLANT 65 MG
HISTRELIN IMPLANT 50 MG
HISTRELIN IMPLANT 50 MG
MECHLORETHAMINE HCL/10 MG
No
Yes
Yes
No
Description
INJECTION EPIRUBICIN HCL 2 MG
ETOPOSIDE, 10 MG
ETOPOSIDE 100 MG
FLUDARABINE PHOSPHATE 50 MG
FLUOROURACIL 500 MG
FLOXURIDINE 500 MG
GEMCITABINE HCL 200 MG
GOSERELIN ACETATE IMPLANT/3.6 MG
IRINOTECAN 20 MG
IFOSFAMIDE PER 1 GM
MESNA, 200 MG
IDARUBICIN HYDROCHLORIDE, 5MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9240
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
J9245
J9250
J9260
J9263
No
No
No
No
J9264
J9265
No
No
J9266
J9268
J9270
J9280
J9290
J9291
J9293
J9300
J9310
J9320
J9340
J9350
J9355
J9357
J9360
J9370
J9375
J9380
J9390
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
INJ MELPHALAN HYDROCHLORIDE 50 MG
METHOTREXATE SODIUM 5 MG
METHOTREXATE SODIUM 50 MG
INJECTION OXALIPLATIN 0.5 MG
INJECTION PACLITAXEL PROTEINBOUND
PARTICLES 1 MG
PACLITAXEL 30 MG
PEGASPARGASE, PER SINGLE DOSE
VIAL
PENTOSTATIN PER 10 MG
PLICAMYCIN 2500 MCG
MITOMYCIN 5 MG
MITOMYCIN 20 MG
MITOMYCIN 40 MG
MITOXANTRONE HCL/5 MG
Gemtuzumab ozogamicin, 5 mg
RITUXIMAB 100 MG
STREPTOZOCIN 1 GM
THIOTEPA 15 MG
TOPOTECAN 4 MG
TRASTUZUMAB 10 MG
VALRUBICIN INTRAVESICAL 200 MG
VINBLASTINE SULFATE 1 MG
VINCRISTINE SULFATE 1 MG
VINCRISTINE SULFATE 2 MG
VINCRISTINE SULFATE 5 MG
VINORELBINE TARTRATE, PER 10 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9395
J9600
J9999
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
L0120
L0210
No
No
L0220
L1800
L1810
Yes
No
No
L1815
No
L1820
Yes
L1830
L1902
No
No
L1906
No
L3000
L3030
Yes
No
L3100
Description
INJECTION FULVESTRANT 25 MG
PORFIMER SODIUM 75 MG
NOC ANTINEOPLASTIC DRUGS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
CERV FLEX NON ADJUS (FOAM COLLAR)
THORACIC RIB BELT
THORACIC RIB BELT CUSTOM
FABRICATED
KNEE ORTHOSIS ELASTIC W/STAYS
KO ELASTIC W/JOINTS
KO ELAS/OTH ELAS MAT W/CONDYLAR
PAD
KO ELAST W/CONDYLR PADS&JNT
PRFAB INCL FIT&ADJ
KO IMMOBILIZER CANVAS
LONGITUDINAL
AFO ANKLE GAUNTLET
AFO MULTILIGAMENTUS ANKLE
SUPPORT
No, under $200
No, under $200
No, under $200
No, under $200
No
FT INSRT MOLD UCB, BERKELEY SHELL
FT INSERT FORMED TO PT FT EA
HALLUS-VALGUS NIGHT DYNAMIC
SPLINT
L3140
Yes
FT/ABDUCT ROTATION BAR INCL SHOES
No, under $200
L3150
L3170
No
No
FT/ABDUCT ROTATION BAR/WO SHOES
FT PLASTIC HEEL STABILIZER
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
L3215
No
L3219
No
L3230
L3310
L3320
L3334
L3340
L3350
L3360
L3400
Yes
No
No
No
No
No
No
No
L3410
No
L3420
L3650
L3700
No
No
No
Description
ORTHO FOOTWEAR LADIES SHOE
OXFORD
ORTHO FOOTWEAR MENS SHOE
OXFORD
ORTHO FTWEAR CUST SHOES DPTH
INLAY
LIFT ELEV HEEL/SOLE NEOPRENE/IN
LIFT ELEV HEEL/SOLE CORK/IN
LIFT ELEVATE HEEL PER IN
HEEL WEDGE SACH
