PA by CPT code effective 01-01-09(1)

This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00100
00102
00103
00104
00120
00124
00126
00140
00142
00144
00145
00147
00148
00160
00162
00164
00170
00172
00174
00176
00190
00192
00210
00212
00214
00215
00216
00218
00220
00222
00300
00320
00322
00326
00350
00352
00400
00402
00404
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
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
ANES- EXT/MID/INNER EAR W/BX; OTOSC
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
ANES- NOSE/ACCES SINUSES; BX TISS
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
ANES- INTRACRAN PROC; SUBDURAL TAPS
ANES-CRAN; BURR HOLES-VENTRICOGRPHY
ANES- INTRACRAN; ELEVAT SKULL FX
ANES- INTRACRAN PROC; VASCULAR PROC
ANES- INTRACRAN; PROC SITTING POSIT
ANES- INTRACRAN; SPINAL FLUID SHUNT
ANES- INTRACRAN; ELECTROCOAG NERV
ANES-INTEG-MUSC/NRV-HEAD/TRUNK-NOS
ANES- PROC ESOPHA/THYROID/TRAC; NOS
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
ANES-INTEG-TRUNK; RAD BREAST PROC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00406
00410
00450
00452
00454
00470
00472
00474
00500
00520
00522
00524
00528
00529
00530
00532
00534
00537
00539
00540
00541
00542
00546
00548
00550
00560
00562
00563
00566
00580
00600
00604
00620
00622
00625
00626
00630
00632
00634
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANES-INTEG; RAD BRST W/NODE DISSEC
ANES-INTEG SYS-TRNK; CONVERT ARRYTH
ANES- CLAV & SCAPULA; NOS
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
ANES-CLO CHEST; (INCL BRONCH) NOS
ANES-CLO CHEST; NEEDLE BX PLEURA
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
ANES- TRANSVENOUS INSRT CARDIOVERT
ANES-CARDIAC ELECTROPHYSIOLOGIC PROC
ANESTHESIA FOR TRACHEOBRONCHIAL RECONSTRUCTION
ANES- THORACOT W/LUNGS; NOS
ANES-THORACOT PROC; UTILIZING 1 LUNG VENTILATION
ANES- THORACOT W/LUNGS; DECORTIC
ANES- THORACOT W/LUNGS; THORACOPLST
ANES- THORCOT W/LUNGS; INTHOR TRACH
ANES-STERNAL DEBRID
ANES- HEART; WO PUMP OXYGENATOR
ANES- HEART; W/ PUMP OXYGENATOR
ANES-W PUMP OXYGENATOR W HYPOTHERM CIRCU ARREST
ANES-DIRECT CORONARY ARTERY BYPASS GRAFT
ANES- HEART TRANSPL OR HEART/LUNG
ANES- CERV SPINE & CORD; NOS
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00635
00640
00670
00700
00702
00730
00740
00750
00752
00754
00756
00770
00790
00792
00794
00796
00797
00800
00802
00810
00820
00830
00832
00834
00836
00840
00842
00844
00846
00848
00851
00860
00862
00864
00865
00866
00868
00870
00872
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
ANES- HERNIA REPR UPPER ABD; NOS
ANES- HERNIA REPR UP ABD; & DEHISCE
ANES- HERNIA REPR UP ABD; OMPHALOCE
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
ANES- HERNIA REPR LOWER ABD; NOS
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
ANES- INTRAPERITONEAL LO ABD; NOS
ANES- INTRAPERITONEAL LO ABD; AMNIO
ANES- INTRAPERITONEAL; ABD-PERINEAL
ANES- INTRAPERITONL W/LAP; RAD HYST
ANES- INTRAPERITONEAL; PELVIC EXENT
ANES- STERILIZATIONS
ANES- EXTRAPERITONEAL URINARY; NOS
ANES- EXTRAPERIT; UP 1/3 URETER
ANES- EXTRAPERIT; TOT CYSTECTOMY
ANES- EXTRAPERIT; RAD PROSTATECTOMY
ANES- EXTRAPERIT; ADRENALECTOMY
ANES- EXTRAPERIT; RENAL TRANSPL
ANES- EXTRAPERIT; CYSTOLITHTOMY
ANES- LITH EXTRACORPOR; W/H2O BATH
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
00873
00880
00882
00902
00904
00906
00908
00910
00912
00914
00916
00918
00920
00921
00922
00924
00926
00928
00930
00932
00934
00936
00938
00940
00942
00944
00948
00950
00952
01112
01120
01130
01140
01150
01160
01170
01173
01180
01190
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANES- LITH EXTRACORPOR; WO H2O BATH
ANES- MAJOR LOWER ABD VESSELS; NOS
ANES- MAJOR VESS; INFER VENA CAVA
ANES- PERINEAL INTEG; ANORECTAL
ANES- PERINEAL INTEG; RAD PERINEAL
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
ANES- MALE EXT GENIT; SEMINAL VESIC
ANES-MALE GNT INCL OP URETH; VASECT UNILAT/BILAT
ANES- MALE EXT GENIT; SEMINAL VESIC
ANES- MALE; UNDESCEN TESTIS UNI/BIL
ANES- MALE; RAD ORCHIECTOMY ING
ANES- MALE; RAD ORCHIECTOMY ABD
ANES- MALE; ORCHIOPEXY UNI/BILAT
ANES- MALE; COMPLT AMPUT PENIS
ANES- MALE; RAD AMP PENIS ING LYMPH
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
ANES- INTERPELVIABDOMINAL AMPUTA
ANES- RAD PROC TUMOR PELV EX AMPUT
ANES- CLO PROC W/S PUBIS/SACROIL JT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
01200
01202
01210
01212
01214
01215
01220
01230
01232
01234
01250
01260
01270
01272
01274
01320
01340
01360
01380
01382
01390
01392
01400
01402
01404
01420
01430
01432
01440
01442
01444
01462
01464
01470
01472
01474
01480
01482
01484
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANES- ALL CLO PROC INVOLV HIP JT
ANES- ARTHROSCOPIC PROC HIP JT
ANES- OPEN PROC INVOLV HIP JT; NOS
ANES- OPEN PROC INVOLV HIP; DISART
ANES- OPEN HIP; TOT HIP REPLC/REVIS
ANES- REVIS OF TOTAL HIP ANTHROPSCOPY
ANES- ALL CLO INVOLV UP 2/3 FEMUR
ANES- OPEN INVOLV UP 2/3 FEMUR; NOS
ANES- OPEN UPPER 2/3 FEMUR; AMPUTA
ANES- OPEN UP 2/3 FEMUR; RAD RESECT
ANES- ALL NERV/MUSCL/FASCIA UP LEG
ANES- ALL INVOLV VEIN UP LEG W/EXPL
ANES- INVOLV ART UP LEG W/GFT; NOS
ANES- INVOLV ART LEG W/GFT; FEM LIG
ANES- INVOLV ART LEG W/GFT; FEM EMB
ANES- NERV/MUSCL/BURSAE KNEE/POP
ANES- ALL CLO PROC LOWER 1/3 FEMUR
ANES- ALL OPEN PROC LOWER 1/3 FEMUR
ANES- ALL CLO PROC KNEE JT
ANES- ARTHROSCOPIC PROC KNEE JT
ANES- ALL CLO UP ENDS TIB/FIB/PATEL
ANES- ALL OPEN UP END TIB/FIB/PATEL
ANES- OPEN PROC KNEE JT; NOS
ANES- OPEN KNEE JT; TOT KNEE REPLAC
ANES- OPEN KNEE JT; DISART AT KNEE
ANES- ALL CAST APPLIC/REPR W/KNEE
ANES- VEINS KNEE & POP AREA; NOS
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
ANES- NERV LO LEG; REPR ACHILLES
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
01486
01490
01500
01502
01520
01522
01610
01620
01622
01630
01632
01634
01636
01638
01650
01652
01654
01656
01670
01680
01682
01710
01712
01714
01716
01730
01732
01740
01742
01744
01756
01758
01760
01770
01772
01780
01782
01810
01820
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANES- OPEN BON LO LEG; TOT ANK REPL
ANES- LO LEG CAST APPLIC/REMOV/REPR
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
ANES- ALL CLO HUMERAL/AC/SHLDR JT
ANES- ARTHROSCOPIC PROC SHOULDER JT
ANES- OPEN HUMERAL/AC/SHLDR JT; NOS
ANES- OPEN HUMER/AC JT; RAD RESECT
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
ANES- ART SHLDR & AXIL; BYPASS GFT
ANES- ART SHLDR & AX; AX-FEM BYPASS
ANES- ALL VEINS SHLDR & AXILLA
ANES- SHLDR CAST APPLIC REPR; NOS
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
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
ANES- ART UPPER ARM & ELBOW; NOS
ANES- ART UP ARM/ELBOW; EMBOLECTOMY
ANES- VEINS UPPER ARM & ELBOW; NOS
ANES- VEINS UP ARM; PHLEBORRHAPHY
ANES- ALL NERV/MUSCL FOREARM/HAND
ANES- ALL CLO RADIUS/ULNA/HAND BONE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
01829
01830
01832
01840
01842
01844
01850
01852
01860
01905
01916
01920
01922
01924
01925
01926
01930
01931
01932
01933
01951
01952
01953
01958
01960
01961
01962
01963
01965
01966
01967
01968
01969
01990
01991
01992
01995
01996
01999
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PROC WRIST
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
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
ANES-DX/TX NRV BLKS&INJ; PRONE PSTN
REGIONL IV ADMIN LOCAL ANES/OTH MED
ANES- DA MGMT EPIDUR DRUG ADMIN
UNLISTED ANES PROC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
10021
10022
10040
10060
10061
10080
10081
10120
10121
10140
10160
10180
11000
11001
11004
11005
11006
11008
11010
11011
11012
11040
11041
11042
11043
11044
11055
11056
11057
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
INCS & REMOV FB SUBQ TISS; COMPLIC
I&D HEMATOMA/SEROMA/FLUID COLLEC
PUNCT ASPIR ABSCES/HEMAT/BULLA/CYST
I&D COMPLX POSTOP WOUND INFEC
DEBRID EXTEN INFEC SKIN; TO 10% SUR
DEBRID EXTEN INFEC SKIN; EA AD 10%
DEBRID SKN SUBQ TISS MUSC&FASC; EXT GENITL&PERIN
DEBRID SKN SUBQ TISS MUSC&FASC; ABD WALL
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-SUBQ-MUSC
DEBRID W/REMOV MAT; SKIN-MUSC-BONE
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
SHAVING 1 LES SCALP; 0.6 TO 1.0 CM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
EXC SKIN HIDRADEN AX; SIMPL/INTERM
EXC SKIN HIDRADEN AX; COMPLX REPR
EXC SKIN HIDRADEN ING; SIMPL/INTERM
EXC SKIN HIDRADEN ING; COMPLX REPR
EXC SKIN HIDRADEN PERIANAL; SIMPL
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
11623
11624
11626
11640
11641
11642
11643
11644
11646
11719
11720
11721
11730
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
11920
11921
11922
11950
11951
11952
11954
11960
11970
11971
11975
11976
11977
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Not Reimbursable
YES
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Not Reimbursable
No
Not Reimbursable
Description
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
DEBRID NAIL(S) ANY METHD(S); 6/MORE
AVULSION PLATE PART/COMPLT SIMPL; 1
AVULSION PLATE PART/COMPLT SMPL; EA
EVACUATION SUBUNGUAL HEMATOMA
EXC NAIL/MATRIX PART/COMPLT PERM
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
Not Reimbursable
YES
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
11980
11981
11982
11983
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
SUBQ HORMONE PELLET IMPLNT
INSRT NON-BIODEGRADABLE RX DEL IMPL
REMV NON-BIODEGRADABLE RX DEL IMPL
REMV REINS NONBIODEGRAD RX DEL IMPL
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
SIMPL REPR SCLP/TRUNK; 12.6-20.0 CM
SIMPL REPR SCLP/TRUNK; 20.1-30.0 CM
SIMPL REPR SCLP/TRUNK; OVER 30.0 CM
SIMPL REPR FACE/MUCOUS; 2.5/LESS
SIMPL REPR FACE/MUCOUS; 2.6-5.0 CM
SIMPL REPR FACE/MUCOUS; 5.1-7.5 CM
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
SIMPL REPR FACE/MUCOUS; OVER 30.0
TX SUPERF WOUND DEHISCENCE; SIMPL
TX SUPERF WOUND DEHISCENCE; W/PACK
LAYER CLO SCLP/TRUNK; 2.5 CM/LESS
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
LAYER CLO SCLP/TRUNK; OVER 30.0 CM
LAYER CLO NECK/FT/GENIT; 2.5CM/LESS
LAYER CLO NECK/FT/GENIT; 2.6 TO 7.5
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
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
REPR COMPLX TRUNK; 1.1 CM TO 2.5 CM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14300
14350
15000
15001
15002
15003
15004
15005
15040
15050
15100
15101
15110
15111
15115
15116
15120
15121
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Description
REPR COMPLX TRUNK; 2.6 CM TO 7.5 CM
REPR COMPLX-TRUNK; EA ADD 5 CM/LESS
REPR COMPLX SCLP/EXTREM; 1.1-2.5 CM
REPR COMPLX SCLP/EXTREM; 2.6-7.5 CM
REPR CMPLX-SCLP/ARM/LEG; EA AD 5 CM
REPR COMPLX FOREHEAD/AX/FT; 1.1-2.5
REPR COMPLX FOREHEAD/AX/FT; 2.6-7.5
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
SECNDRY CLO DEHISCENCE COMPLIC
ADJAC TISS TRANSF TRUNK; 10 SQ CM
ADJAC TISS TRANSF TRUNK; 10.1-30.0
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
ADJAC TRANSF > 30.0 SQ CM COMPLIC
FILLETED FINGER/TOE FLP W/PREP SITE
SURG PREP RECIP SITE; 1ST 100/1%
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
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%
SPLT GFT FACE; EA ADD 100/EA ADD 1%
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15130
15131
15135
15136
15150
15151
15152
15155
15156
15157
15170
15171
15175
15176
15200
15201
15220
15221
15240
15241
15260
15261
15300
15301
15320
15321
15330
15331
15335
15336
15340
15341
15360
15361
15365
15366
15400
15401
15420
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Description
DRM AGRFT T/A/L 1ST 100 CM
DRM AGRFT T/A/L EA 100 CM/EA
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
CLTR EPIDRM AGRFT T/A/L 1ST 25 CM/<
CLTR EPIDRM AGRFT T/A/L ADDL 1 CM-75 CM
CLTR EPIDRM AGRFT T/A/L EA 100 CM/EA 1 % BDY
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
FULL THICK GFT TRUNK; 20 SQ CM/LESS
FULL THICK GFT TRUNK; EA AD 20 SQ
FULL THICK GFT SCLP; 20 SQ CM/LESS
FULL THICK GFT SCLP; EA AD 20 SQ CM
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
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15421
15430
15431
15570
15572
15574
15576
15600
15610
15620
15630
15650
15731
15732
15734
15736
15738
15740
15750
15756
15757
15758
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15819
15820
15821
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
Yes
Yes
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
XENOGRF SKN TEMP CLSR F/S/N/H/F/G/M/D EA 100CM
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
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
DELAY FLAP/SECT; LIDS/NOSE/EARS/LIP
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15822
15823
15824
15825
15826
15828
15829
15830
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841
15842
15845
15847
15850
15851
15852
15860
15876
15877
15878
15879
15920
15922
15931
15933
15934
15935
15936
15937
15940
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Not Reimbursable
Bundled
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
BLEPHAROPLASTY UPPER EYELID
BLEPHAROPLASTY UPPER; W/EXCESS SKIN
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
EXC EXCESS SKIN/SUBQ TISS; BUTTOCK
EXC EXCESS SKIN/SUBQ TISS; ARM
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; MUSCL-MICRO
GFT FACE NERV PARALYS; MUSCL TRANSF
EXC SKIN ABD ADD-ON
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
SUCTION ASSISTED LIPECTOMY; TRUNK
SUCTION ASSIST LIPECTOMY; UP EXTREM
SUCTION ASSIST LIPECTOMY; LO EXTREM
EXC COCCYGEAL ULCER; PRIM SUTURE
EXC COCCYGEAL ULCER; FLAP CLO
EXC SACRAL PRESS ULCER W/PRIM SUTUR
EXC SACRAL ULCER W/SUTUR; W/OSTECT
EXC SACRAL ULCER W/SKIN FLAP CLO
EXC SACRAL ULCER W/FLAP; W/OSTECT
EXC SACRAL ULCR PREP-FLAP/SKIN GFT;
EXC SACRL ULCR PREP-FLP/GFT; OSTECT
EXC ISCHIAL ULCER W/PRIM SUTURE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
Bundled
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
EXC ISCHIAL ULCER W/SUTUR; W/OSTECT
EXC ISCHIAL ULCER W/SKIN FLAP CLO
EXC ISCHIAL ULCER W/FLAP; W/OSTECT
EXC ISCH ULCER-OSTECT PREP-FLAP/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
INIT TX 1ST DEGREE BURN W/LOCAL TX