HEEL WEDGE
SOLE WEDGE OUTSIDE SOLE
METATARSAL BAR WEDGE ROCKER
METATARSAL BAR WEDGE BETWEEN
SOLE
FULL SOLE & HEEL WEDGE BETWEEN
SOLE
SO FIG 8 DESIGN ABDUCT RESTRAIN
EO ELASTIC W/STAYS
L3807
Yes
WHFO/AIR SUPPRT W/WO THUMB EXTEN
No, under $200
L3908
No
No, under $200
L3909
L3928
No
No
L4350
No
WHO WRIST EXTEN COCK-UP NONMOLD
WRIST ORTHOSIS ELASTIC PREFAB
INCLUDES FIT&ADJ
HFO FINGER EXTEN W/CLOCK SPRING
ANKLE CNTRL ORTHOSIS STIRRUP RIGID
PRFAB FIT&ADJ
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
L4360
L4380
Yes
Yes
L4386
L8000
Yes
No
L8010
No
L8600
Yes
L8603
L8606
L8614
L8619
Yes
No
Yes
Yes
L8623
Yes
L8624
Yes
L8690
Yes
L8691
Yes
L8695
L8699
Yes
Yes
L9900
Yes
Description
WALKING BOOT PNEUMATC W/WO JNTS
PREFAB W/FIT&ADJ
PNEUMATIC KNEE SPLINT
WALKING BOOT NON-PNEUMATC
PREFAB W/FIT&ADJ
BREAST PROSTH MASTECTOMY BRA
BREAST PROSTHESIS MASTECTOMY
SLEEVE
IMPLNT BREAST PROSTH SLCN/EQUAL
COLLAGEN IMPLNT/URIN/2.5CC
SYR/SUPP
INJ SYN IMP URIN TRACT 1 ML SYRNG
Cochlear device/system
Replace cochlear processor
LITHIUM ION BATTERY OTH THAN EAR
LEVEL REPL EA
LITHIUM ION BATTERY EAR LEVEL REPL
EA
AUDITORY OSSEOINTEGRATED DEVC
INT/EXT COMPONENTS
AUDITORY OSSEOINTEGRATD DEVC EXT
SOUND PROC REPL
EXT RECHARGING SYSTEM BATTERY
W/IMPL NEUROSTIM
Prosthetic Implant
ORTHO/PROSTH SUPP ACCES &/OR
SERV
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
NA
NA
No, under $200
No, under $200
No, under $200
No, under $200
No, under $200
NA
No, under $200
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
P3000
No
P3001
P9010
P9011
P9012
P9016
No
No
No
No
No
P9017
P9019
P9020
P9021
No
No
No
No
P9022
No
P9023
No
P9031
P9032
No
No
P9033
P9034
No
No
P9035
No
P9036
No
P9037
No
Description
SCREEN PAP <=3 SMEARS TECH/PHYS
DIR
SCREEN PAP <=3 SMEARS
INTERPT/PHYS
BLOOD (WHOLE)/TRANSFUSION/UNIT
BLOOD (SPLIT UNIT) SPECIFY AMOUNT
CRYOPRECIPITATE EACH UNIT
LEUKOCYTE POOR BLOOD EACH UNIT
FRESH FRZN PLASMA FRZN WITHIN 8
HRS CLCT EA UNIT
PLATELET CONCENTRATE EACH UNIT
PLATELET RICH PLASMA EACH UNIT
RED BLOOD CELLS EACH UNIT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
WASHED RED BLOOD CELLS EACH UNIT
PLASMA POOL SOL/DTRGNT FROZ EA
UNIT
PLATELETS LEUKOCYTES REDUC EA
UNT
PLATELETS IRRADIATED EA UNT
No
PLATELETS LEUKOCYTES REDUC IRRAD
PLATELETS PHERESIS EA UNT
PLATELETS PHERESIS LEUKOCYTES
RED
No
No
PLATELETS PHERESIS IRRADIATED EA
PLTLTS PHERESIS LEUKOCYTS RED
IRRAD
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
P9038
P9039
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
P9040
P9041
P9042
No
No
No
P9043
No
P9044
P9045
P9046
P9047
No
No
No
No
P9048
Description
RED BLD CELLS IRRADIATED EA UNT
RB CELLS DEGLYCEROLIZED EA UNT
RED BLD CELLS LYTES RED IRRADIATED
INFUS ALBUMIN (HUMAN) 5% 50 ML
INFUS PLASMA PROT FRACTION 5% 50
ML
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
PLASMA CRYOPRECIPITATE REDUC EA
INFUSION ALBUMIN 5% 250 ML
INFUSION ALBUMIN 25% 20 ML
INFUSION ALBUMIN 25% 50 ML
INFUS PLASMA PROT FRACTION 5%
250ML
P9050
No
GRANULOCYTES PHERESIS EACH UNIT
No
P9612
P9615
Q0081
Q0083
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
CATH COLLECT SPECMN 1 PT ALL POS
CATH COLLECT SPEC MULT PTS
INFUS THERAP NOT CHEMO/VISIT
CHEMO ADMIN NOT INFUS TECH/VISIT
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Q0084
Not Reimbursable
CHEMO ADMIN INFUS TECH ONLY/VISIT
Not Reimbursable
Q0085
Not Reimbursable
CHEMO ADMIN INFUS & OTH TECH/VISIT
Not Reimbursable
Q0091
Q0092
Not Reimbursable
Not Reimbursable
SCREEN PAP OBTAIN PREP CONVEY LAB
SET-UP PORTABLE X-RAY EQUIPMENT
Not Reimbursable
Not Reimbursable
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Q0111
Q0112
Q0113
Q0114
Q0115
Q0144
Q0156
Q0157
Q0160
Q0161
Q0163
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
No
No
Q0164
No
Q0165
Q0166
No
No
Q0167
Q0168
Q0169
Q0170
No
No
No
No
Q0171
No
Q0172
No
Q0173
No
Q0174
No
Description
WET MOUNTS/PREP VAG/CERV/SKIN
ALL POTASSIUM HYDROXIDE PREP
PINWORM EXAM
FERN TEST
POST-COITAL DIR QUAL EXAM
AZITHROMYCIN DIHYDRATE ORAL-1GM
DIPHENHYDRAMINE HCL 50 MG ORAL
PROCHLORPERAZINE MALEATE 5 MG
ORAL
PROCHLORPERAZINE MALEATE 10 MG
ORAL
GRANISETRON HCL 1 MG ORAL
DRONABINOL 2.5 MG ORAL ANTI-EMETIC
DRONABINOL 5 MG ORAL ANTI-EMETIC
PROMETHAZINE HCL 12.5 MG ORAL
PROMETHAZINE HCL 25 MG ORAL
CHLORPROMAZINE HCL 10 MG ORAL
CHEMO
CHLORPROMAZINE HCL 25 MG ORAL
CHEMO
TRIMETHOBENZAMIDE HCL 250 MG
ORAL
THIETHYLPERAZINE MALEATE 10 MG
ORAL
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Q0175
No
Q0176
Q0177
Q0178
Q0179
No
No
No
No
Description
PERPHENZAINE 4 MG ORAL ANTIEMETIC
PERPHENZAINE 8 MG ORAL ANTIEMETIC
HYDROXYZINE PAMOATE 25 MG ORAL
HYDROXYZINE PAMOATE 50 MG ORAL
ODANSETRON HCL 8 MG ORAL
Q0180
No
DOLASETRON MESYLATE 100 MG ORAL
No
Q0181
No
No
Q0515
No
Q1003
Not Reimbursable
Q1004
Not Reimbursable
Q1005
Not Reimbursable
UNSPEC ORAL DOSE FORM ANTI-EMETIC
INJECTION SERMORELIN ACETATE 1
MICROGRAM
NEW TECH INTRAOCULAR LENS
CATEGORY
NEW TECH INTRAOCULAR LENS
CATEGORY
NEW TECH INTRAOCULAR LENS
CATEGORY
Q2004
Q2009
Q2017
Q3000
No
No
No
No
IRRIG SOLN TX OF BLDR CALCULI 500ML
INJ FOSPHENYTOIN 50 MG
INJ TENIPOSIDE 50 MG
No
No
No
No
Q3001
Q3002
Q3003
Q3004
Not Reimbursable
No
No
No
RADIOELEMENTS FOR BRACHYTHERAP
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Q3005
Q3006
Q3007
Q3008
Q3009
Q3010
Q3011
Q3012
Q3014
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
No
No
No
No
No
No
No
Q3019
Not Reimbursable
Q3020