DSG/DEBRID INIT/SUBSQT; WO ANES SM
DSG/DEBRID INIT/SUBSQT; WO ANES MED
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
DESTRCT-ANY METHD-BEN LES; 2-14, EA
DESTRCT-ANY METHD-BEN LES 15/> LES
DESTRCT CUT VASCUL LES; < 10 SQ CM
DESTRCT CUT VASCUL LES; 10-50 SQ CM
DESTRCT CUT VASCUL LES; > 50 SQ CM
DESTRCT WARTS/MOLLUSCUM TO 14 LES
DESTRCT WARTS/MOLLUSCUM; 15/> LES
CHEM CAUT GRANULATION TISS
DESTRCT MALIG LES TRUNK; 0.5/LESS
DESTRCT MALIG LES TRUNK; 0.6-1.0 CM
DESTRCT MALIG LES TRUNK; 1.1-2.0 CM
DESTRCT MALIG LES TRUNK; 2.1-3.0 CM
DESTRCT MALIG LES TRUNK; 3.1-4.0 CM
DESTRCT MALIG LES TRUNK; > 4.0 CM
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
DESTRCT MALIG LES SCLP; OVER 4.0 CM
DESTRCT MALIG LES FACE; 0.5 CM/LESS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
17281
17282
17283
17284
17286
17304
17305
17306
17307
17310
17311
17312
17313
17314
17315
17340
17360
17380
17999
19000
19001
19020
19030
19100
19101
19102
19103
19105
19110
19112
19120
19125
19126
19140
19160
19162
19180
19182
19200
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
Yes
No
No
Yes
No
No
No
No
No
Not Reimbursable
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
DESTRCT MALIG LES FACE; 0.6-1.0 CM
DESTRCT MALIG LES FACE; 1.1-2.0 CM
DESTRCT MALIG LES FACE; 2.1-3.0 CM
DESTRCT MALIG LES FACE; 3.0-4.0 CM
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
19220
19240
19260
19271
19272
19290
19291
19295
19296
19297
19298
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
19396
19499
20000
20005
20100
20101
20102
20103
20150
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20526
20550
20551
20552
20553
20555
20600
20605
20610
20612
20615
20650
20660
20661
20662
20663
20664
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Yes
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
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
Description
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
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
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
ARTHROCENTESIS/ASPIR/INJ; INTERM JT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
20665
20670
20680
20690
20692
20693
20694
20802
20805
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20975
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Bundled
Yes
Bundled
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
REPLANTATION ARM; COMPLT AMPUTA
REPLANTATION FOREARM; COMPLT AMPUTA
REPLANTATION HAND; COMPLT AMPUTA
REPLANTATION DIGIT (MCP JT); COMPLT
REPLANT DIGIT (DISTAL TIP); COMPLT
REPLANT THUMB (CM-MP JT); COMPLT
REPLANT THUMB (DISTAL TIP); COMPLT
REPLANTATION FT; COMPLT AMPUTA
BONE GFT ANY DONOR AREA; MINOR/SM
BONE GFT ANY DONOR AREA; MAJOR/LG
CARTILAGE GFT; COSTOCHONDRAL
CARTILAGE GFT; NASAL SEPTUM
FASCIA LATA GFT; BY STRIPPER
FASCIA LATA GFT; INCS & AREA EXPOSU
TENDON GFT FROM A DISTANCE
TISS GFT OTHER
ALLOGFT SPINE SURG ONLY; MORSELIZED
ALLOGFT SPINE SURG ONLY; STRUCTURAL
AUTOGFT SPIN SURG; LOCAL-SAME INCIS
AUTOGFT SPINE SURG ONLY; MORSELIZED
AUTOGFT SPIN SURG; STRUC/BI-TRICORT
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
ELEC STIM-AID BONE HEAL; NONINVASIV
ELEC STIM-AID BONE HEAL; INVASIVE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
No
Bundled
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
20979
20982
20985
20986
20987
20999
21010
21015
21025
21026
21029
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21073
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
US STIM-AID BONE HEALING-NONINVAS
ABLATION BONE TUMOR RADIOFREQ PERQ CT GUID
CPTR-ASST DIR MS PX
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; INTRA-ORAL OSTEOTOMY
EXC BEN CYST/TUMOR MANDIB; EXTRA-ORAL OSTEOTOMY
EXC BEN CYST/TUMOR MAXILLA; INTRA-ORAL OSTEOTOMY
EXC BEN CYST/TUMOR MAXILLA; EXTRA-ORAL 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
IMPRESS/CUST PREP; MANDIB RESECT
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
IMPRESS/CUST PREP; NASAL PROSTH
IMPRESS/CUST PREP; FACIAL PROSTH
UNLISTED MAXILLOFACIAL PROSTH PROC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
APPLIC HALO-MAXILLOFAC (SEP PRO)
APPLIC INTERDENTAL DEVICE-NOT FX
INJ PROC TMJ ARTHROGRAPHY
GENIOPLASTY; AUGMEN
GENIOPLASTY; SLIDING OSTEOTOMY 1
GENIOPLASTY; SLIDING OSTEOT 2/MORE
GENIOPLASTY; SLIDING AUGMEN W/GFT
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
RECON MIDFACE LEFORT I; 3/> WO GFT
RECON MIDFACE LEFORT I; 1 REQ GFT
RECON MIDFACE LEFORT I; 2 REQ GFT
RECON MIDFACE LEFORT I; 3/MORE-GFT
RECON MIDFACE LEFORT II; ANT INTRUS
RECON MIDFACE LEFORT II; REQ GFT
RECON MIDFACE REQ GFT; WO LEFORT I
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
RECON MAJ FORHD/ORBIT RIMS; W/GFT
RECON MAJ FORHD/ORBIT RIM; W/AUTOGT
RECON CONTOUR BEN TUMOR CRAN BONE
RECON ORBIT-EXC BONE; GFT < 40 CM2
RECON ORBIT; BONE GFT >40 BUT <80CM
RECON ORBIT-EXC BONE; GFT > 80 CM2
RECON MIDFACE OSTEOTOMIES/BONE GFT
RECON MANDIB RAMI OSTEOT; WO GFT
RECON MANDIB RAMI OSTEOT; W/GFT
RECON MANDIB RAMI/BODY; WO INT FIX
RECON MANDIB RAMI/BODY; W/INT FIXA
OSTEOTOMY MANDIB SEGMT
OSTEOTOMY W/ GENIOGLOSSUS ADVANCEMENT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21206
21208
21209
21210
21215
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21300
21310
21315
21320
21325
21330
21335
21336
21337
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Description
OSTEOTOMY MAXIL SEGMT
OSTEOPLASTY FACIAL BONES; AUGMEN
OSTEOPLASTY FACIAL BONES; REDUCTION
GFT BONE; NASAL/MAXIL/MALAR AREAS
GFT BONE; MANDIB
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
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; INTRA-EXTRACRAN
PERIORBIT OSTEOTOM; W/FORHD ADVANCE
ORBIT REPOSIT-UNILAT; EXTRACRANIAL
ORBIT REPOSIT-UNILAT; INTRA-EXTRACR
MALAR AUGMEN PROSTH MAT
SECNDRY REVIS ORBITOCRAN-FACE RECON
MEDIAL CANTHOPEXY (SEPART PROC)
LAT CANTHOPEXY
REDUCTION MASSETER MUSCL & BONE; EX
REDUCT MASSETER MUSCL; INTRAORAL
UNLISTED CRANIO-MAXILLOFACIAL PROC
CLO TX SKULL FX WO OR
CLO TX NASAL BONE FX WO MANIP
CLO TX NASAL BONE FX; WO STABILIZAT
CLO TX NASAL BONE FX; W/STABILIZAT
OPEN TX NASAL FX; UNCOMP
OPEN TX NAS FX; COMPL W/INT-EXT FIX
OPEN TX NASAL FX; W/CONCOM TX SEPTM
OPEN TX SEPTAL FX; W/WO STABILIZAT
CLO TX SEPTAL FX W/WO STABILIZAT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366
21385
21386
21387
21390
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
OPEN TX NASOETHMOID FX; WO EXT FIXA
OPEN TX NASOETHMOID FX; W/EXT FIXA
PERCUT TX NASOETH FX W/FIXA W/REPR
OPEN TX DEPRESSED FRONTAL SINUS FX
OPEN TX FRONT SINUS FX VIA CORONAL
CLO TX NASOMAXIL FX W/FIXA/SPLINT
OPEN TX NASOMAXIL FX; W/WIRING/FIXA
OPEN TX NASOMAX FX; REQ MX APPROACH
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
OPEN TX ORBIT "BLOWOUT" FX; COMBO
OPEN TX ORBIT BLOWOUT FX; W/IMPLNT
OPEN TX ORBIT "BLOWOUT" FX; W/GFT
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
OPEN TX FX ORBIT EX BLOWOUT; W/GFT
CLO TX PALATAL FX W/INTERDENT FIXA
OPEN TX PALATAL/MAXIL FX
OPEN TX PALATAL/MAXIL FX; COMPLIC
CLO TX CRANIOFAC SEPART W/WIRE FIX
OPEN TX CRANIOFAC SEPAR; W/INT FIXA
OPEN TX CRANIOFAC SEPART; COMPLIC
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
PERCUT TX MANDIB FX W/EXT FIXA
CLO TX MANDIB FX W/INTERDENTAL FIXA
OPEN TX MANDIB FX W/EXT FIXA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21461
21462
21465
21470
21480
21485
21490
21495
21497
21499
21501
21502
21510
21550
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21685
21700
21705
21720
21725
21740
21742
21743
21750
21800
21805
21810
21820
21825
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
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
No
No
No
No
No
Description
OPEN TX MANDIB FX; WO INTERDENT FIX
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
CLO TX TM DISLOC; COMPLIC INIT/SUBS
OPEN TX TEMPOROMANDIBULAR DISLOC
OPEN TX HYOID FX
INTERDENT WIRING-CONDITION NOT FX
UNLISTED MS PROC HEAD
I&D DEEP ABSCESS SOFT TISS NECK
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
EXC TUMOR SOFT TISS NECK; DEEP/IM
RAD RESECT TUMOR SOFT TISS NECK
EXC RIB PART
COSTOTRANSVERSECTOMY (SEPART PROC)
EXC 1ST &/OR CERV RIB;
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
DIVIS SCALENUS ANTICUS; W/CERV RIB
DIVIS STERNOCLEIDOMASTOID; WO CAST
DIVIS STERNOCLEIDOMASTOID; W/CAST
RECON REPR PECTUS EXCAVAT/CARINATUM
RECON REP PECTUS EXCAVATM/CARINATM;NO THORACSCPY
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
21899
21920
21925
21930
21935
22010
22015
22100
22101
22102
22103
22110
22112
22114
22116
22206
22207
22208
22210
22212
22214
22216
22220
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22520
22521
22522
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
No
No
No
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
PART EXC VERT BODY WO DECOM-1; THOR
PART EXC VERT BODY WO DECOM-1; LUMB
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
OSTEOT SPINE W/DISKECT-ANT-1; CERV
OSTEOT SPINE W/DISKECT-ANT-1; THOR
OSTEOT SPINE W/DISKECT-ANT-1; LUMB
OSTEOT SPINE W/DISKECT-ANT; EA ADD
CLO TX VERTEBRAL PROCESS FX
CLO TX VERT BODY FX WO MANIP-W/CAST
CLO TX VERT FX/DISLOC W/CAST-MANIP
OP TX ODONTOID FX/DISLOC; WO GFT
OP TX ODONTOID FX/DISLOC; W/GFT
OPEN TX VERT FX/DISLOC-POST-1; LUMB
OPEN TX VERT FX/DISLOC-POST-1; CERV
OPEN TX VERT FX/DISLOC-POST-1; THOR
OP TX VERT FX/DISLOC-POST; EA ADD
MANIP SPINE REQUIR ANES ANY REGION
PERCTANEOUS VERTEBROPLASTY
PERC VERTEBROPLASTY-LUMBAR
PERC VERTEBROPLASTY-EA ADD THORACIC OR LUMBAR VERT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
22523
22524
22525
22526
22527
22532
22533
22534
22548
22554
22556
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Bundled
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
ARTHRODESIS-C1 C2-W/WO EXC ODONTOID
ARTHRODESIS W/MINI DISKECT; C3-C7
ARTHRODESIS W/MINI DISKECT; THOR
ARTHRODESIS W/MINI DISKECT; LUMB
ARTHRODESIS W/MINI DISKECT; EA ADD
ARTHRODESIS-POST TECH, CRANIOCERV
ARTHRODESIS-POST TECH, ATLAS-AXIS
ARTHRODESIS-POST/POSTLAT-1; C3-C7
ARTHRODESIS-POST/POSTLAT-1; THOR
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
ARTHRODESIS-ANT; 2 TO 3 VERT SEGMT
ARTHRODESIS-ANT; 4-7 VERTEB SEGMT
ARTHRODESIS-ANT; 8/MORE VERT SEGMT
KYPHECTOMY, RESECT VERT SEGMT; 1-2
KYPHECTOMY, RESECT VERT SEGMT; 3/>
EXPLOR SPINAL FUSION
POST NON-SEG INSTRUM-PEDICLE/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
ANT INSTRUM; 8/MORE VERTEB SEGMT
PELV FIX OTH THAN SACRUM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
22849
22850
22851
22852
22855
22857
22862
22865
22899
22900
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REINSERTION SPINAL FIXA DEVICE
REMOV POST NONSEGMENTAL INSTRUM
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
ARTHROT GLENOHUMERAL JT INCL BX
ARTHROT AC/SC JT W/BX/EXC CARTIL
ARTHROT; GLENOHUM JT-SYNVCT W/WO BX
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
23331
23332
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Description
SEQUEST HUMERAL HEAD TO SURG NECK
PART EXC BONE CLAV
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)
INJ PROC SHOULDER ARTHROGRAPHY
MUSCL TRANSF-SHOULDER/UP ARM; SNGL
MUSCL TRANSF-SHOULDER/UP ARM; MX
SCAPULOPEXY
TENOT SHLDR AREA; SNGL TENDON
TENOT SHLDR; MX TENDONS-SAME INCS
REPR RUPT MUSCULOTENDIN CUFF; ACUTE
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
CLO TX CLAV FX; WO MANIP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
23505
23515
23520
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
24000
24006
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
CLO TX CLAV FX; W/MANIP
OPEN TX CLAV FX W/WO INT/EXT FIXA
CLO TX STERNOCLAV DISLOC; W/O MANIP
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
CLO TX SCAP FX; W/MANIP W/WO TRACT
OPEN TX SCAPULAR FX W/WO INT FIXA
CLO TX PROX HUMERAL FX; WO MANIP
CLO TX PROX HUMER FX; W/MANIP
OPEN TX PROX HUMER FX W/WO FIX-REPR
OPEN TX PROX HUMER FX; W/PROS REPLA
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
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
ARTHRODESIS GLENOHUMERAL JOINT;
ARTHRODESIS GH JOINT; W/AUTOG GFT
INTERTHORACOSCAPULAR AMPUTA
DISART SHOULDER
DISART SHLDR; SECNDRY CLO/SCAR REVI
UNLISTED PROC SHOULDER
I&D UPPER ARM/ELBOW; DEEP ABSCESS
I&D UPPER ARM/ELBOW AREA; BURSA
INCS DEEP W/OPEN BONE CORTEX HUMER
ARTHROT ELBOW EXPLOR/REMOV FB
ARTHROTOMY ELBO W/CAP EXC (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
24065
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24201
24220
24300
24301
24305
24310
24320
24330
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
BX SOFT TISS UP ARM/ELBOW; SUPERF
BX SOFT TISS UPPER ARM/ELBOW; DEEP
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
EXC BONE CYST HUMERUS; W/AUTOGFT
EXC BONE CYST HUMERUS; W/ALLOGFT
EXC BONE CYST-HEAD/NECK RADIUS
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
REMOV FB UPPER ARM/ELBOW; SUBQ
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
TENOT OP ELBOW-SHLDR EA TENDON
TENOPLSTY W/MUSCL TRNSF ELBO-SHDL 1
FLEXOR-PLASTY ELBOW
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
24331
24332
24340
24341
24342
24343
24344
24345
24346
24350
24351
24352
24354
24356
24357
24358
24359
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
24535
24538
24545
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Description
FLEXOR-PLASTY ELBOW; W/EXTENSOR ADV
TENOLYSIS TRICEPS
TENODESIS BICEPS TEND ELB (SEP PRO)
REPR TEND/MUSC-ARM/ELB-EA-PRI/SECND
REINSRT RUPT BICEPS/TRICEPS DISTAL
REPR LAT COLLAT LIG ELB W/LOC TISS
RECON LAT COLLAT LIG ELB W/TEND GFT
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
ARTHROPLASTY ELBOW; (TOT ELBOW)
ARTHROPLASTY RADIAL HEAD
ARTHROPLASTY RADIAL HEAD; W/IMPLNT
OSTEOTOMY HUMERUS W/WO INT FIXA
MX OSTEOTOMIES W/REALIGN-HUMERAL
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
24615
24620
24635
24640
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
OPEN TX HUM SUPRACON FX; W/INTERCON
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
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