Q3025
Q3026
Q3031
Not Reimbursable
No
No
Bundled
Q4001
No
Q4002
No
ALS vehicle Emerg transprt no ALS level srvc
ALS vehicle non-Emerg transprt no ALS levl
srvc
IM INJ INTERFERON BETA 1-A
SUB INJ INTERFERON BETA 1-A
COLLAGEN SKIN TEST
CAST BDY CAST ADLT W/WO HEAD
PLAST
CAST BDY CAST ADLT W/WO HEAD FGLSS
Q4003
No
CAST SPL SHLDR CAST ADULT PLASTR
No
Q4004
No
No
Q4005
No
Q4006
No
CAST SPL SHLDR CAST ADULT FIBRGLS
CAST SPL LONG ARM CAST ADULT
PLASTR
CAST SPL LONG ARM CAST ADLT
FIBRGLS
Description
TELEHEALTH ORIG SITE FACILITY FEE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Q4007
No
CAST SPL LNG ARM CAST PED PLASTR
No
Q4008
No
No
Q4009
No
Q4010
No
Q4011
No
Q4012
No
Q4013
No
Q4014
No
CAST SPL LNG ARM CAST PED FIBRGLS
CAST SPL SHORT ARM CAST ADLT
PLASTR
CAST SPL SHRT ARM CAST ADLT
FIBRGLS
CAST SPL SHORT ARM CAST PED
PLASTR
CAST SPL SHORT ARM CAST PED
FIBRGLS
CAST SPL GAUNTLT CAST ADULT
PLASTR
CAST SPL GAUNTLET CAST ADLT FGLASS
Q4015
No
Q4016
No
Q4017
No
Q4018
No
Q4019
No
Q4020
No
Description
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
CAST SPL GAUNTLT CAST PED PLASTR
CAST SPL GAUNTLET CAST PED FGLASS
CAST SPL LNG ARM SPLINT ADLT
PLASTR
CAST SPL LNG ARM SPLNT ADLT
FIBRGLS
No
CAST SPL LNG ARM SPLINT PED PLASTR
CAST SPL LNG ARM SPLINT PED
FIBRGLS
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Q4021
No
Q4022
No
Q4023
No
Q4024
Q4025
Q4026
No
No
No
Q4027
Q4028
No
No
Q4029
No
Q4030
No
CAST SPL HIP SPICA PEDIATRIC PLASTR
CAST SPL HIP SPICA PED FIBRGLS
CAST SPL LONG LEG CAST ADULT
PLASTR
CAST SPL LONG LEG CAST ADLT
FIBRGLS
Q4031
No
CAST SPL LNG LEG CAST PED PLASTR
No
Q4032
No
CAST SPL LNG LEG CAST PED FIBRGLS
No
Q4033
No
No
Q4034
No
CAST LNG LEG CYCLE CAST ADLT PLAST
CAST LNG LEG CYCLE CAST ADLT FGLSS
Q4035
No
CAST LNG LEG CYCLE CAST PED PLAST
No
Q4036
No
CAST LNG LEG CYCLE CAST PED F-GLSS
No
Description
CAST SPL SHRT ARM SPLINT ADLT
PLAST
CAST SPL SHRT ARM SPLNT ADLT FGLSS
CAST SPL SHORT ARM SPLINT PED
PLAST
CAST SPL SHRT ARM SPLNT PED
FIBRGLS
CAST SPL HIP SPICA ADULT PLASTR
CAST SPL HIP SPICA ADULT FIBRGLS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Q4037
No
Q4038
No
Q4039
No
Q4040
No
Q4041
No
Q4042
No
Description
CAST SPL SHORT LEG CAST ADLT
PLASTR
CAST SPL SHRT LEG CAST ADLT
FIBRGLS
CAST SPL SHORT LEG CAST PED
PLASTR
CAST SPL SHORT LEG CAST PED
FIBRGLS
CAST SPL LNG LEG SPLINT ADLT
PLASTR
CAST SPL LNG LEG SPLNT ADLT
FIBRGLS
Q4043
No
CAST SPL LNG LEG SPLINT PED PLASTR
No
Q4044
No
No
Q4045
No
Q4046
No
Q4047
No
Q4048
Q4049
No
No
CAST SPL LNG LEG SPLINT PED FIBRGLS
CAST SPL SHRT LEG SPLINT ADLT
PLAST
CAST SPL SHRT LEG SPLNT ADLT FGLSS
CAST SPL SHORT LEG SPLINT PED
PLAST
CAST SPL SHRT LEG SPLNT PED
FIBRGLS
FINGER SPLINT STATIC
Q4050
Q4051
Q4076
No
No
No
CAST SPL UNLIST TYPES&MATL CASTS
SPLINT SUPPLIES MISCELLANEOUS
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Q4077
Q9951
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
No
No
R0070
R0075
No
No
R0076
Bundled
S0012
S0014
S0017
Not Reimbursable
Not Reimbursable
Not Reimbursable
S0020
S0021
Not Reimbursable
Not Reimbursable
S0023
S0028
S0030
S0032
S0034
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S0039
S0040
S0073
S0074
S0077
S0078
S0079
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
Description
TRANSP PORT X-RAY/PERS/TRIP SNGL
PT
TRANSP PORT X-RAY/PERS MX PT EA
TRANSP PORT EKG/FACIL/LOCATION/PT
BUTORPHANOL TARTRATE NAS SPRAY
25MG
TACRINE HYDROCHLORIDE 10 MG
INJ AMINOCAPROIC ACID 5 GMS
INJ BUPIVICAINE HYDROCHLORIDE 30
ML
INJ CEFTOPERAZONE NA 1 GM
INJ CIMETIDINE HYDROCHLORIDE 300
MG
INJ FAMOTIDINE 20 MG
INJ METRONIDAZOLE 500 MG
INJ NAFCILLIN NA 2 GMS
INJ OFLOXACIN 400 MG
INJ
SULFAMETHOXAZOLE/TRIMETHOPRIM
INJ TICARCILLIN/CLAVULANATE 3.1 GM
INJ AZTREONAM 500 MG
INJ CEFOTETAN DINA 500 MG
INJ CLINDAMYCIN PHOSPHATE 300 MG
INJ FOSPHENYTOIN NA 750 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S0080
S0081
S0087
S0088
S0090
S0091
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
S0092
No
S0093
S0104
No
No
S0106
S0107
S0108
S0114
S0115
S0116
S0122
S0126
S0128
S0130
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
S0132
S0135
S0136
S0137
S0138
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
INJ PENTAMIDINE ISETHIONATE 300 MG
INJ PIPERACILLIN NA 500 MG
IMATINIB 100 MG
SILDENAFIL CITRATE 25 MG
GRANISETRON HYDROCHLORIDE 1 MG
INJECTION HYDROMORPHONE HCL 250
MG
INJECTION MORPHINE SULFATE 500 MG
ZIDOVUDINE, ORAL, 100 MG
BUPROPION HCI SUSTAINED RLSE TAB
150 MG 60 TABS
MERCAPTOPURINE ORAL 50 MG
INJECTION MENOTROPINS 75 IU
INJECTION FOLLITROPIN ALFA 75 IU
INJECTION FOLLITROPIN BETA 75 IU
INJECTION GANIRELIX ACETATE 250
MCG
CLOZAPINE 25 MG
DIDANOSINE 25 MG
FINASTERIDE 5 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
S0139
S0140
S0141
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
Not Reimbursable
No
Not Reimbursable
S0147
Yes
S0155
S0156
S0157
S0158
S0159
No
No
No
No
No
S0160
S0161
S0162
No
No
No
S0164
S0170
S0171
S0172
S0173
S0174
S0175
S0176
No
No
No
No
No
No
No
No
S0177
S0178
S0179
No
No
No
Description
MINOXIDIL 10 MG
ZALCITABINE 0375 MG
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
No
Not Reimbursable
INJECTION ALGLUCOSIDASE ALFA 20 MG
STERILE DILUTANT EPOPROSTENOL 50
ML
EXEMESTANE 25 MG
BECAPLERMIN GEL 0.01% 0.5 GM
Yes
DEXTROAMPHETAMINE SULFATE 5 MG
CALCITROL 0.25 MG
INJECTION EFALIZUMAB 125 MG
INJECTION PANTOPRAZOLE SODIUM 40
MG
ANASTROZOLE ORAL 1 MG