CLO TX RADIAL HEAD SUBLUXA CHILD
CLO TX RADIAL HEAD/NECK FX;WO MANIP
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
CLO TX ULNAR FX PROX END; WO MANIP
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; RE-AMPUTA
AMPUTA ARM THRU HUMERUS; W/IMPLNT
STUMP ELONGATION UPPER EXTREM
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
25025
25028
25031
25035
25040
25065
25066
25075
25076
25077
25085
25100
25101
25105
25107
25109
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
No
No
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
Yes
Yes
Yes
Yes
Yes
No
Yes
Description
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
EXC TUMOR FOREARM/WRIST; DEEP/IM
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
EXC BONE CYST/TUMOR RADIUS/ULNA
EXC BONE CYST RADIUS/ULNA; W/AUTOGF
EXC BONE CYST RADIUS/ULNA; W/ALLOGF
EXC BONE CYST/TUMOR CARPAL BONES
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
RADICAL RESECT TUMOR RADIUS/ULNA
CARPECTOMY; 1 BONE
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REMOV WRIST PROSTH; (SEPART PROC)
REMOV PROSTH; COMPLIC-"TOT WRIST"
MANIPULATION WRIST UNDER ANESTHESIA
REPR TENDON-FLEXOR-WRIST; PRIM SNGL
REPR TENDON-FLEXOR-WRIST; 2ND 1 EA
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
FLEXOR ORIGIN SLIDE FOREARM/WRIST;
FLEXOR SLIDE WRIST; W/TENDON TRANSF
CAPSULOR/RECON WRIST ANY METHOD
ARTHROPLASTY WRIST; W/WO INTERPOSIT
CENTRALIZATION WRIST ULNA
RECON WRST-SCND-W/WO OPEN RED RU JT
OSTEOTOMY RADIUS; DISTAL THIRD
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
REPR NONUNION RAD & ULNA; WO GFT
REPR NONUNION RAD & ULNA; W/AUTOGFT
REPR DEFECT W/AUTOGFT; RADIUS/ULNA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25606
25607
25608
25609
25611
25620
25622
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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 INTERPOSIT-CARPOMETACAR
REVIS ARTHROPLSTY REMOV IMPLT WRIST
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
OPEN TX RADIAL SHAFT FX W/WO FIXA
CLO TX RADIAL FX W/DISLOC RAD/ULNA
OPEN TX RAD FX W/FIX-CLO TX RU JT
OPEN TX RAD FX W/FIX-OPEN TX RU JT
CLO TX ULNAR SHAFT FX; WO MANIP
CLO TX ULNAR SHAFT FX; W/MANIP
OPEN TX ULNAR SHAFT FX W/WO FIXA
CLO TX RAD & ULNA SHAFT FX; WO MANI
CLO TX RAD & ULNA SHAFT FX; W/MANIP
OPEN TX RAD & ULNA FX; RADIUS/ULNA
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
25624
25628
25630
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Description
CLO TX CARPAL SCAPHOID FX; W/MANIP
OPEN TX CARPAL SCAPHOID FX W/WO FIX
CLO TX CARPAL BONE FX; WO MANIP EA
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
CLO TX RADIOCARPAL DISLOC W/MANIP
OPEN TX RADIOCARPAL DISLOC 1/MORE
PERQ SKEL FIX DIST RADIOULNR DISLOC
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
ARTHRODESIS WRIST; COMPLT WO GFT
ARTHRODESIS WRIST;W/SLIDING GFT
ARTHRODESIS WRIST JT; W/ILIAC/AUTOG
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
DISART THRU WRIST
DISART THRU WRIST; 2ND CLO/SCAR REV
DISART THRU WRIST; RE-AMPUTA
TRANSMETACARPAL AMPUTA
TRANSMETACARPAL AMPUT; SCAR REVIS
TRANSMETACARPAL AMPUTA; RE-AMPUTA
UNLISTED PROC FOREARM/WRIST
DRAINAGE FINGER ABSCESS; SIMPL
DRAINAGE FINGER ABSCESS; COMPLIC
DRAIN TENDON SHEATH/DIGIT &/PALM EA
DRAIN PALMAR BURSA; SNGL BURSA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
ARTHROT W/EXPLOR/DRAIN; MCP JT EA
ARTHROT W/EXPLOR/DRAIN; IP JT EA
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
RAD RESECT TUMOR TISS HAND/FINGER
FASCIECT PALM W/WO Z-PLASTY/GFT
FASCIECT PART PALM W/REL 1 DIGIT;
FASCIECT PART PALM W/REL; EA ADD
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
EXC TENDON PALM SNGL (SEP PRO) EA
EXC TEND FINGR FLEX (SP) EA TEND
SESAMOIDECTMY THUMB/FING (SEP PROC)
EXC/CURET BONE CYST/TUMOR METACARPA
EXC BONE CYST METACARPAL; W/AUTOGFT
EXC BONE CYST PROX/MID/DIST PHALANX
EXC BONE CYST PHALANX; W/AUTOGFT
PART EXC BONE; METACARPAL
PART EXC BONE; PROX/MID PHAL-FINGR
PART EXC BONE; DIST PHALANX-FINGR
RAD RESECT METACARPAL; (TUMOR)
RAD RESECT METACARP; AUTOGFT
RAD RESECT PROX/MID FINGR (TUMOR);
RAD RESECT PROX/MID FINGR; AUTOGFT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
RAD RESECT DISTAL FINGR (TUMOR)
REMOV IMPLNT FROM FINGER/HAND
MANIP FNGR JNT UNDER ANES-EA JNT
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
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
EXC FLEX TEND W/ROD HAND/FINGR EA
REMOV ROD-INSRT FLX GFT HND/FING EA
REPR EXTEN TEND HND PRIM/SEC; EA
REPR EXTEN TEND HAND PRIM; GFT-EA
EXC EXTEN TEND-ROD-GFT HAND/FINGR
REMOV ROD-INSRT TEND GFT HAND-EA
REPR EXTEN TEND FINGR; WO-EA TEND
REPR EXTEN TEND FINGR; GFT EA TEND
REPR EXTEN TEND-CNTRL SLIP-SCND; EA
REPR EXTEN TEND-CENTRL-SEC; GFT EA
CLO TX DIST EXTEN TEND INSRT-PIN
REPR EXTEN TEND-DIST INSRT; WO GFT
REPR EXTEN TEND-DIST INSRT; W/GFT
REALIGN EXTEN TEND HAND EA TEND
TENOLYSIS FLEX; PALM/FINGR EA TEND
TENLYSIS FLEX; PALM & FINGR EA TEND
TENLYSIS EXTEN TEND HAND/FINGR EA
TENOLYS COMPLX-EXTEN-FINGR-FOREARM
TENOT FLEX PALM OP EA TENDON
TENOT FLEX FINGR OP EA TENDON
TENOT EXTEN HAND/FINGR OP EA TEND
TENODESIS; PROX IP JT EA JT
TENODESIS; DIST JT EA JT
LENGTHEN TEND EXTEN HAND/FINGR EA
SHORTEN TENDON EXTEN HAND/FINGR EA
LENGTHEN TEND FLEX HAND/FINGR EA
SHORTEN TENDON FLEX HAND/FINGR EA
TRANSF/TEND DORSUM HAND; WO GFT EA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
CORRECT CLAW FINGER OTHER METHD
RECONS TEND PULLEY EA; LOC TISS (SP
RECONS TENDON PULLEY EA; GFT (SP)
RECONS TEND PULLEY EA; PROSTH (SP)
RELEASE THENAR MUSCL
CROSS INTRINSIC TRANSF
CAPSULODESIS MCP JT; SINGL DIGIT
CAPSULODES METACARPOPHALANG JT; 2
CAPSULODES METACARPOPHAL JT; 3 OR 4
CAPSULECT/CAPSULOT; MCP JT EA JT
CAPSULECT/CAPSULOT; IP JT EA JT
ARTHROPLASTY MCP JT; EA JT
ARTHROPLASTY MCP JT; PROSTH EA JT
ARTHROPLASTY IP JT; EA JT
ARTHROPLASTY IP JT; W/PROSTH EA JT
REPR COLLAT LIGAMNT MCP/IP JT
RECON LIGAMNT MCP JT-1; W/TEND GFT
RECON LIGAMNT MCP JT-1; W/LOC TISS
RECON LIG IP JT SNGL INCL GFT EA JT
REPR NON-UNION METACARPAL/PHALYNX
REPR & RECON FING VOLAR PLATE IP JT
POLLICIZATION A DIGIT
TRANSF TOE-HAND-ANASTOM; GR TOE
TRANSF TOE-HAND-ANAS; NOT GR TOE-1
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26565
26567
26568
26580
26587
26590
26591
26593
26596
26600
26605
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
26740
26742
26746
26750
26755
26756
26765
26770
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
Description
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/Z-PLASTIES
CLO TX METACARP FX 1; WO MANIP EA
CLO TX METACARP FX 1; W/MANIP EA
CLO TX METACARPAL FX W/MANIP W/FIXA
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
OPEN TX FX DISLOC THUMB W/WO FIXA
CLO TX DISLOC-NOT THUMB; WO ANES
CLO TX DISLOC-NOT THUMB; REQ ANES
PERCUT SKELET FIX-NOT THUMB; W/MANI
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
PERCUT FIXA MCP DISLOC SNGL W/MANIP
OPEN TX MCP DISLOC SNGL W/WO FIXA
CLO TX PHALANGEAL FX; WO MANIP EA
CLO TX PHALANGEAL FX; W/WO TRACT
PERCUT FIXA FX PROX/MID W/MANIP EA
OPEN TX PHALANGEAL FX W/WO FIXA EA
CLO TX ARTIC FX MCP/IP JT; WO MANIP
CLO TX ARTIC FX MCP/IP JT; W/MANIP
OPEN TX ARTIC FX MCP/IP JT W/WO FIX
CLO TX DIST PHALANGEAL FX; WO MANIP
CLO TX DIST PHALANGEAL FX; W/MANIP
PERCUT SKELETAL FIX DIST PHALANG FX
OPEN TX DIST PHALANG FX W/WO FIX EA
CLO TX IP JT DISLOC W/MANIP; WO ANE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26989
26990
26991
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
27036
27040
27041
27047
27048
27049
27050
27052
27054
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
CLO TX IP JT DISLOC W/MANIP; W/ANES
PERCUT FIXA IP JT DISLOC 1 W/MANIP
OPEN TX IP JT DISLOC W/WO FIX SNGL
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
ARTHRODESIS IP JT W/WO FIX; EA ADD
ARTHRODESIS IP JT W/WO FIX; W/AUTOG
ARTHRODESIS IP JT; W/AUTOGFT EA ADD
AMPUTA METACARPAL 1 W/WO TRANSF
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
I&D PELVIS/HIP JT AREA; INFEC BURSA
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)
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
RAD RESECT TUMOR SOFT TISS PELVIS
ARTHROTOMY W/BX; SACROILIAC JT
ARTHROTOMY W/BX; HIP JT
ARTHROTOMY W/SYNOVECTOMY HIP JT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
EXC; ISCHIAL BURSA
EXC; TROCH BURSA/CALCIFICATION
EXC BONE CYST; SUPERF W/WO AUTOGFT
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)
REMOV HIP PROSTH; COMPLIC TOT HIP
INJ PROC HIP ARTHROGRAPHY; WO ANES
INJ PROC HIP ARTHROGRAPHY; W/ANES
INJ-S I JT ARTHROG &/ ANES/STEROID
RELEASE/RECESSION HAMSTRING PROX
TRANSF ADDUCTOR TO ISCHIUM
TRANSF EXT OBLIQ MUSCL-GR TROCH
TRANSF PARASPINAL MUSCL TO HIP
TRANSF ILIOPSOAS; TO GREATER TROCH
TRANSF ILIOPSOAS; TO FEMORAL NECK
ACETABULOPLASTY
ACETABULOPLASTY; RESECT FEM HEAD
HEMIARTHROPLASTY HIP PART
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
OSTEOTOMY ILIAC; W/OPEN REDUC HIP
OSTEOTOMY ILIAC; W/FEM OSTEOTOMY
OSTEOT; W/FEM OSTEOT/OPEN REDUC HIP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
Description
OSTEOT PELVIS BILAT
OSTEOTOMY FEMORAL NECK (SEP PROC)
OSTEOTOMY INTER-/SUBTROCH INCL FIXA
BONE GFT FEM HEAD/INTER-SUBTROCH
TX SLIPPED FEM EPIPHYSIS; BY TRACT
TX SLIPPED FEM EPIPHYSIS; BY PIN
OPEN TX SLIP'D FEM EPIPHYS; PIN/GFT
OPEN TX SLIP'D FEM EPIPHYS; CLO MAN
OPEN TX SLIP'D FEM EPIPHYS; OSTEOPL
OPEN TX SLIP'D FEM EPIPHYS; OSTEOT
EPIPHYSEAL ARREST-EPIPHYSIODESIS
PROPHYLACTIC TX FEM NECK & FEMUR
CLO TX PELVIC RING FX; WO MANIP
CLO TX PELVIC RING FX; W/MANIP-ANES
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
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 END-DISPLACE
OPEN TX FEM FX PROX END FIX/PROSTH
CLO TX INTERTROCH FEM FX; WO MANIP
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
CLO TX GREATER TROCH FX WO MANIP
OPEN TX GR TROC FX W/WO INT/EXT FIX
CLO TX HIP DISLOC TRAUMA; WO ANES
CLO TX HIP DISLOC TRAUMA; W/ANES
OPEN TX HIP DISLO TRAUMA WO INT FIX
OPEN TX HIP DISLOC TRAUMA W/FEM FX
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27256
27257
27258
27259
27265
27266
27267
27268
27269
27275
27280
27282
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27315
27320
27323
27324
27325
27326
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
TX SPON HIP DISLOC; WO ANES/MANIP
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
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
ARTHRODESIS HIP JT;
ARTHRODES HIP JT; W/SUBTROCH OSTEOT
INTERPELVIABDOMINAL AMPUTA
DIASART HIP
UNLISTED PROC PELVIS/HIP JT
I&D DEEP ABSCESS BURSA THIGH/KNEE
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
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
ARTHROTOMY KNEE; W/SYNOVIAL BX ONLY
ARTHROT KNEE; JT EXPLOR BX/REMOV FB
ARTHROT EXCIS SEMILUN-KNEE; MED/LAT
ARTHROT EXCS SEMILUNR KNEE; MED-LAT
ARTHROT W/SYNOVECT KNEE; ANT/POST
ARTHROT-SYNOVECT KNEE; ANT-POST-POP
EXC PREPATELLAR BURSA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27412
27415
27416
27418
27420
27422
27424
27425
27427
27428
27429
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
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
Yes
Yes
Yes
Description
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
EXC CYST/BENIGN TUMOR FEM; INT FIXA
PART EXC BONE FEM/PROX TIB/FIBULA
RAD RESECT TUMOR BONE FEMUR/KNEE
INJ PROC KNEE ARTHROGRAPHY
REMOV FB DEEP THIGH REGION/KNEE
SUTURE INFRAPATELLAR TENDON; PRIM
SUTURE INFRAPATELL TEND; 2ND RECON
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
TRANSPL HAMSTRING TEND-PATELLA; 1
TRANSPL HAMSTRING TEND-PATELLA; MX
TRANSF TEND/MUSCL HAMSTRINGS-FEM
ARTHROT W/MENISCUS REPR KNEE
REPR PRIM TORN LIGAM KNEE; COLLATER
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; EXTRA-ARTICULAR
LIGAMNT RECON KNEE; INTRA-ARTICULAR
LIG RECON KNEE; INTRA/EXTRA-ARTICUL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27501
27502
27503
27506
27507
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Description
QUADRICEPSPLASTY
CAPSULOT POST CAPSULAR RELEASE KNEE
ARTHROPLASTY PATELLA; WO PROSTH
ARTHROPLASTY PATELLA; W/PROSTH
ARTHROPLASTY KNEE TIBIAL PLATEAU
ARTHROPLSTY TIB; W/DEBRID/SYNOVECT
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
OSTEOT PROX TIB; AFTER EPIPHYS CLO
OSTEOPLASTY FEMUR; SHORTENING
OSTEOPLASTY FEMUR; LENGTHENING
OSTEOPLSTY FEM; COMBO LENGTH/SHORT
REPR NON-MALUNION FEMUR; WO GFT
REPR NON-/MALUNION FEM; W/ILIAC GFT
ARREST EPIPHYSEAL; DIST FEM
ARRST EPIPHYSEAL; TIBIA-FIBULA PROX
ARRST EPIPHYSEAL; COMBO FEM-TIB/FIB
ARREST HEMIEPIPHYSEAL DIST FEM
REVIS TOT KNEE ARTHROPL; 1 COMPON
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
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
OPEN TX FEM SHAFT FX W/WO FIX/SCREW
OPEN TX FEM SHAFT FX W/PLATE/SCREWS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27508
27509
27510
27511
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
27600
27601
27602
27603
27604
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
CLO TX FEM EPIPHYSEAL SEP; W/MANIP
OPEN TX FEM EPIPHYS SEPAR W/WO FIXA
CLO TX PATELLAR FX WO MANIP
OPEN TX PATELLA FX W/FIX PATELLECT
CLO TX TIBIAL FX PROX; WO MANIP
CLO TX TIB FX; W/WO MANIP W/TRACT
OPEN TX TIB FX; UNICONDYL W/WO FIXA
OPEN TX TIB FX; BICONDYLAR W/WO FIX
CLO TX FX KNEE W/WO MANIP
OPEN TX FX KNEE W/WO FIX
CLO TX KNEE DISLOC; WO ANES
CLO TX KNEE DISLOC; REQUIRING ANES
OPEN TX KNEE DISLO; WO PRI LIG REPR
OPEN TX KNEE DISLO; W/PRIM LIG REPR
OPEN TX KNEE DISLO; W/LIG REPR/AUGM
CLO TX PATELLAR DISLOC; WO ANES
CLO TX PATELLAR DISLOC; REQ ANES
OPEN TX PATEL DISLO W/WO PATELLECT
MANIP KNEE JT UNDER GEN ANES
ARTHRODESIS KNEE ANY TECH
AMPUTA THIGH THRU FEMUR ANY LEVEL
AMPUTA THIGH THRU FEMUR; IMMED FIT
AMPUTA THIGH THRU FEMUR; OPEN CIRC
AMPUTA THIGH FEMUR; 2ND CLO/REVIS
AMPUTA THIGH THRU FEMUR; RE-AMPUTA
DIASART AT KNEE
UNLISTED PROC FEMUR/KNEE
DECOMP FASCIOT LEG; ANT/LAT COMPART
DECOMP FASCIOT LEG; POST COMPART
DECOMP FASCIOT LEG; ANT/LAT/POST
I&D LEG/ANK; DEEP ABSCESS/HEMATOMA
I&D LEG/ANK; INFEC BURSA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27605