INJECTION BUMETANIDE 0.5 MG
CHLORAMBUCIL ORAL 2 MG
No
No
No
DOLASETRON MESYLATE ORAL 50 MG
FLUTAMIDE ORAL 125 MG
HYDROXYUREA ORAL 500 MG
LEVAMISOLE HYDROCHLORIDE ORAL 50
MG
LOMUSTINE ORAL 10 MG
MEGESTROL ACETATE ORAL 20 MG
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S0181
No
S0182
No
S0183
S0187
S0189
S0190
S0191
No
No
No
No
No
S0194
Not Reimbursable
S0195
Not Reimbursable
S0201
Not Reimbursable
S0207
Not Reimbursable
S0265
No
S0315
S0316
Not Reimbursable
Not Reimbursable
S0317
Not Reimbursable
S0320
S0390
Not Reimbursable
Not Reimbursable
Description
ONDANSETRON HYDROCHLORIDE ORAL
4 MG
PROCARBAZINE HYDROCHLORD ORAL
50 MG
PROCHLORPERAZINE MALEATE ORAL 5
MG
TAMOXIFEN CITRATE ORAL 10 MG
TESTOSTERONE PELLET 75 MG
MITEPRISTONE, ORAL, 200 MG
MISOPROSTOL, ORAL 200 MCG
DIALYSIS/STRESS VITAMIN SUPL ORAL
100 CAPSULES
PNEUMCOCCL CONJUGAT VAC IM 5-9 YR
NOT PREV RECVD
PARTIAL HOSITALIZTION SERVICES < 24
HR PER DIEM
PARAMEDIC INTERCPT NON-HOSP ALS
SRVC NON-TRNSPRT
GENETIC COUNSELING PHYS
SUPERVISION EA 15 MINS
DISEASE MANAGEMENT PROGM; INIT
ASSESS&INIT PROGM
FOLLOW-UP/REASSESSMENT
DISEASE MANAGEMENT PROGRAM; PER
DIEM
TEL CALL BY RN TO DZ MGMT PROG
MEMBER MON;-MONTH
ROUTINE FOOT CARE; PER VISIT
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S1040
Not Reimbursable
S2070
Not Reimbursable
S2078
Yes
S2079
Yes
S2083
Not Reimbursable
S2095
Not Reimbursable
S2107
Not Reimbursable
S2135
Not Reimbursable
S2152
Not Reimbursable
S2213
S2225
Not Reimbursable
Not Reimbursable
S2230
Not Reimbursable
S2235
Not Reimbursable
S2262
Not Reimbursable
Description
CRANIL REMOLD ORTHOS RIGD
W/INTERFCE MATL CSTM
CYSTO
W/URETERSCPY&/PYELSCPY;LASR TX
URETRL CALC
LAP SUPRACERVICAL HYST W/ W/O
REMV TUBE OVARY
LAP ESOPHAGOMYOTOMY HELLER TYPE
ADJ GASTRIC BAND DIAM SUBQ PORT
INJ/ASPIR SALINE
TRNSCATH OCCL/EMBOLIZ TUMR
DESTRUC PERQ METH USI
ADOPTIVE IMMUNOTHERAPY PER
COURSE OF TREATMENT
NEUROLYSIS INJ MT
NEUROMA/INTERDIGTL NEURITIS IN
SOLID ORGAN; TRANSPLANTATION &
RELATED COMP
IMPLANTATION OF GASTRIC E-STIM
DEVICE
MYRINGOTOMY LASER-ASSISTED
IMPL MAGNET CMPNT SEMI-IMPL
HEARING DEVC MID EAR
IMPLANTATION OF AUDITORY BRAIN
STEM IMPLANT
ABORTION MATERNAL INDICATION 25
WEEKS OR GREATER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S2265
Not Reimbursable
S2266
Not Reimbursable
S2267
S2325
Not Reimbursable
Yes
S2344
Not Reimbursable
S2362
Not Reimbursable
S2363
Not Reimbursable
S2405
Not Reimbursable
S2900
No
S3000
Not Reimbursable
S3625
Not Reimbursable
S3626
S3655
No
Not Reimbursable
S3820
Not Reimbursable
S3822
Not Reimbursable
Description
ABORTION FOR FETAL INDICATION 25-28
WEEKS
ABORTION FOR FETAL INDICATION 29-31
WEEKS
ABORTION FETAL INDICATION 32 WEEKS
OR GREATER