27606
27607
27610
27612
27613
27614
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
TENOT PERCUT ACHILLS (SP); LOC ANES
TENOT PERCUT ACHLLES (SP); GEN ANES
INCIS LEG/ANK
ARTHROT ANK-EXPLOR/DRAIN/REMOV FB
ARTHROT POST CAPSULAR RELASE ANK
BX SOFT TISS LEG/ANK AREA; SUPERF
BX SOFT TISS LEG/ANK AREA; DEEP
RAD RESECT TUMOR SOFT TISS LEG/ANK
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;
ARTHROT W/SYNOVECT ANK; TENOSYNOVEC
EXC LES TENDON SHEATH/CAPSULE LEG
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
RADICAL RESECT BONE TUMOR; FIBULA
RAD RESECT BONE TUMOR; TALUS/CALCAN
INJ PROC ANK ARTHROGRAPHY
REPR PRIM OP/PERCUT RUPT ACHILLES
REPR PRIM OP RUPT ACHILLES; W/GFT
REPR SECNDRY ACHILLES TEND W/WO GFT
REPR FASCIAL DEFECT LEG
REPR FLEX TEND LEG; PRIM WO GFT EA
REPR FLEX TEND LEG; SECND EA TENDON
REPR EXTEN TEND LEG; PRIM WO GFT EA
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 January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27726
27727
27730
27732
27734
27740
27742
27745
27750
27752
27756
27758
27759
27760
27762
27766
27767
27768
27769
27780
27781
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
ARTHROPLAS ANK; W/IMPLNT (TOT ANK)
ARTHROPLASTY ANK; REVIS TOT ANK
REMOV ANK IMPLNT
OSTEOTOMY; TIBIA
OSTEOTOMY; FIBULA
OSTEOTOMY; TIBIA & FIBULA
OSTEOT; MX REALIGN INTRAMEDUL ROD
OSTEOPLAS TIB-FIB LENGTHEN/SHORTEN
REPR NON/MALUNION TIBIA; WO GFT
REPR NON/MALUNION TIBIA; W/SLID GFT
REPR NON/MALUNION TIBIA; W/GFT
REPR NONUNION TIB; SYNOSTOSIS W/FIB
REPAIR FIBULA NONUNION
REPR CONGEN PSEUDARTHROSIS TIBIA
ARRST EPIPHYSEL ANY METHD; DIST TIB
ARRST EPIPHYSEL ANY METHD; DIST FIB
ARRST EPIPHYSEAL; DIST TIBIA-FIBULA
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
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
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
CLO TX PROX FIB/SHAFT FX; WO MANIP
CLO TX PROX FIB/SHAFT FX; W/MANIP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
OPEN TX PROX FIB/SHAFT FX W/WO FIXA
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
CLO TX BIMALLEOLAR ANK FX; W/MANIP
OPEN TX BIMALLEOLAR ANK FX W/WO FIX
CLO TX TRIMALLEOLAR ANK FX; WO MANI
CLO TX TRIMALLEOLAR ANK FX; W/MANIP
OPEN TX TRIMALLEOLR FX; WO FIXA LIP
OPEN TX TRIMALLEOLAR FX; W/FIXA LIP
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
OPEN TX DIST TIBIOFIBULR JT DISRUPT
CLO TX PROX TIB-FIB JT DISL; WO ANE
CLO TX PROX TIB-FIB JT DISL; W/ANES
OPEN TX PROX TIB-FIB JT DISLO W/EXC
CLO TX ANK DISLOC; WO ANES
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
MANIP ANK UNDER GEN ANES
ARTHRODESIS ANK ANY METHD
ARTHRODESIS TIB-FIB JT PROX/DISTAL
AMPUTA LEG THRU TIBIA & FIBULA
AMPUT LEG-TIB & FIB; W/FIT & CAST
AMPUTA LEG-TIBIA & FIB; OPEN CIRC
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
DECOMP FASCIOT LEG; POST COMPRT
DECOMP FASCI LEG; A-P/LAT W/DEBRID
UNLISTED PROC LEG/ANK
I&D BURSA FT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035
28043
28045
28046
28050
28052
28054
28055
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
RADICAL RESECT TUMOR SOFT TISS FT
ARTHROT W/BX; INTERTARSAL JT
ARTHROT W/BX; METATARSOPHALANG JT
ARTHROT W/BX; INTERPHALANGEAL JT
NEURECTOMY, FOOT
FASCIECTOMY PLANTAR; PART (SP)
FASCIECT PLANTAR FASCIA; RAD (SP)
SYNOVECTOMY; INTERTARSAL JT EA
SYNOVECT; METATARSOPHALANGEAL JT EA
EXC INTERDIGITAL NEUROMA SNGL EA
SYNOVECT TENDON SHEATH FT; FLEXOR
SYNOVECT TENDON SHEATH FT; EXTENSOR
EXC LES TENDON/SHEATH/CAPSULE; FT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28116
28118
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171
28173
28175
28190
28192
28193
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
OSTECTOMY EXC TARSAL COALITION
OSTECTOMY CALCAN
OSTECTOMY CALCAN; W/WO PLANT RELEAS
PART EXC BONE; TALUS/CALCAN
PART EXC BONE; TARSAL EX TALUS
PART EXC BONE; PHALANX TOE
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
REPR TEND FLEX FT; 1ST/2ND EA TEND
REPR TENDON FLEX FT; SECND W/GFT EA
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
28345
28360
28400
28405
28406
28415
28420
28430
28435
28436
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Description
CORRECT HAMMERTOE
CORRECT COCK-UP 5TH TOE-PLSTC CLO
OSTECT PART EXOSTECT MTATRS HEAD-EA
HALLUX RIGIDIS CORRECT W/CHEILECTMY
HALLUX VALGUS; SIMPL EXOSTECT
HALLUX VALGUS; KELLER/MAYO TYPE PRO
HALLUX VALGUS; RESEC JT W/IMPLNT
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
OSTEOT; PROX PHALANX 1ST TOE (SP)
OSTEOT-CORRECT; OTH PHALANG-ANY TOE
RECON ANGULAR DEFORM TOE SOFT TISS
SESAMOIDECTOMY 1ST TOE (SEP PRO)
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
PERCUT SKELE FIX CALCAN FX W/MANIP
OPEN TX CALCAN FX W/WO INT/EXT FIXA
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28445
28446
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
28675
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
PERCUT FIX TARSAL BONE FX W/MANIP
OPEN TX TARSAL BONE FX W/WO FIX EA
CLO TX METATARSAL FX; WO MANIP EA
CLO TX METATARSAL FX; W/MANIP EA
PERCUT FIX METATARSAL FX W/MANIP EA
OPEN TX METATARSAL FX W/WO FIX EA
CLO TX FX GRT TOE PHALANX; WO MANIP
CLO TX FX GRT TOE PHALANX; W/MANIP
PERCUT FIX FX GRT TOE-PHALAN-W/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
OPEN TX SESAMOID FX W/WO INT FIXA
CLO TX TARSAL BONE DISLOC; WO ANES
CLO TX TARSAL BONE DISLOC; W/ANES
PERCUT FIX TARSAL DISLOC W/MANIP
OPEN TX TARSAL BONE DISLOC W/WO FIX
CLO TX TALOTARS JT DISLOC; WO ANES
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
OPEN TX METATARSOPHAL JT DISLOC
CLO TX IP JT DISLOC; WO ANES
CLO TX IP JT DISLOC; REQUIRING ANES
PERCUT SKELET FIX IP JT DISL W/MANI
OPEN TX IP JT DISLOC W/WO FIXA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28890
28899
29000
29010
29015
29020
29025
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ARTHRODESIS; PANTALAR
ARTHRODESIS; TRIPLE
ARTHRODESIS; SUBTALAR
ARTHRODESIS MIDTARS/TARSOMETAT MX
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
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
APPL RISSER JACKET BODY; INCL HEAD
APPLIC TURNBUCKLE JACKET BODY; ONLY
APPLIC TURNBUCKLE JACKET BODY; W/HD
APPLIC BODY CAST SHOULDER TO HIPS
APPLIC BODY CAST; INCL HEAD-MINERVA
APPLIC BODY CAST; INCL 1 THIGH
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
APPLIC FINGER SPLINT; DYNAMIC
STRAPPING; THORAX
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29220
29240
29260
29280
29305
29325
29345
29355
29358
29365
29405
29425
29435
29440
29445
29450
29505
29515
29520
29530
29540
29550
29580
29590
29700
29705
29710
29715
29720
29730
29740
29750
29799
29800
29804
29805
29806
29807
29819
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
STRAPPING; UNNA BOOT
DENIS-BROWNE SPLINT STRAPPING
REMOV/BIVALV; GAUNTLET/BOOT CAST
REMOV/BIVALV; FULL ARM/LEG CAST
REMOV/BIVALV; SHOULDR/HIP SPICA
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
SCOPE SHOULDER SURGICAL; CPSLORR
SCOPE SHLDR SURG; REPR SLAP LESION
ARTHROSCOPY SHOULDR SURG; REMOV FB
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29820
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29867
29868
29870
29871
29873
29874
29875
29876
29877
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
ARTHROSCPY SHOULDR SURG; SYNOV PART
ARTHROSCPY SHLDR SURG; SYNOV COMPLT
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
ARTHROS WRIST SURG; SYNOVEC COMPLT
ARTHROS WRIST SURG; EXC/REPR FIBROC
ARTHROSCOPY WRIST SURG; INT FIX-FX
ENDO WRST SURG-RELEAS TRNS CARP LIG
ARTHROSCOPIC AIDED TX KNEE; WO FIX
ARTHROSCOPIC AIDED TX KNEE; W/FIX
ARTHROSCOPIC AIDED TX TIB FX; UNICO
ARTHROSCOPIC AIDED TX TIB FX; BICON
ARTHROS HIP DX W/WO BX (SEP PROC)
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
ARTHROS KNEE DX W/WO BX (SEP PRO)
ARTHROSCOPY KNEE SURG; INFEC/DRAIN
ARTHROSCOPY KNEE SURGICAL; WITH LATERAL RELEASE
ARTHROSCOPY KNEE SURG; REMOV FB
ARTHROS KNEE; SYNOVEC LTD (SEP PRO)
ARTHROSCOPY KNEE; SYNOVECTOMY MAJOR
ARTHROS KNEE; DEBRID/SHAVE CARTIL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29904
29905
29906
29907
29999
30000
30020
30100
30110
30115
30117
30118
30120
30124
30125
30130
30140
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Description
ARTHROSCOP KNEE SURG; ABRAS PLASTY
ARTHROS KNEE; W/MENISECT (MED & LAT
ARTHROS KNEE; W/MENISECT (MED/LAT)
ARTHROS KNEE W/MENISCUS (MED/LAT)
ARTHROS KNEE; W/MENISCUS (MED & LAT
ARTHROS KNEE; W/LYSIS ADH (SEP PRO)
ARTHROS KNEE; DRILL W/GFT W/WO FIX
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
ARTHROSCOPY ANK SURG; DEBRID LTD
ARTHROSCOPY ANK SURG; DEBRID EXTEN
ARTHROSCOPY ANKLE SURG; W/ANKLE ARTHRODESIS
SCOPE MCP JOINT DX INCL SYNOVIAL BX
SCOPE MCP JOINT SURGICAL; W/DEBRID
SCOPE MCP JNT;RDUC ULNAR COLLAT LIG
SUBTALAR ARTHRO W/FB RMVL
SUBTALAR ARTHRO W/EXC
SUBTALAR ARTHRO W/DEB
SUBTALAR ARTHRO W/FUSION
UNLISTED PROCEDURE ARTHROSCOPY
DRAIN ABSCESS/HEMATOMA-NASAL-INT
DRAIN ABSCESS/HEMATOMA NASAL SEPTUM
BX INTRANASAL
EXC NASAL POLYP SIMPL
EXC NASAL POLYP EXTEN
EXC INTRANASAL LES; INT APPROACH
EXC INTRANASAL LES; EXT APPROACH
EXC/SURG PLANING NOSE RHINOPHYMA
EXC DERMOID CYST NOSE; SIMPL/SUBQ
EXC DERMOID CYST NOSE; COMPLX
EXC TURBINATE PART/COMPLT ANY METHD
SMR TURBINATE PART/COMPLT ANY METHD
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
30150
30160
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620
30630
30801
30802
30901
30903
30905
30906
30915
30920
30930
30999
31000
31002
31020
31030
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Description
RHINECTOMY; PART
RHINECTOMY; TOT
INJ INTO TURBINATE THERAP
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
RHINOPLASTY SECNDRY; MINOR REVIS
RHINOPLASTY SECNDRY; INTERMED REVIS
RHINOPLASTY SECNDRY; MAJOR REVIS
RHINOPLASTY-DEFORM CLEFT LIP; TIP
RHINOPLSTY-DEFORM; TIP/SEPTUM/OSTEO
REPR OF NASAL VESTIBULAR STENOSIS
SEPTOPLSTY/SMR W/WO SCORING/REPLAC
REPR CHOANAL ATRESIA; INTRANASAL
REPR CHOANAL ATRESIA; TRANSPALATINE
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
CONTRL NASAL HEMORR-ANT-COMPLX
CONTRL NASAL HEMORR-POST; INIT
CONTRL NASAL HEMORR-POST; SUBSQT
LIG ART; ETHMO
LIG ART; INT MAXIL ART TRANSANTRAL
FX NASAL TURBINATE THERAP
UNLISTED PROC NOSE
LAVAGE BY CANNULATION; MAXIL SINUS
LAVAGE-CANNULATION; SPHENOID SINUS
SINUSOTOMY MAXIL; INTRANASAL
SINUSOTMY MAXIL; RAD WO REMOV POLYP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
31233
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31299
31300
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Description
SINUSOTMY MAXIL; RAD W/REMOV POLYPS
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 FLAP-BROW
SINUSOTOMY FRONT; WO FLAP-CORONAL
SINUSOTOMY FRONT; OBLIT-W/FLAP-BROW
SINUSOTOMY FRONT; W/FLAP-CORONAL
SINUSOTMY FRONT; NONOBL-W/FLAP-BROW
SINUSOTMY FRONT; NONBL-W/FLAP-CORON
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)
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
NASAL/SINUS ENDO-OR; W/PART ETHMO
NASAL/SINUS ENDO-OR; W/TOT ETHMO
NAS/SINUS ENDO-OR-W/MAXIL ANTROST;
NAS/SINUS ENDO; W/TISS REMOV MAXIL
NAS/SINUS ENDO-OR-W/FRONT EXPLOR
NASAL/SINUS ENDO SURG W/SPHENOIDOT
NASAL ENDO W/SPHENOIDOT; REMOV TISS
NASAL ENDO REPR CSF LEAK; ETHMOID
NASAL ENDO REPR CSF LEAK; SPHENOID
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31320
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31500
31502
31505
31510
31511
31512
31513
31515
31520
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31545
31546
31560
31561
31570
31571
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
Description
LARYNGOTOMY; DX
LARYNGECT; TOT WO RAD NECK DISSECT
LARYNGECT; TOT W/RAD NECK DISSECT
LARYNGECTOMY; SUBTL WO RAD NECK
LARYNGECTOMY; SUBTL W/RAD NECK
PART LARYNGECTOMY; HORIZONTAL
PART LARYNGECTOMY; LATEROVERTICAL
PART LARYNGECTOMY; ANTEROVERTICAL
PART LARYNGEC; ANTERO-LAT-VERTICAL
PHARYNGOLARYNGEC W/RAD NEC; WO RECN
PHARYNGOLARYNGEC W/RAD NEC; W/RECON
ARYTENOIDECTOMY EXT APPROACH
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
LARYNGOSCPY DIRECT OR W/BX; W/MICRO
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31575
31576
31577
31578
31579
31580
31582
31584
31587
31588
31590
31595
31599
31600
31601
31603
31605
31610
31611
31612
31613
31614
31615
31620
31622
31623
31624
31625
31628
31629
31630
31631
31632
31633
31635
31636
31637
31638
31640
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
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
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
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 January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
31641
31643
31645
31646
31656
31700
31708
31710
31715
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31825
31830
31899
32000
32002
32005
32019
32020
32035
32036
32095
32100
32110
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
BRONCHOSCOPY; W/DESTRUC TUMOR
BRONCHOSCP; W/PLCMT CATH RAD APPLIC
BRONCHOSCOPY; W/THERAP ASPIR-INIT
BRONCHOSCOPY; W/THERAP ASPIR-SUBSEQ
BRONCHOSCOPY; W/ INJ CM-BRONCHGRPH
CATH TRANSGLOTTIC (SEPART PROC)
INSTILL CONTRAST-LARYNGOGRAPHY
CATH BRONCHOGRAPHY W/WO CONTRST MAT
TRANSTRACHEAL INJ BRONCHOGRAPHY
CATH W/BRONCHIAL BRUSH BX
CATH ASPIRA (SEP PRO); NASOTRACHEAL
CATH ASPIRAT (SEP PRO);TRACHEOBRONC
TRANSTRACH INTRO TUBE-O2 THERAP
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
SURG CLO TRACH/FISTULA; WO PLASTIC
SURG CLO TRACH/FISTULA; W/PLASTIC
REVIS TRACHEOSTOMY SCAR
UNLISTED PROC TRACHEA BRONCHI
THORACENTESIS-ASPIRAT-INIT/SUBSQT
THORACENTESIS W/INSRT TUBE (SEP PRO
CHEM PLEURODESIS
INSERTION INDWELLING TUNNLED PLEURAL CATH W/CUFF
TUBE THORACOSTOMY (SEPART PROC)
THORACOSTOMY; W/RIB RESECT EMPYEMA
THORACOSTMY; W/OPEN FLAP-DRAIN EMPY
THORACOTOMY LTD BX LUNG/PLEURA
THORACOTOMY MAJOR; W/EXPLOR & BX
THORACOTOMY MAJOR; W/CONTRL HEMORR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
32120
32124
32140
32141
32150
32151
32160
32200
32201
32215
32220
32225
32310
32320
32400
32402
32405
32420
32421
32422
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32503
32504
32540
32550
32551
32560
32601
32602