HIP CORE DECOMPRESSION
NASAL/SINUS ENDO; ENLARGE OSTIUM
INFLAT DEVICE
KYPHOPLASTY 1 VERT BODY
UNILAT/BILAT INJECTION
KYPHPLSTY 1 VERT BDY UNILAT/BILAT
INJ; EA ADD VE
REPR SACROCOC TERATOMA FETUS IN
UTERO
SURG TECHNIQUES REQUIRING USE
ROBOTIC SURG SYS
DIABETIC INDICATOR; RETINAL EYE
EXAM DILAT BILAT
MATERNL SERUM TRIPLE MARKR SCR
W/AFP ESTRIOL&HCG
MATERNAL SERUM SCR W/AFP ESTRIOL
HCG INHIBIN A
ANTISPERM ANTIBODIES TEST
COMPL BRCA1&BRCA2 GENE SEQ
ANALY BRST&OVARN CA
SINGLE-MUTAT ANALY SUSCEPT
BREAST&OVARIAN CANCER
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S3823
Not Reimbursable
S3828
Not Reimbursable
S3829
Not Reimbursable
S3833
Not Reimbursable
S3834
Not Reimbursable
S3840
Not Reimbursable
S3841
Not Reimbursable
S3842
Not Reimbursable
S3843
Not Reimbursable
S3844
Not Reimbursable
S3845
Not Reimbursable
S3846
Not Reimbursable
S3847
Not Reimbursable
S3848
Not Reimbursable
Description
3-MUTATION BRCA1&BRCA2 ANALYSIS
ASHKENAZI IND
COMPLETE GENE SEQUENCE ANALYSIS;
MLH1 GENE
COMPLETE GENE SEQUENCE ANALYSIS;
MLH2 GENE
CMPL APC GENE SEQ ANALY SUSCPT
FAP&ATTENUATD FAP
SINGLE-MUTAT ANALY SUSCEPT
FAP&ATTENUATED FAP
DNA ANALYSIS GERMLINE MUTATS RET
PROTO-ONCOGENE
GENETIC TESTING FOR
RETINOBLASTOMA
GENETIC TESTING FOR VON HIPPELLINDAU DISEASE
DNA ANALYSIS F5 GENE FCT V LEIDEN
THROMBOPHILIA
DNA ANALY CONNEXIN 26 GENE CONGN
PFND DEAFNESS
GENETIC TESTING FOR ALPHATHALASSEMIA
GENETIC TESTING HEMOGLOBIN E BETATHALASSEMIA
GENETIC TESTING FOR TAY-SACHS
DISEASE
GENETIC TESTING FOR GAUCHER
DISEASE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S3849
Not Reimbursable
S3850
Not Reimbursable
S3851
Not Reimbursable
S3852
Not Reimbursable
S3853
Not Reimbursable
S3854
Not Reimbursable
S3855
Not Reimbursable
S3890
Not Reimbursable
S4013
Not Reimbursable
S4014
Not Reimbursable
S4017
Not Reimbursable
S4023
Not Reimbursable
S4035
S4036
Not Reimbursable
Not Reimbursable
S4037
Not Reimbursable
Description
GENETIC TESTING FOR NIEMANN-PICK
DISEASES
GENETIC TESTING FOR SICKLE CELL
ANEMIA
GENETIC TESTING FOR CANAVAN
DISEASE
DNA ANALY APOE EPSILON 4 ALLELE
SUSECPT ALZS DZ
GENETIC TESTING FOR MYOTONIC
MUSCULAR DYSTROPHY
GENE EXPRSSGENE EXPRSSION
PROFILING PANL MGMT BR
GENETIC TEST DETECT MUTATIONS
PRESENILIN 1 GENE
DNA ANALYSIS FECAL COLORECTAL
CANCER SCREENING
CMPL CYCLE GAMETE INTRAFALLOPIAN
TRNSF CASE RATE
CMPL CYCLE ZYGOTE INTRAFALLOPIAN
TRNSF CASE RATE
INCPL CYCLE TX CANCELED PRIOR TO
STIM CASE RATE
DONOR EGG CYCLE INCOMPLETE CASE
RATE
STIM INTRAUTERINE INSEMINATION
CASE RATE
INTRAVAGINAL CULTURE CASE RATE
CRYOPRESERVED EMBRYO TRANSFER
CASE RATE
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S4040
S4995
S5000
S5001
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5010