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Description
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
PNEUMONOSTOMY; W/PERCUT DRAIN ABSC
PLEURAL SCARIFICATION REPEAT PNEUMO
DECORTIC PULM (SEPART PROC); TOT
DECORTIC PULM (SEPART PROC); PART
PLEURECTOMY, PARIETAL (SEPART PROC)
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
REMOV LUNG OTHER THAN TOT; 1 SEGMT
REMOV LUNG NOT TOT; W/CIRCUM RESECT
REMOV LUNG; AFTER PREV REMOV-PORTIN
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
32603
32604
32605
32606
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
32663
32664
32665
32800
32810
32815
32820
32850
32851
32852
32853
32854
32856
32900
32905
32906
32940
32960
32997
32998
32999
33010
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
Yes
Description
THORACOSCPY DX; PERICARD SAC WO BX
THORACOSCPY DX; PERICARD SAC W/BX
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 FB-PERICAR
THORACOSCPY SURG; CREAT PERICAR WIN
THORACOSCPY SURG; W/TOT PERICARDECT
THORACOSCPY SURG; EXC PERICARD CYST
THORACOSCPY SURG; EXC MEDIASTN CYST
THORACOSCPY SURG; W/LOBEC TOT/SEGMT
THORACOSCPY SURG; THORAC SYMPATHECT
THORACOSCPY SURG; W/ESOPHAGOMYOTOMY
REPR LUNG HERNIA THRU CHEST WALL
CLO CHEST WALL FOLLOWING OPEN FLAP
OPEN CLO MAJOR BRONCHIAL FISTULA
MAJOR RECON CHEST WALL
DONOR PNEUMONECTOMY FROM CADAVER DONOR
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33200
33201
33202
33203
33206
33207
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
33233
33234
33235
33236
33237
33238
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
INSRT PERM PACEMAKER; BY XIPHOID
INSERT EPICARD ELTRD, OPEN
INSERT EPICARD ELTRD, ENDO
INSRT/REPLAC PERM PACEMAKR; ATRIAL
INSRT/REPLAC PERM PACEMAKR; VENTRIC
INSRT/REPLAC PACEMKR; ATRIL/VENTRIC
INSRT/REPLC TEMP 1 ELECT (SEP PRO)
INSRT/REPLC TEMP ELECTROD (SEP PRO)
INSRT/REPLAC PACEMKR GEN; 1 CHMBR
INSRT/REPLC PACEMKR GEN; DUAL CHMBR
UPGRADE IMPLNT PACEMKR SYST 1-DUAL
REPSTN PREV IMPL PACEMKR/CARDIOVRT-DFIB ELEC
INSRT TRNSVEN ELECTROD; 1 CHMB-PERM
INSRT TRNSVEN ELECTROD; 2 CHMB-PERM
REPR ELECTRODE-1 CHMBR PACER/DEFIB
REPR ELECTRODE-2 CHMBR PACER/DEFIB
REVIS/RELOCAT SKIN POCKET-PACEMAKER
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
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 ELECT-THORACOT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33240
33241
33243
33244
33245
33246
33249
33250
33251
33253
33254
33255
33256
33257
33258
33259
33261
33265
33266
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
33411
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
INSRT PACING CARDIOVERT-DEFIB GEN
SUBQ REMOV CARDIOVERT-DEFIB GENERAT
REMOV CARDIOVERT ELECTROD; THORACOT
REMOV CARDIOVERT ELECTROD; TRNSVEN
INSRT EPICAR DEFIB ELECTRO-THORCOT;
INSRT EPICARD DEFIB ELECTROD; W/GEN
INSRT/REPOS LEAD-DEFIB & INSRT GEN
OR ABLAT SUPRAVENT FOCUS; WO BYPASS
OR ABLAT SUPRAVENT FOCUS; W/BYPASS
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
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
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
REPLCMT AORTIC VALVE; W/TISS VALVE
REPLAC AORTIC VALV; W/AORT ANNULUS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33412
33413
33414
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33507
33508
33510
33511
33512
33513
33514
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Description
REPLAC AORTIC VALV; W/TRANSVEN AORT
REPLC AORTC VALV; TRNSLOC PULM VALV
REPR LT VENT OUTFLO OBSTRUC-PATCH
RESECT/INCS SUBVALVULAR TISS-STENOS
VENTRICULOMYOTOMY-IDIOPATHIC STENOS
AORTOPLASTY SUPRAVALVULAR STENOSIS
VALVOTOMY MITRAL VALV; CLO HEART
VALVOT MITRAL; OPEN HEART W/BYPASS
VALVULOPLASTY-MITRAL W/CP BYPASS
VALVULOPL-MITRAL W/BYPASS; W/RING
VALVULOPL-MITRAL W/BYPAS; RAD RECON
REPLAC MITRAL VALV W/CP BYPASS
VALVECTOMY TRICUSPID; W/CP BYPASS
VALVULOPLSTY TRICUSPD; WO RING INSR
VALCULOPLSTY TRICUSPD; W/RING INSRT
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
REPR ANOMALOUS CORONARY ART; LIG
ANOMALOUS CORON ART; GFT WO BYPASS
ANOMALOUS CORON ART; GFT W/BYPASS
REPR CORON ART; CONSTRUC PULM ART
REPR CORON ART; TRNSLOC PULM-AORTA
RPR ANOM AORTIC ORIGIN C ART UNROOFING/TLCJ
ENDO SURG W/VIDEO-ASSTD HARV VEINS COR ART BYPS
CAB-VEIN ONLY; 1 CORON VENOUS GFT
CAB-VEIN ONLY; 2 CORON VENOUS GFT
CAB-VEIN ONLY; 3 CORON VENOUS GFT
CAB-VEIN ONLY; 4 CORON VENOUS GFT
CAB-VEIN ONLY; 5 CORON VENOUS GFT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33548
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33641
33645
33647
33660
33665
33670
33675
33676
33677
33681
33684
33688
33690
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
CAB-VEIN ONLY; 6/MORE VENOUS GFT
CAB W/VENOUS & ART GFT; 1 VEIN GFT
CAB W/VENOUS & ART GFT; 2 VEIN GFT
CAB W/VENOUS & ART GFT; 3 VEIN GFT
CAB W/VENOUS & ART GFT; 4 VEIN GFT
CAB W/VENOUS & ART GFT; 5 VEIN GFT
CAB W/VENOUS & ART GFT; 6/MORE GFT
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 VALV-SUTURE/PATCH
CLO SEMILUNAR VALV-SUTURE/PATCH
ANASTOM PULM ART TO AORTA
REPR COMPLX CARD ANOMAL NOT ATRESIA
REPR COMPLX CARD ANOMAL-ENLARG DEFC
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
BANDING PULM ART
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33692
33694
33697
33702
33710
33720
33722
33724
33726
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33768
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
33800
33802
33803
33813
33814
33820
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
COMPLT REPR TETRALOGY WO PULM ATRES
COMPLT REPR TETRALOGY; W/PATCH
COMPLT REPR TETRALOGY FALLOT
REPR SINUS VALSALVA FIST W/BYPASS
REPR FISTULA W/BYPASS; W/REPR SEPTL
REPR SINUS VALSALVA ANEURY W/BYPASS
CLO AORTICO-LT VENTRICULAR TUNNEL
REPAIR VENOUS ANOMALY
REPAIR PUL VENOUS STENOSIS
COMPLT REPR ANOMALOUS VENOUS RETURN
REPR COR TRIATRIATUM/SUPRAVALV RING
ATRIAL SEPTECT/SEPTOST; CLO HEART
ATRIAL SEPTEC/SEPTOS; OPEN HRT W/CP
ATRIAL SEPTEC/SEPTOS; OPEN HRT W/OC
SHUNT; SUBCLAVIAN PULM ART
SHUNT; ASCENDING AORTA PULM ART
SHUNT; DESCENDING AORTA PULM ART
SHUNT; CENTRAL W/PROSTH GFT
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33822
33824
33840
33845
33851
33852
33853
33860
33861
33863
33864
33870
33875
33877
33880
33881
33883
33884
33886
33889
33891
33910
33915
33916
33917
33920
33922
33924
33925
33926
33930
33933
33935
33940
33944
33945
33960
33961
33967
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
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 CARDIECTOMY-PNEUMONECTOMY
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
INSRT INTRA-AORTC BALLN DEVC PERQ
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33999
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
34800
34802
34803
34804
34805
34806
34808
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
34812
34813
Yes
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
IMPLNT VENTRIC DEVICE; 1 VENT SUPPT
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 ART-NECK
EMBOLECT; INNOMINATE THORACIC INCS
EMBOLECT; AXILRY ART-ARM INCS
EMBOLECT; RADIAL ART BY ARM INCS
EMBOLECT; RENAL ART BY ABD INCS
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 AORTO-UNIILIAC/UNIFEM PROS
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35180
35182
35184
35188
35189
35190
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
DIREC REPR; ANEURY VERTEBRAL ART
DIREC REPR; ANEURY AX-BRACH-ARM INC
DIREC REPR; RUTP ANEURY AX-BRACH
DIR REPR; ANEUR INNOM/SUBCLAV-THORA
DIREC REPR; RUPT ANEURY INNOM ART
DIREC REPR; ANEURY RADIAL/ULNAR ART
DIREC REPR; ANEURY/OCCLUD ABD AORTA
DIREC REPR; RUPT ANUERY ABD AORTA
DIREC REPR; ANEURY ABD AORTA W/VISC
DIR REPR; RUPT ANEUR ABD AORT W/VIS
DIR REPR; ANEURY ABD AORTA W/ILIAC
DIR REPR; RUPT ANEUR ABD AORT W/ILI
DIREC REPR; ANEURY SPLENIC ART
DIREC REPR; RUPT ANEURY SPENIC ART
DIREC REPR; ANEURY VISCERAL ARTS
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
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
REPR ACQUIR AV FIST; THORAX & ABD
REPR ACQUIRED AV FISTULA; EXTREM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35302
35303
35304
35305
35306
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35381
35390
35400
35450
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REPR BLD VESSEL DIRECT; NECK
REPR BLD VESSEL DIRECT; UPPR EXTREM
REPR BLD VESSEL DIRECT; HAND-FINGER
REPR VESS DIR; INTRATHORAC W/BYPASS
REPR VESS DIR; INTRATHORAC WO BYPAS
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
REPR BLD VESS W/VEIN GFT; INTRA-ABD
REPR VESS W/VEIN GFT; LOWER EXTREM
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; INTRA-ABD
REPR VESS W/GFT NOT VEIN; LOWR EXTM
THROMBOENDARTEREC; CAROTID-NECK INC
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
RECHANNELING OF ARTERY
THROMBOENDART; SUBCLAV-THORAC INCS
THROMBOENDARTERECT; AXILRY-BRACHIAL
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
REOPER CAROTID THROMBOENDARTER >1MO
ANGIOSCOPY DURING THERAP INTERVENTN
TRNSLM BALOON ANGIOP OPEN; RENL ART
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35452
35454
35456
35458
35459
35460
35470
35471
35472
35473
35474
35475
35476
35480
35481
35482
35483
35484
35485
35490
35491
35492
35493
35494
35495
35500
35501
35506
35507
35508
35509
35510
35511
35512
35515
35516
35518
35521
35522
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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; FEM-POP
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; TIB-PER
TRNSLUM PERIPH ATHEREC PERCU; RENAL
TRNSLUM PERIPH ATHEREC PERQ; AORTIC
TRNSLUM PERIPH ATHEREC PERCU; ILIAC
TRNSLM PERIPH ATHEREC PERQ; FEM-POP
TRNSLM ATHEREC-PERC; BRACHCEP/BRNCH
TRNSLUM PERIPH ATHEREC PERQ; TIBPER
HARVST UP EXTREM VEIN-L-EXTREM/CABG
BYPASS GFT W/VEIN; CAROTID
BYPASS GFT W/VEIN; CAROTID-SUBCLAV
BYPASS GFT W/VEIN; SUBCLAV-CAROTID
BYPASS GFT W/VEIN; CAROTID-VERTEB
BYPASS GFT W/VEIN; CAROTID-CAROTID
BYPASS GRAFT WITH VEIN; CAROTID-BRACHIAL
BYPASS GFT W/VEIN; SUBCLAV-SUBCLAV
BYPASS GRAFT WITH VEIN; SUBCLAVIAN-BRACHIAL
BYPASS GFT W/VEIN; SUBCLAV-VERTEB
BYPASS GFT W/VEIN; SUBCLAV-AXILRY
BYPASS GFT W/VEIN; AXILRY-AXILRY
BYPASS GFT W/VEIN; AXILRY-FEMORAL
BYPASS GRAFT WITH VEIN; AXILLARY-BRACHIAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35523
35525
35526
35531
35533
35536
35537
35538
35539
35540
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
35572
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35636
35637
35638
35641
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
ARTERY BYPASS GRAFT
BYPASS GRAFT WITH VEIN; BRACHIAL-BRACHIAL
BYPASS GFT W/VEIN; AORTOSUBCLAVIAN
BYPASS GFT W/VEIN; AORTOCELIAC
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
BYPASS GFT W/VEIN; AORTOFEM/BIFEM
BYPASS GFT W/VEIN; AORTOILIOFEM UNI
BYPASS GFT W/VEIN; AORTOILIOFEM BIL
BYPASS GFT W/VEIN; AORTOFEMORAL-POP
BYPASS GFT W/VEIN; FEMORAL-POP
BYPASS GFT W/VEIN; FEMORAL-FEMORAL
BYPASS GFT W/VEIN; AORTORENAL
BYPASS GFT W/VEIN; ILIOILIAC
BYPASS GFT W/VEIN; ILIOFEMORAL
BYPASS GFT W/VEIN; FEM-ANT TIB/DIST
BYPASS GFT W/VEIN; POP-TIB/DISTAL
HARVEST FEMPOP VEIN 1 SEGMENT VASC RECNSTR PROC
IN-SITU VEIN BYPASS; FEMORAL-POP
IN-SITU VEIN BYPASS; FEM-ANT TIB
IN-SITU VEIN BYPASS; POP-TIB/PERONL
HARVEST OF UPPER EXTREMITY ARTERY FOR BYPASS PROC
BYPASS GFT NOT VEIN; CAROTID
BYPASS GFT NOT VEIN; CAROTID-SUBCLA
BYPASS GFT NOT VEIN; SUBCLAV-SUBCLA
BYPASS GFT NOT VEIN; SUBCLAV-AXILRY
BYPASS GFT NOT VEIN; AXILRY-FEMORAL
BYPASS GFT NOT VEIN; AX-POP/-TIB
BYPASS GFT NOT VEIN; AORTOSUBCLAV
BYPASS GFT NOT VEIN; AORTOCELIAC
BYPASS GFT NOT VEIN; SPLENORENAL
ARTERY BYPASS GRAFT
ARTERY BYPASS GRAFT
BYPASS GFT NOT VN; AOILIAC/BI-ILIAC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35642
35645
35646
35647
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35697
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35883
35884
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
BYPASS GFT NOT VEIN; CAROTID-VERTEB
BYPASS GFT NOT VEIN; SUBCLAV-VERTEB
BYPASS GFT NOT VEIN; AORTOFEB/BIFEM
BYPS GFT W/OTH THAN VEIN; AORTOFEM
BYPASS GFT NOT VEIN; AXILRY-AXILRY
BYPASS GFT NOT VEIN; AORTOFEM-POP
BYPASS GFT NOT VEIN; AXILRY-FEM-FEM
BYPASS GFT NOT VEIN; FEMORAL-POP
BYPASS GFT NOT VEIN; FEMORAL-FEMORL
BYPASS GFT NOT VEIN; ILIOILIAC
BYPASS GFT NOT VEIN; ILIOFEMORAL
BYPASS GFT NOT VEIN; FEM-ANT-TIB
BYPASS GFT NOT VEIN; POP-TIB/-PERON
BYPASS GFT; COMPOSITE PROSTH VEIN
BYPASS GFT; AUTOG-2 SEGMT 2 LOCATNS
BYPASS GFT; AUTOG-3/> SEGMT 2/> LOC
PLCMT VEIN PATCH@DIST ANASTOM GFT
CREAT DIST AV FIST DUR LW EXTRM BYP
TRANSPOSIT/REIMPLNT; VERTEB-CAROTID
TRANSPOSIT/REIMPLNT; VERTEB-SUBCLAV
TRANSPOSIT/REIMPLNT; SUBCLAV-CAROTD
TRANSPOSIT/REIMPLNT; CAROTID-SUBCLV
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
EXPLOR POSTOP HEMORR/INFEC; NECK
EXPLOR POSTOP HEMORR/INFEC; CHEST
EXPLOR POSTOP HEMORR/INFEC; ABD
EXPLOR POSTOP HEMORR/INFEC; EXTREM
REPR GFT-ENTERIC FISTULA
THROMBECTOMY ART/VENOUS GFT;
THROMBECT ART/VENOUS GFT; W/REVIS
REVIS LO EXTR ART BYPASS; W/PATCH
REVIS LO EXTR ART BYPAS; W/INTERPOS
REVISE GRAFT W/NONAUTO GRAFT
REVISE GRAFT W/VEIN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
36100
36120
36140
36145
36160
36200
36215
36216
36217
36218
36245
36246
36247
36248
36260
36261
36262
36299
36400
36405
36406
36410
36415
36416
36420
36425
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
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
Yes
No
No
No
No
No
No
No
No
Description
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
INTRO CATH RT HEART/MAIN PULM ART
SELECT CATH PLCMT LT/RT PULM ART
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
INTRO NEEDLE/AORTIC TRANSLUMBAR
INTRO CATH AORTA
SELECT CATH PLCMT ART; EA 1ST ORDER
SELECT CATH PLCMT ART; INIT 2ND ORD
SELECT CATH PLCMT ART; INIT 3RD ORD
SELEC CATH PLCMT ART; ADD 2ND & 3RD
SELECT CATH PLCMT ART; EA 1ST ABD
SELECT CATH PLCMT ART; INIT 2ND ABD
SELECT CATH PLCMT ART; INIT 3RD ABD
SELECT CATH PLCMT; 2ND & 3RD ABD
INSRT IMPLNT INTRA-ART INFUSN PUMP
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
36430
36440
36450
36455
36460
36468
36469
36470
36471
36475
36476
36478
36479
36481
36500
36510
36511
36512
36513
36514
36515
36516
36522
36540
36550
36555
36556
36557
36558
36560
36561
36563
36565
36566
36568
36569
36570
36571
36575
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Yes
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
Not reimbursable
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
Description
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
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
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
INSERTION PERIPHLY INSRT CVAD SUBQ PORT; 5 YR/>
REP CV ACSS CATH NO SUBQ PORT/PUMP CNTRL/PERIPH
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
Not reimbursable
Not reimbursable
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36591
36592
36593
36595
36596
36597
36598
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
INSRT CANNULA (SEP PROC); VEIN-VEIN
INSRT CANNULA (SEP PROC); AV-EXT
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
INSRT CANNULA PROLNG EXTRACORP (SP)
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)
REVIS AV FIST; W/THROMBECT-DIAL GFT
PLASTIC REPR AV ANEURY (SEP PROC)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
36835
36838
36860
36861
36870
37140
37145
37160
37180
37181
37182
37183
37184
37185
37186
37187
37188
37195
37200
37201
37202
37203
37204
37205
37206
37207
37208
37209
37210
37215
37216
37250
37251
37500
37501
37565
37600
37605
37606
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
INSRT THOMAS SHUNT (SEPART PROC)
DIST REVASC&INTRVL LIG UPPER EXTREM HD ACSS
EXT CANNULA DECLOT (SP); WO CATH
EXT CANNULA DECLOT (SP); W/CATH
THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA
VENOUS ANASTOM; PORTOCAVAL
VENOUS ANASTOM; RENOPORTAL
VENOUS ANASTOM; CAVAL-MESENTERIC
VENOUS ANASTOM; SPLENORENAL PROX
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
THROMBOLYSIS CEREBRAL BY IV INFUS
TRANSCATH BX
TRANSCATH THERAP INFUS-THROMBOLYSIS
TRANSCATH THERAP INFUS-NOT THROMBOL
TRANSCATH RETRIEVAL PERCUT-IV FB
TRANSCATH OCCLUD-PERCUT-NON CNS
TRANSCATH PLCMT INTRAVASC STENT PERQ; INIT VES
TRANSCATH PLCMT INTRAVASC STENT PERQ; EA ADD VES
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
37607
37609
37615
37616
37617
37618
37620
37650
37660
37700
37718
37722
37735
37760
37765
37766
37780
37785
37788
37790
37799
38100
38101
38102
38115
38120
38129
38200
38204
38205
38206
38207
38208
38209
38210
38211
38212
38213
38214
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Bundled
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
LIG & STRIP LNG/SHRT SAPHEN W/EXC
LIG PERFORATORS-RADICAL W/WO GFT
STAB PHLEBECT VARICOS VNS 1 EXT; 10-20 STAB INCI
STAB PHLEBECT VARICOSE VNS 1 EXTREM; > 20 INCI
LIG SHORT SAPHENOUS VEIN (SEP PRO)
LIGATION DIV &/ EXC VARICOSE VEIN CLUSTER 1 LEG
PENILE REVASCULARIZ ART W/WO GFT
PENILE VENOUS OCCLUD PROC
UNLISTED PROC VASCULAR SURG
SPLENECTOMY; TOT (SEPART PROC)
SPLENECTOMY; PART (SEPART PROC)
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 January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
38215
38220
38221
38230
38240
38241
38242
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38589
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
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
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
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
LTD LYMPHADENECT (SEP PRO); PELVIC
LTD LYMPHADENEC (SEP PRO); RETROPER
LAP SURG; W/RETRO LYMPH NODE SAMP
LAP SURG; W/BIL TOT PELV LYMPHECTMY
LAP SURG; PELV LYMPHEC-NODE SAMP
UNLISTED LAP PROC-LYMPHATIC SYST
SUPRAHYOID LYMPHADENECTOMY
CERV LYMPHADENECTOMY (COMPLETE)
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)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
38790
38792
38794
38999
39000
39010
39200
39220
39400
39499
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
39599
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
40720
40761
40799
40800
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
REPR LACERAT DIAPHRAGM ANY APPROACH
REPR PARAESOPHAGEAL HIATUS HERNIA
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
IMBRICAT DIAPHRAGM; PARALYTIC/NON
RESECT DIAPHRAGM; W/SIMP REPR
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
EXC LIP; FULL THICK RECON W/LIP FLP
RESECT LIP > 1/4 WO RECON
REPR LIP FULL THICK; VERMILION ONLY
REPR LIP FULL THICK; TO HALF VERTIC
REPR LIP FULL THICK; > 1/2 VERTICAL
PLASTIC REPR CLEFT LIP; PRIM UNILAT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
40801
40804
40805
40806
40808
40810
40812
40814
40816
40818
40819
40820
40830
40831
40840
40842
40843
40844
40845
40899
41000
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41019
41100
41105
41108
41110
41112
41113
41114
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
DRAIN ABSCESS VESTIBULE MOUTH; COMP
REMOV EMBEDDED FB MOUTH; SIMPL
REMOV EMBEDDED FB MOUTH; COMPLIC
INCS LABIAL FRENUM
BX VESTIBULE MOUTH
EXC LES-VESTIBULE MOUTH; WO REPR
EXC LES-MOUTH; W/SIMPL REPR
EXC LES-MOUTH; W/COMPLX REPR
EXC LES-MOUTH; COMPLX W/EXC MUSCL
EXC MUCOS VESTIBULE MOUTH-DONOR GFT
EXC FRENUM LABIAL/BUCCAL
DESTRCT LES VESTIBULE MOUTH-PHYSICL
CLO LACERATION MOUTH; 2.5 CM/LESS
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
INTRAORAL I&D ABSCESS; SUBLINGUAL
INTRAORAL I&D; SUPRAMYLOHYOID
INTRAORAL I&D ABSCESS; SUBMENTAL
INTRAORAL I&D; SUBMANDIBULAR SPACE
INTRAORAL I&D; MASTICATOR SPACE
INCS LINGUAL FRENUM
EXTRAORAL I&D ABSCESS; SUBLINGUAL
EXTRAORAL I&D ABSCESS; SUBMENTAL
EXTRAORAL I&D; SUBMANDIBULAR
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
EXC LES TONGUE W/CLO; ANT 2-THIRDS
EXC LES TONGUE W/CLO; POST 1-THIRD
EXC LES TONGUE W/CLO; W/TONGUE FLAP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41251
41252
41500
41510
41520
41599
41800
41805
41806
41820
41821
41822
41823
41825
41826
41827
41828
41830
41850
41870
41872
41874
41899
42000
42100
42104
42106
42107
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
EXC LINGUAL FRENUM
EXC LES FLOOR MOUTH
GLOSSECTOMY; < ONE-HALF TONGUE
GLOSSECTOMY; HEMIGLOSSECTOMY
GLOSSECTOMY; PART W/UNILAT RAD NECK
GLOSSECTOMY; COMPLT WO RAD NECK
GLOSSECTOMY; TOT W/UNILAT RAD NECK
GLOSSECTOMY; COMPOSITE WO RAD NECK
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
EXC OSSEOUS TUBEROSITIES DENTOALVEO
EXC LES DENTOALVEOLAR; WO REPR
EXC LES DENTOALVEOLAR; W/SIMPL REPR
EXC LES DENTOALVEOLAR; W/COMPLX REP
EXC HYPERPLASTIC ALVEOLAR MUCOS
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
EXC LES PALATE UVULA; W/FLAP CLO
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
42120
42140
42145
42160
42180
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42280
42281
42299
42300
42305
42310
42320
42330
42335
42340
42400
42405
42408
42409
42410
42415
42420
42425
42426
42440
42450
42500
42505
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
RESECT PALATE/EXTEN RESECT LES
UVULECTOMY EXC UVULA
PALATOPHARYNGOPLASTY
DESTRCT LES PALATE/UVULA
REPR LACERATION PALATE; UP TO 2 CM
REPR LACERATION PALATE; > 2 CM
PALATOPLASTY-CLEFT PALATE SOFT/HARD
PALATOPLASTY-CLEFT PALATE; SOFT TIS
PALATOPLASTY CLEFT PALATE; W/GFT
PALATOPLASTY CLEFT PALATE; REVIS
PALATOPLASTY; SECNDRY LENGTHENING
PALATOPLASTY; ATTACH PHARYNGEAL FLP
LENGTHENING PALATE & PHARYNGEAL FLP
LENGTHENING PALATE W/ISLAND FLAP
REPR ANT PALATE INCL VOMER FLAP
REPR NASOLABIAL FISTULA
MAXIL IMPRESSION PALATAL PROSTH
INSRT PIN-RETAINED PALATAL PROSTH
UNLISTED PROC PALATE UVULA
DRAINAGE ABSCESS; PAROTID SIMPL
DRAINAGE ABSCESS; PAROTID COMPLIC
DRAIN ABSCESS; SUBMAXIL INTRAORAL
DRAINAGE ABSCESS; SUBMAXILLARY EXT
SIALOLITHOTOMY; UNCOMP INTRAORAL
SIALOLITHOTOMY; SUBMANDIB COMPLIC
SIALOLITHOTOMY; PAROTID COMPLIC
BX SALIVARY GLAND; NEEDLE
BX SALIVARY GLAND; INCS
EXC SUBLINGUAL SALIVARY CYST
MARSUPIALIZATION SUBLINGUAL CYST
EXC PAROTID TUMOR; LAT LOBE
EXC PAROTID TUMOR; LAT W/DISSECTION
EXC PAROTID TUMOR; TOT W/DISSECT
EXC PAROTID TUMOR; TOT W/NERVE
EXC PAROTID TUMOR; TOT W/RAD NECK
EXC SUBMANDIBULAR GLAND
EXC SUBLINGUAL GLAND
PLASTIC REPR SALIV DUCT; PRIM/SIMPL
PLASTIC REPR SALIV DUCT; SECNDRY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
42507
42508
42509
42510
42550
42600
42650
42660
42665
42699
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Description
PAROTID DUCT DIVERSION BILAT
PAROTID DIVERS BILAT; W/EXC 1 GLAND
PAROTID DIVERS BILAT; W/EXC GLANDS
PAROTID DIVERS BILAT; W/LIG DUCTS
INJ PROC SIALOGRAPHY
CLO SALIVARY FISTULA
DILAT SALIVARY DUCT
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
I&D ABSCESS; RETROPHARYNGEAL EXT
BX; OROPHARYNX
BX; HYPOPHARYNX
BX; NASOPHARYNX VISIBLE LES SIMPL
BX; NASOPHARYNX SURVEY-UKN PRIM LES
EXC/DESTRCT LES PHARYNX ANY METHD
REMOV FB FROM PHARYNX
EXC BRANCHIAL CLEFT CYST-SKIN/SUBQ
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
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
EXC/DESTRCT LING TONSIL (SEP PRO)
LTD PHARYNGECTOMY
RESECT LAT PHARYNGEAL WALL DIRECT
RESECT PHARYNG WALL W/CLO W/FLAP
SUTURE PHARYNX WOUND/INJURY
PHARYNGOPLASTY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
42953
42955
42960
42961
42962
42970
42971
42972
42999
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
No
No
No
No
No
Yes
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
Description
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
ESOPHAGECT W/THORCTMY; W/GASTROST
ESOPHAGECT W/THORCTMY; W/SB RECON
PART ESOPHAGECT-CERV-W/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
ESOPHAGOSCPY RIGID/FLEX; W/BAND LIG
ESOPHAGOSCOPY; W/REMOV FB
ESOPHAGOSCPY RIGID/FLEX; REMOV TUMR
ESOPHAGOSCOPY; W/REMOV LES-SNARE
ESOPHAGOSCOPY; INSRT TUBE/STENT
ESOPHAGOSCOPY; W/BALLOON DILAT
ESOPHAGOSCOPY; W/INSRT GUIDE WIRE
ESOPHAGOSCOPY; W/CONTRL BLEEDING
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
43228
43231
43232
43234
43235
43236
43237
43238
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43257
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43280
43289
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
Yes
Yes
Description
ESOPHAGOSCOPY; W/ABLAT TUMR-NOT AMN
ESOPHAGOSCOPY; W/ENDOSCOPIC ULTRASOUND
ESOPHAGOSCOPY; W/TRANSENDOSCOPIC ULTRASOUND
UGI ENDO SIMPL PRIM EXAM (SEP PRO)
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
UP GI ENDO;TRANSENDO US FINE NDLE ASPIR/BX ESOPH
UGI ENDO; W/BX 1/MX
ESOPHAGOSCOPY; W/TRANSMURAL DRAINAGE OF PSEUDOCYST
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
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
UGI ENDO; W/REMOV TUMOR/POLYP/LES
UGI ENDO; W/REMOV TUMOR/LES-SNARE
UGI ENDO; W/CONTRL BLEED ANY METHD
UGI ENDO; W/TRANSENDOSCOPIC STENT PLACEMNT
UP GI ENDO;DEL THRML ENRGY MUSC LW ESOPH SPHNCTR
UGI ENDO; W/ABLAT LES NOT SNARE
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
ERCP; W/ENDO RETRO REMOV STONE
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 DILAT-DUC
ERCP; W/ABLAT TUMOR/LES NOT SNARE
LAP SURG-ESOPHAGOGASTRIC FUNDOPLSTY
UNLISTED LAP PROC-ESOPHAGUS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43453
43456
43458
43460
43496
43499
43500
43501
43502
43510
43520
43600
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
ESOPHAGOPLASTY CERV; WO REPR FIST
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
ESOPHAGOMYOTOMY; ABD APPROACH
ESOPHAGOMYOTOMY; THORACIC APPROACH
ESOPHAGOJEJUNOSTOMY; ABD APPROACH
ESOPHAGOJEJUNOSTOMY; THORACIC
ESOPHAGOSTOMY FISTULIZ-EXT; ABD
ESOPHAGOSTOMY FISTULIZ-EXT; THORACI
ESOPHAGOSTOMY FISTULIZ-EXT; CERV
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/BALLOON-ACHALASIA
ESOPHAGOGASTRIC TAMPONADE W/BALLOON
FREE JEJUNUM TRANS W/MICROVAS ANAST
UNLISTED PROC ESOPHAGUS
GASTROTOMY; W/EXPLOR/FB REMOV
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43640
43641
43644
43645
43647
43648
43651
43652
43653
43659
43750
43752
43760
43761
43770
43771
43772
43773
43774
43800
43810
43820
43825
43830
43831
43832
43840
43842
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Bundled
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Description
BX STOMACH; BY LAPAROTOMY
EXC LOCAL; ULCER/BEN TUMOR-STOMACH
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
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 NRV-TRUNCAL
LAP SURG; TRANSECT VAGUS NERVES-SEL
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
LAPS GSTR RSTCV PX RMVL&RPLCMT BAND
LAPS GSTR RSTCV PX RMVL BAND&PORT
PYLOROPLASTY
GASTRODUODENOSTOMY
GASTROJEJUNOSTOMY; WO VAGOTOMY
GASTROJEJUNOSTOMY; W/VAGOTOMY
GASTROSTMY; WO GAST TUBE (SEP PRO)
GASTROSTOMY-OP; NEONATAL FEEDING
GASTROSTOMY; W/CONSTRUC GAST TUBE
GASTRORRHAPHY SUTURE-ULCER/WOUND
GASTRIC RESTRIC WO BYP; VERTCL BAND
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
Bundled
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
43843
43845
43846
43847
43848
43850
43855
43860
43865
43870
43880
43881
43882
43886
43887
43888
43999
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44132
44133
44135
44136
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Description
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
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 JEJUNOSTMY-INTRAOP
ENTEROT-SM BOWEL; EXPLO/BX/FB REMOV
ENTEROTOMY-SM BOWEL; DECOMP
COLOTOMY EXPLOR BX/FB REMOV
REDUCT VOLVULUS BY LAPAROTOMY
CORRECT MALROTATION BY LYSIS BANDS
BX INTESTINE-CAPSULE/TUBE/PERORAL
EXC 1/MORE LES-BOWEL; 1 ENTEROTOMY
EXC 1/MORE LES-BOWEL; MX ENTEROTOMS
ENTERECT SM INTES; 1 RESECT & ANAS
ENTERECTOMY SM INTES; EA ADD RESECT
ENTERECTOMY SM INTES; W/ENTEROSTOMY
ENTERECT RES SM INTST;W/O TAPERING
ENTERECT RES SM INTST; W/TAPERING
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
INTESTINAL ALLTRANSPLANTATION FROM LIVING DONOR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44157
44158
44160
44180
44186
44187
44188
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44213
44227
44238
44300
44310
44312
44314
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REMOVAL TRANSPLANTED INTESTINAL ALLOGFT COMPETE
MOBILIZA SPLENIC FLEX DUR COLECTOMY
COLECTOMY PART; W/ANASTOM