No
S5011
No
S5012
No
S5013
No
S5014
No
S5100
Not Reimbursable
S5101
Not Reimbursable
S5102
Not Reimbursable
S5105
Not Reimbursable
S5108
Not Reimbursable
S5109
Not Reimbursable
S5110
Not Reimbursable
Description
MON & STORAGE CRYOPRESERVED
EMBRYOS PER 30 DAYS
SMOKING CESSATION GUM
SCRIPT DRUG GENERIC
SCRIPT DRUG BRAND NAME
5% DEXTROSE AND 45% NORM SAL
1000ML
5% DEXTROSE-LACTATD RINGER S
1000ML
5% DEXTROSE W/POT CHLORIDE 1000
ML
5% DEXTROSE/45% NORM
SALINE/1000ML
5% DEXTROSE/45% NORM
SALINE/1500ML
DAY CARE SERVICES ADULT; PER 15
MINUTES
DAY CARE SERVICES ADULT; PER HALF
DAY
DAY CARE SERVICES, ADULT; PER DIEM
DAY CARE SRVC CENTER-BASED; NOT
W/PROG FEE-DIEM
HOME CARE TRAINING HOME CARE
CLIENT PER 15 MIN
HOME CARE TRAINING HOME CARE
CLIENT PER SESSION
HOME CARE TRAINING FAMILY; PER 15
MINUTES
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S5111
Not Reimbursable
S5115
Not Reimbursable
S5116
S5120
S5121
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5126
Not Reimbursable
S5130
Not Reimbursable
S5131
Not Reimbursable
S5135
S5136
S5140
S5141
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
S5145
Not Reimbursable
S5146
Not Reimbursable
S5150
Not Reimbursable
S5151
Not Reimbursable
S5160
Not Reimbursable
Description
HOME CARE TRAINING FAMILY; PER
SESSION
HOME CARE TRAINING NON-FAMILY; PER
15 MINUTES
HOME CARE TRAINING NON-FAMILY; PER
SESSION
CHORE SERVICES; PER 15 MINUTES
CHORE SERVICES; PER DIEM
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
ATTENDANT CARE SERVICES; PER DIEM
HOMEMAKER SERVICE NOS; PER 15
MINUTES
Not Reimbursable
HOMEMAKER SERVICE, NOS; PER DIEM
COMPANION CARE ADULT ; PER 15
MINUTES
COMPANION CARE, ADULT ; PER DIEM
FOSTER CARE, ADULT; PER DIEM
FOSTER CARE, ADULT; PER MONTH
FOSTER CARE THERAPEUTIC CHILD;
PER DIEM
FOSTER CARE THERAPEUTIC CHILD;
PER MONTH
UNSKILLED RESPITE CARE NOT
HOSPICE; PER 15 MIN
UNSKILLED RESPITE CARE NOT
HOSPICE; PER DIEM
EMERGENCY RESPONSE SYSTEM;
INSTALLATION&TESTING
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children’s Health Insurance Plan (SCHIP), Basic
Health Plan Plus (BH+), Washington Medicaid Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Prior Authorization Required
Outpatient Facility Place of
Serivce 22, 24 effective
November 2008
S5161
Not Reimbursable
S5162
Not Reimbursable
Description
EMERGENCY RESPONSE SYSTEM;
SERVICE FEE PER MONTH
EMERGENCY RESPONSE SYSTEM;
PURCHASE ONLY
Prior Authorization
Required Office Setting
Place of Service 11, 20
effective November 2008
Not Reimbursable
Not Reimbursable
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment
is subject to eligibility and benefits at the time of service. Claim processing edits will apply.