COLECTOMY PART; W/CECOSTOMY
COLECTOMY PART; W/END COLOSTOMY
COLECTOMY PART; W/RESECT & MUCOFIST
COLECTOMY PART; W/COLOPROCTOSTOMY
COLECTMY PART; W/COLOPROCTO W/COLOS
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
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
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)
ILEOSTOMY NON-TUBE (SEPART PROC)
REVIS ILEOSTOMY; SIMPL (SEP PRO)
REVIS ILEOSTOMY; COMPLIC (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
44500
44602
44603
44604
44605
44615
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Description
CONTINENT ILEOSTOMY (SEPART PROC)
COLOSTOMY/CECOSTOMY (SEPART PROC)
COLOSTOMY; W/MX BX (SEPART PROC)
REVIS COLOSTOMY; SIMPL (SEP PRO)
REVIS COLOSTOMY; COMPLIC (SEP PRO)
REVIS COLOSTOMY; W/HERNIA (SEP PRO)
SM INTEST ENDO NOT ILEUM; DX (SP)
SM INTEST ENDO NOT ILEUM; W/BX 1/MX
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
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
ENDO EVAL SM INTEST POUCH; DX (SP)
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)
SUTURE SM INTESTINE; 1 PERFORATION
SUTURE SM INTEST; MX PERFORATIONS
SUTURE LG INTESTINE; WO COLOSTOMY
SUTURE LG INTESTINE; W/COLOSTOMY
INTEST STRICTUROPLASTY W/WO DILAT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44715
44720
44721
44799
44800
44820
44850
44899
44900
44901
44950
44955
44960
44970
44979
45000
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
CLO ENTEROSTOMY LG/SM INTEST
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
INTESTINAL PLICATION (SEPART PROC)
EXCLUS SM BOWEL FROM PELV-MESH/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
EXC LES MESENTERY (SEPART PROC)
SUTURE MESENTERY (SEPART PROC)
UNLISTED PROC MECKEL'S DIVERTIC
I&D APPENDICEAL ABSC; OPEN
I&D APPENDICEAL ABSC; PERCUT
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
BX ANORECTAL WALL ANAL APPROACH
ANORECTAL MYOMECTOMY
PROCTECTOMY; COMPLT-ABDPERI W/COLOS
PROCTECTOMY; PART RESECT RECTUM
PROCTECTOMY ABDOMPERINEAL PULL-THRU
PROCTECT PART W/RECTAL MUCOSEC-ANAS
PROCTECTOMY PART W/ANASTOM; ABD
PROCTECTMY PART W/ANASTOM; TRANSACR
PROCTECTOMY-COLON RESVOIR W/WO OST
PROCTECT COMPLT; W/PULL-THRU & ANAS
PROCTECT COMP; W/SUBTL/TOT COLECTMY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
45123
45126
45130
45135
45136
45150
45160
45170
45190
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
45378
45379
45380
45381
45382
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
Description
PROCTECTOMY PART WO ANASTOM
PELV EXENTERATION-COLOREC MALIG
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
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 LES-FORC
PROCTOSIGMOID RIGID; REMOV LES-SNAR
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 LES-CAUT
SIGMOIDOSCOPY FLEX; W/CONTRL BLEED
SIGMOIDSCPY FLXIBLE; W/DIR SUBMUCOS INJ SBSTNC
SIGMOIDOSCOPY FLEX; W/DECOMP VOLVUL
SIGMOIDOSCOPY FLEX; REMOV LES-SNARE
SIGMOIDOS FLEX; ABLAT LES-NOT AMENA
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
45383
45384
45385
45386
45387
45391
45392
45395
45397
45400
45402
45499
45500
45505
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
45990
45999
46020
46030
46040
46045
46050
46060
46070
46080
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Description
COLONOSCOPY FLEX; W/ABLAT LES
COLONOSOCPY FLEX; REMOV LES-FORCEPS
COLONOSCOPY FLEX; W/REMOV LES-SNARE
COLNSPY FIBRPTC BEYND SPLNC; W/RETRGRDE LAVAGE
COLONOSCOPY W/TRANSENDO STENT PLACEMNT
COLONSCPY FLEX PROX SPLENIC FLXURE; W/ENDO US EX
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
PROCTOPEXY COMBO W/RESECT-ABD
REPR RECTOCELE (SEPART PROC)
EXPLOR, REPR & DRAIN-RECTAL INJURY;
EXPLOR-REPR-DRAIN RECTAL; W/COLOST
CLO RECTOVESICAL FISTULA
CLO RECTOVESICAL FIST; W/COLOSTOMY
CLO RECTOURETHRAL FISTULA
CLO RECTOURETHRAL FIST; W/COLOSTOMY
REDUCT PROCIDENTIA (SEP PRO) W/ANES
DILAT ANAL SPHINCT (SEP PRO) W/ANES
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
I&D ISCHIORECTAL ABSCESS (SEP PRO)
I&D INTRAMURAL ABSCESS TRANSANAL
I&D PERIANAL ABSCESS SUPERF
I&D ISCHIORECTAL/INTRAMURAL ABSCESS
INCS ANAL SEPTUM (INFANT)
SPHINCTEROTOMY ANAL (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46320
46500
46505
46600
46604
46606
46608
46610
46611
46612
46614
46615
46700
46705
46706
46710
46712
46715
46716
46730
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Description
INCS THROMBOSED HEMORRHOID EXT
FISSURECTOMY W/WO SPHINCTEROTOMY
CRYPTECTOMY; SNGL
CRYPTECTOMY; MX (SEPART PROC)
PAPILLECTOMY ANUS (SEPART PROC)
HEMORRHOIDECTOMY BY SIMPL LIG
EXC EXT HEMORRHOID TAGS/MX PAPILLAE
HEMORRHOIDECTOMY EXT COMPLT
HEMORRHOIDECTOMY INT & EXT SIMPL
HEMORRHOIDECTOMY SIMPL; W/FISSURECT
HEMORRHOIDECTOMY SIMPL; W/FISTULECT
HEMORRHOIDECTOMY COMPLX/EXTEN
HEMORRHOIDECT COMPLX; W/FISSURECTMY
HEMORRHOIDECT COMPLX; W/FISTULECTMY
SURG TX ANAL FISTULA; SUBQ
SURG TX ANAL FISTULA; SUBMUSCULAR
SURG TX ANAL FISTULA; COMPLX/MX
SURG TX ANAL FISTULA; 2ND STAGE
CLO ANAL FIST W/RECTAL ADVANC FLAP
ENUCLEATION EXT THROMBOTIC HEMORRHO
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 LES-FORCEP/CAUT
ANOSCOPY; W/REMOV 1 TUMOR/LES-SNARE
ANOSCOPY; W/REMOV MX LES-CAUT/SNARE
ANOSCOPY; W/CONTRL BLEED ANY METHD
ANOSCPY; ABLAT LES NOT AMENAB-FORCP
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
REPR LO IMPERFORAT ANUS; W/FISTULA
REPR LO IMPERFORAT ANUS; W/TRNSPOST
REPR HI IMPERFORAT ANUS; PERINL/SAC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46760
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46942
46945
46946
46947
46999
47000
47001
47010
47011
47015
47100
47120
47122
47125
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REPR HIGH IMPERFORATE ANUS; COMBO
REPR HI IMPERFOR ANUS W/FIST; PERIN
REPR HI IMPERFOR ANUS; COMBO APPROC
REPR CLOACAL ANOMALY-SACROPERINEAL
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
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
DESTRCT LES ANUS SIMPL; SURG EXC
DESTRCT LES ANUS EXTEN ANY METHD
DESTRCT HEMORRHOIDS ANY METHD; INT
DESTRCT HEMORRHOIDS ANY METHD; EXT
DESTRCT HEMORRHOIDS; INT & EXT
CRYOSURGERY RECTAL TUMOR; BEN
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
47130
47133
47135
47136
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381
47382
47399
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47530
47550
47552
47553
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Description
HEPATECTOMY; TOT RT LOBEC
DONOR HEPATECTOMY FROM CADAVER DONOR
LIVER ALLOTRANSPL; ORTHOTOP-PRT/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
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
LAP ABLAT 1/> LIVR TUMR; RADIOFREQ
LAP ABLAT 1/> LIVR TUMR; CRYOSURG
UNLISTED LAPAROSCOPIC PROC, LIVER
ABLAT OPN 1/> LIVR TUMR; RADIOFREQ
ABLAT OPN 1/> LIVR TUMR; CRYOSURG
ABLAT 1/> LIVR TUMR PERQ RADIOFREQ
UNLISTED PROC LIVER
HEPATICOTOMY W/EXPLOR/REMOV CALCU
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
INTRO TRANSHEPATIC CATH BILI DRAIN
INTRO TRANSHEPATIC STENT BILI DRAIN
CHANGE PERCUT BILI DRAINAGE CATH
REVIS/REINSERT TRANSHEPATIC TUBE
BILI ENDO INTRAOPERATIVE
BILI ENDO VIA T-TUBE; DX (SEP PROC)
BILI ENDO VIA T-TUBE; W/BX 1/MX
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
47554
47555
47556
47560
47561
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620
47630
47700
47701
47711
47712
47715
47716
47719
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
47999
48000
48001
48005
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
BILI ENDO VIA T-TUBE; W/REMOV STONE
BILI ENDO; W/DILAT DUCT WO STENT
BILI ENDO; W/DILAT DUCT W/STENT
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
BILI DUCT STONE EXTRACT VIA T-TUBE
EXPLOR ATRESIA BILE DUCTS WO REPR
PORTOENTEROSTOMY
EXC BILE DUCT TUMOR; EXTRAHEPATIC
EXC BILE DUCT TUMOR; INTRAHEPATIC
EXC CHOLEDOCHAL CYST
ANASTOM CHOLEDOCHAL CYST WO EXC
FUSION OF BILE DUCT CYST
CHOLECYSTOENTEROSTOMY; DIRECT
CHOLECYSTOENTEROS; W/GASTROENTEROST
CHOLECYSTOENTEROSTOMY; ROUX-EN-Y
CHOLECYSTOENTEROS; ROUX-EN-Y W/GAST
ANAS EXTRAHEP BIL DUCTS & GI TRACT
ANASTOM INTRAHEPAT DUCTS & GI TRACT
ANASTOM ROUX-EN-Y EXTRAHEPATIC DUCT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
48020
48100
48102
48105
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48180
48400
48500
48510
48511
48520
48540
48545
48547
48548
48550
48551
48554
48556
48999
49000
49002
49010
49020
49021
49040
49041
49060
49061
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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
EXT DRAIN PSEUDOCYST PANCREAS; OPEN
EXT DRAIN PSEUDOCYST PANCREAS; PERC
INT ANAST PANCREATIC CYST-GI; DIREC
INT ANAST PANCREAT CYST; ROUX-EN-Y
PANCREATORRHAPHY TRAUMA
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
REMOV TRANSPL PANCREATIC ALLOGFT
UNLISTED PROC PANCREAS
EXPLOR LAPAROTOMY W/WO BX (SEP PRO)
REOPENING RECENT LAPAROTOMY
EXPLOR RETROPERITONEAL (SEP PRO)
DRAIN PERITONEAL ABSC; OPEN
DRAIN PERITONEAL ABSC; PERCUT
DRAIN SUBDIAPHRAGMATIC ABSC; OPEN
DRAIN SUBDIAPHRAGMATIC ABSC; PERCUT
DRAIN RETROPERITONEAL ABSC; OPEN
DRAIN RETROPERITONEAL ABSC; PERCUT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
49062
49080
49081
49085
49180
49200
49201
49203
49204
49205
49215
49220
49250
49255
49320
49321
49322
49323
49324
49325
49326
49329
49400
49402
49419
49420
49421
49422
49423
49424
49425
49426
49427
49428
49429
49435
49436
49440
49441
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Description
DRAIN EXTRAPERITON LYMPHOCELE, OPEN
PERITONEOCENTESIS; INIT
PERITONEOCENTESIS; SUBSQT
REMOV PERITONEAL FB FROM CAVITY
BX ABD/RETROPERITONEAL MASS PERCUT
EXC INTRA-ABD/RETROPERITONEAL TUMOR
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
EXC PRESACRAL/SACROCOCCYGEAL TUMOR
STAGING CELIOTOMY-HODGKIN'S DISEASE
UMBILECTOMY/OMPHALECTOMY (SEP PRO)
OMENTECTOMY/EPIPLOECTOMY (SEP PRO)
LAP SURG-ABD; DX-W/WO SPECMN (SP)
LAP SURG-ABD PERITNM & OMENTM; W/BX
LAP SURG-ABD PERITNM; W/ASPIR
LAP SURG-ABD; W/DRAIN LYMPHOCELE
LAP INSERTION PERM IP CATH
LAP REVISION PERM IP CATH
LAP W/OMENTOPEXY ADD-ON
UNLIST LAP PROC-ABD/PERITONM/OMENTM
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)
CONTRST INJ-ABSC/CYST VIA CATH (SP)
INSRT PERITONEAL-VENOUS SHUNT
REVIS PERITONEAL-VENOUS SHUNT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
49442
49446
49450
49451
49452
49460
49465
49491
49492
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49605
49606
49610
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
REPR INIT ING HERNIA <6 MO; REDUCIB
REPR INIT ING HERNIA <6MO; INCARCER
REPR INIT ING HERNIA 6MO-<5YR; REDU
REPR ING HERNIA 6MO-<5YR;INCAR/STRN
REPR INIT ING HERNIA 5YR/MORE; REDU
REPR INIT ING HERNIA > 5YR; INCARC
REPR RECUR ING HERNIA; REDUCIBLE
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
REPR RECUR FEM HERNIA; REDUCIBLE
REPR RECUR FEM HERNIA; INCARC/STRAN
REPR INIT INCS/VENT HERNIA; REDUCIB
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
REPR EPIGASTRIC HERNIA; REDUCIBLE
REPR EPIGAST HERNIA; INCARC/STRANG
REPR UMBILIC HERNIA <5YR; REDUCIBLE
REPR UMBILIC HERNIA <5YR; INCAR/STR
REPR UMBIL HERNIA 5YR/OVER; REDUCIB
REPR UMBIL HERNIA 5YR/OVER; INCARCR
REPR SPIGELIAN HERNIA
REPR SM OMPHALOCELE W/PRIM CLO
REPR LG OMPHALOCELE; W/WO PROSTH
REPR LG OMPHALOCELE; W/REMOV PROSTH
REPR OMPHALOCELE; FIRST STAGE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
49611
49650
49651
49659
49900
49904
49905
49906
49999
50010
50020
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50250
50280
50290
50300
50320
50323
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
Yes
Yes
Yes
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REPR OMPHALOCELE; SECOND STAGE
LAP SURG; REPR INIT INGUINAL HERNIA
LAP SURG; REPR RECUR INGUIN HERNIA
UNLISTED LAP PROC-HERNIOPLSTY/OTOMY
SUTURE 2ND ABD WALL EVISCERATION
OMENTL FLAP EXTRA-ABDOMINAL
OMENTAL FLAP
FREE OMENTAL FLAP W/MICROVASC ANAST
UNLIST PROC ABD PERITONEUM/OMENTUM
RENAL EXPLOR WO OTHER SPECIFIC PROC
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
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
RENAL BX; PERCUT-TROCAR/NEEDLE
RENAL BX; BY SURG EXPOSURE KIDNEY
NEPHRECTOMY W/PART URETERECTOMY
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50325
50327
50328
50329
50340
50360
50365
50370
50380
50382
50384
50385
50386
50387
50389
50390
50391
50392
50393
50394
50395
50396
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50549
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
BACKBENCH STD PREP L/D RENAL ALLOGFT OPEN/LAP
BCKBNCH RECONSTR CD/LD RENL ALLOGFT;VEN ANAST EA
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
ASPIRAT &/OR INJ RENAL CYST-NEEDLE
INSTL TX AGT RENL PELV&/URETR THRU EST NEPHROST
INTRO INTRACATH-RENAL PELVIS-DRAIN
INTRO URETERAL CATH THRU RENAL PELV
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
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
LAP ASSISTED NEPHROURETERECTOMY
UNLISTED LAP PROC-RENAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50551
50553
50555
50557
50561
50562
50570
50572
50574
50575
50576
50580
50590
50592
50593
50600
50605
50610
50620
50630
50650
50660
50684
50686
50688
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
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
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
RENAL ENDO-NEPHROTOMY; REMOV FB
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
URETEROLITHOTOMY; MID 1/3 URETER
URETEROLITHOTOMY; LOWER 1/3 URETER
URETERECTMY W/BLADDER CUFF(SEP PRO)
URETERECTOMY TOT-COMBO ABD/VAG
INJ PROC-URETEROGRAPHY THRU CATH
MANOMETRIC STUDIES THRU URETEROSTMY
CHANGE URETEROSTOMY TUBE
INJ PROC-VISUALIZ ILEAL CONDUIT
URETEROPLASTY PLASTIC OR URETER
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
URETERONEOCYSTOSTOMY; SNGL URETER
URETERONEOCYSTOSTOMY; DUPLIC URETER
URETERONEOCYSTOSTOMY; W/TAILORING
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50961
50970
50972
50974
50976
50980
51000
51005
51010
51020
51030
51040
51045
51050
51060
51065
51080
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
LAP SURG; URETERONEOCYSTOSTOMY W/CYSTOSCOPY
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
URETERAL ENDO-URETEROTOMY; W/BX
URETERAL ENDO-URETEROTOMY; W/FULG
URETERAL ENDO-URETEROTOMY; REMOV FB
ASPIRAT BLADDER BY NEEDLE
ASPIRAT BLADDER; TROCAR/INTRACATH
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
51100
51101
51102
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51736
51741
51772
51784
51785
51792
51795
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
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
No
Description
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
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
INSERT OF TEMP INDWELLING BLADDER CATHETER
INSERT OF NON-INDWELLING BLADDER CATHETER COMPL
CHANGE CYSTOSTOMY TUBE; SIMPL
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
51999
52000
52001
52005
52007
52010
52204
52214
52224
52234
52235
52240
52250
52260
52265
52270
52275
52276
52277
52281
52282
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
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
No
Description
VOIDING PRESS STUDIES; INTRA-ABD
MEASUREMENT PVR URIN&/BLADD CAPACTY US NON-IMAG
CYSTOPLASTY/CYSTOURETHROPLASTY
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
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
CYSTOURETHROSCOPY (SEPART PROC)
CYSTURETHRSCPY W/IRRIG&EVAC CLOTS
CYSTOURETHROSCOPY W/URETERAL CATH
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
CYSTOURETHSCPY W/INSRT URETH STENT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
52283
52285
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52400
52402
52450
52500
52510
52601
52606
52612
52614
52620
52630
52640
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
CYSTOURETHROSCOPY W/INSRT STENT
CYSTOURETHROSCPY W/INSRT GUIDE WIRE
CYSTOURETHROSCOPY; W/TREATMNT OF URETERAL STRICTURE
CYSTOURETHROSCOPY; W/URETERPELVIC JUNCT STRICT TRTMNT
CYSTOURETHROSCOPY; W/INTRA-RENAL 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
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
T U R; RESIDUAL OBSTRUC AFTER 90 DA
T U R; REGROWTH OBSTRUC >1YR POSTOP
T U R; POSTOP BLADDR NECK CONTRACTU
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
52647
52648
52649
52700
53000
53010
53020
53025
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
NON-CONTACT LASER COAGULA PROSTATE
CONTACT LASER VAPORIZA W/WO TURP
PROSTATE LASER ENUCLEATION
TRANSURETH DRAIN PROSTATIC ABSCESS
URETHROT EXT (SEP PRO); PENDULOUS
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
EXC URETHRAL DIVERTIC (SEP PRO); FE
EXC URETH DIVERTIC (SEP PRO); MALE
MARSUPIALIZ URETH DIVERTIC; MALE/FE
EXC BULBOURETHRAL GLAND
EXC; URETHRAL POLYP/DISTAL URETHRA
EXC/FULG; URETHRAL CARUNCLE
EXC/FULG; SKENE'S GLANDS
EXC/FULG; URETHRAL PROLAPSE
URETHROPLASTY; 1ST STAGE-FISTULA
URETHROPLASTY; 2ND STAGE W/DIVERS
URETHROPLSTY 1-STAGE RECON MALE
URETHROPLASTY 1 STAGE RECON URETHRA
URETHROPLSTY 2-STAGE RECON; 1ST STG
URETHROPLSTY 2-STAGE RECON; 2ND STG
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
REMV&REPL INFLAT SPHNCTR INF FLD
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
53449
53450
53460
53500
53502
53505
53510
53515
53520
53600
53601
53605
53620
53621
53660
53661
53665
53850
53852
53853
53899
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
URETHRORRHAPHY WOUND; PERINEAL
URETHRORRHAPHY; PROSTATOMEMBRANOUS
CLO URETHROSTMY FIST MALE (SEP PRO)
DILAT URETHRAL STRICT-MALE; INIT
DILAT URETHRAL STRICT-MALE; SUBSQT
DILAT URETHRAL STRICT-MALE-GEN ANES
DILAT URETHRAL-FILLIFORM-MALE; INIT
DILAT URETHRAL FILLIFRM-MALE; SUBSQ
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; WATR-THERMOTX
UNLISTED PROC URIN SYST
SLIT PREPUCE DORSAL (SEP PRO); NB
SLIT PREPUCE DORSL (SEP PRO); EX NB
I&D PENIS DEEP
DESTRCT LES PENIS SIMPL; CHEM
DESTRCT LES PENIS SIMPL; ELECTRODES
DESTRCT LES PENIS SIMPL; CRYOSURG
DESTRCT LES PENIS SIMPL; LASER SURG
DESTRCT LES PENIS SIMPL; SURG EXC
DESTRCT LES PENIS EXTEN ANY METHD
BX PENIS; (SEP PROC)
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
54135
54150
54152
54160
54161
54162
54163
54164
54200
54205
54220
54230
54231
54235
54240
54250
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54405
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Description
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
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
1 STAGE DISTAL REPR; MOBILIZ URETHR
1 STAGE DISTAL REPR; W/EXTEN DISSEC
1 STAGE PENILE REPR W/EXTEN DISSECT
1 STAGE PERINEAL HYPOSPADIAS REPR
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
PLASTIC-PENIS EPISPADIAS; W/INCONT
PLASTIC-PENIS EPISPAD; W/EXSTROPHY
INSRT PENILE PROSTH; NON-INFLATABLE
INSRT PENILE PROSTH; INFLATABLE
INSRT PENILE PROSTH W/PLCMT PUMP
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800
54820
54830
54840
54860
54861
54865
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
REMV INFLATABL PENIL PROSTH NO REPL
REP CMPNT INFLATABLE PENILE PROSTH
REMV&REPL INFLAT PENIL PRSTH-ID OP
REMV&REPL INFLAT PNIL PRSTH-INF FLD
REMV PENILE PROSTH NO REPLACEMENT
REMV&REPL PENILE PROSTH-SAME OP
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
FIXA CONTRALAT TESTIS (SEPART PROC)
ORCHIOPEXY-ING-W/WO HERNIA REPR
ORCHIOPEXY ABD APPROACH
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Not Reimbursable
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
EPIDIDYMOVASOSTOMY; UNILAT
EPIDIDYMOVASOSTOMY; BILAT
PUNCT ASPIRAT HYDROCELE W/WO MEDS
EXC HYDROCELE; UNILAT
EXC HYDROCELE; BILAT
REPR TUNICA VAG HYDROCELE
DRAINAGE SCROTAL WALL ABSCESS
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
VASOVASOSTOMY VASOVASORRHAPHY
LIG VAS DEFER UNI/BILAT (SEP PRO)
EXC HYDROCELE SPERM CORD (SEP PRO)
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
UNLISTED LAP PROC-SPERMATIC CORD
VESICULOTOMY
VESICULOTOMY; COMPLIC
VESICULECTOMY ANY APPROACH
EXC MULLERIAN DUCT CYST
BX PROSTATE; NEEDLE/PUNCH SNGL/MX
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
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
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
55842
55845
55859
55860
55862
55865
55866
55870
55873
55875
55876
55899
55920
55970
55980
56405
56420
56440
56441
56442
56501
56515
56605
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Description
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
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
BX VULVA/PERINEUM (SEP PRO); 1 LES
BX VULVA (SEP PRO); EA SEP ADD LES
VULVECTOMY SIMPL; PART
VULVECTOMY SIMPL; COMPLT
VULVECTOMY RADICAL PART
VULVECTOMY PART; W/INGUINOFEM LYMPH
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)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
Not Reimbursable
No
Yes
Yes
No
No
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57155
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
Yes
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Description
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
DESTRCT VAG LES; SIMPL ANY METHD
DESTRCT VAG LES; EXTEN ANY METHD
BX VAG MUCOS; SIMPL (SEPART PROC)
BX VAG MUCOS; EXTEN REQ SUTURE
VAGINECTOMY PART REMOV VAG WALL;
VAGINECT REMOV WALL; REMOV PARAVAG
VAGINECT REMOV WALL; W/LYMPHADENECT
VAGINECT COMPLT REMOV VAG WALL;
VAGINECT COMPLT REMOV WALL; PARAVAG
VAGINECT COMPLT REMOV; W/LYMPHADEN
COLPOCLEISIS
EXC VAG SEPTUM
EXC VAG CYST/TUMOR
IRRIGA VAG &/OR APPLIC MEDICAMENT
INSRT UTERN TANDEMS &/ VAG OVOIDS
FIT/INSRT PESSARY-OTH SUPPORT DEVIC
DIAPHRAGM/CERVICAL CAP FITTING
INTRO HEMOSTATC AGENT VAG (SEP PRO)
COLPORRHAPHY SUTURE INJURY VAG
COLPOPERINEORRHAPHY SUTURE INJURY
PLASTIC OR URETHRAL SPHINCT-VAGINAL
PLASTIC REPR URETHROCELE
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
REPR ENTEROCELE-VAGINAL (SEP PRO)
REPR ENTEROCELE-ABD (SEPART PROC)
COLPOPEXY ABD APPROACH
COLPOPEXY VAGNIAL; EXTRA-PERITONEAL APPROACH
COLPOPEXY VAGNIAL; INTRA-PERITONEAL APPROACH
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
57284
57285
57287
57288
57289
57291
57292
57295
57296
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57423
57425
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57530
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Description
PARAVAGINAL DEFEC REPR
REPAIR PARAVAG DEFECT, VAG
REMOV & REVIS SLING STRESS INCONT
SLING OPERATION FOR STRESS INCONT
PEREYRA PROC INCL ANT COLPORRHAPHY
CONSTRUCTION ARTIFICIAL VAG; WO GFT
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
CLO RECTOVAG FIST; TRNSPERITONEAL
CLO URETHROVAGINAL FISTULA
CLO URETHROVAG FIST; W/BULBOCAVERN
CLO VESICOVAG FIST; VAG APPROACH
CLO VESICOVAG FIST; TRANSVESICAL
VAGINOPLASTY INTERSEX STATE
DILAT VAG UNDER ANES
PELVIC EXAM UNDER ANES
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
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 EXC-CERV
COLPSCPY CERV W/UP VAG; W/LOOP ELEC CONIZAT CERV
BX 1/MX LOCAL EXC LES (SEPART PROC)
ENDOCERVICAL CURET
CAUT CERV; ELEC/THERMAL
CAUT CERV; CRYOCAUTERY INIT/REPEAT
CAUT CERV; LASER ABLATION
CONIZATION CERV W/WO D&C; KNIF/LASR
CONIZA CERV W/WO D&C; LOOP ELEC EXC
TRACHELECTOMY AMPUTA CERV (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
Yes
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
57531
57540
57545
57550
57555
57556
57558
57700
57720
57800
57820
58100
58110
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58321
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Not Reimbursable
Description
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
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)
MYOMECTOMY SNGL/MX (SEP PRO); ABD
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/COLPO-URETHROCYSTOPEXY
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/COLPO-URETHROCYSTOPEXY
VAG HYST; W/REPR ENTEROCELE
VAG HYST W/TOT/PART COLPECTOMY
VAG HYST W/COLPECT; W/REPR ENTEROCE
VAG HYST RADICAL
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/COLPO-URETHROCYSTPXY
VAG HYST UTERUS > 250 GRAMS; W/REPAIR ENTEROCELE
INSRT INTRAUTERINE DEVICE
REMOV INTRAUTERINE DEVICE
ARTIFICIAL INSEMINATION; INTRA-CERV
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
Yes
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
58322
58323
58340
58345
58346
58350
58353
58356
58400
58410
58520
58540
58541
58542
58543
58544
58545
58546
58548
58550
58552
58553
58554
58555
58558
58559
58560
58561
58562
58563
58565
58570
58571
58572
58573
58578
58579
58600
58605
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
Yes
Not Reimbursable
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
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Description
ARTIFICIAL INSEMINAT; INTRA-UTERINE
SPERM WASH-ARTIFICIAL INSEMINATION
CATH & INTRO SALINE/CONTRAST MATL SIS/HSG
TRANSCERV INTRO FALLOPIAN TUBE CATH
INSERTION HEYMAN CAPS CLIN BRACHYTX
CHROMOTUBATION OVIDUCT INCL MAT
ENDOMETR ABLATION, THERM, W/OUT HYSTEROSCOPIC
ENDOMET CRYOABLAT W/US GUID INCL ENDOMETRL CURET
UTERINE SUSPEN; (SEP PRO)
UTERINE SUSPEN; W/PRESACRAL SYMPATH
HYSTERORRHAPHY REPR UTERUS (NON-OB)
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
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 PROC-UTERUS
LIG/TRANSECT FALLOPIAN TUBE ABD/VAG
LIG FALLOPIAN-SAME HOSP (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
Not Reimbursable
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58956
58957
58958
58960
58970
58974
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
Yes
Yes
No
No
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Description
LIG FALLOPIAN-W/C-SECT/INTRA-ABD
OCCLUD FALLOPIAN TUBE-DEVICE VAG
LAP SURG; W/LYSIS ADHES (SEP PROC)
LAP SURG; W/REMOV ADNEXAL STRUCT
LAP SURG; W/FULG/EXCIS LES-OVARY
LAP SURG; W/FULG OVIDUCTS
LAP SURG; W/OCCLUS OVIDUCTS-DEVICE
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/RECT-PERCUT
TRANSPOSITION OVARY
BX OVARY UNILAT/BILAT (SEPART PROC)
WEDGE RESECT OVARY UNILAT/BILAT
OVARIAN CYSTECTOMY UNILAT/BILAT
OOPHORECTOMY PART/TOT UNILAT/BILAT
OOPHORECTOMY; OVARIAN MALIG W/BX
RESECT OVARIAN MALIG W/SALPINGO-OOP
RESECT OVARIAN MALIG; W/TAH-LYMPHAD
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
58976
58999
59000
59001
59012
59015
59020
59025
59030
59050
59051
59070
59072
59074
59076
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
59350
59400
59409
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
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
Description
GAMETE/ZYGOTE/EMBRYO INFALLOP TRNSF
UNLISTED PROC FE GENIT SYST
AMNIOCENTESIS ANY METHD
AMNIO; THERAPEUTIC AMNIOTIC FL RDUC
CORDOCENTESIS ANY METHD
CHORIONIC VILLUS SAMPL ANY METHD
FETAL CONTRACTION STRESS TEST
FETAL NON-STRESS TEST
FETAL SCLP BLD SAMPL
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
SURG TX ECTOPIC PG; WO SALPINGECT
SURG TX ECTOPIC PG; ABD PG
SURG TX ECTOPIC PG; REQ TOT HYST
SURG TX ECTOPIC PG; RESEC UTERUS
SURG TX ECTOPIC PG; CERV W/EVACUAT
LAP TX ECTOPIC PG; WO SALPINGECT
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 January 2009
Not Reimbursable
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
CERCLAGE CERV DURING PG; ABD
No
HYSTERORRHAPHY RUPT UTERUS
No
ROUTINE OB CARE INCL VAG DEL
No
VAG DELIV ONLY
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Hosp Notification Required at time of
admission; Prior Authorzation required for
Basic Health Plan only
No
No
No
No
No
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
Hosp Notification Required at time of
admission; Prior Authorzation required for
Basic Health Plan only
No
Description
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
ROUTINE OB CARE INCL C SECT
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59897
59898
59899
60000
60001
60100
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60300
60500
60502
60505
60512
60520
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
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
INDUCED AB-INTRA-AMNIOT INJ; W/D&C
INDUCED AB BY INJ; W/HYSTEROTOMY
INDUCED AB BY VAG SUPPOS;
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
UNLISTED PROC MATERN CARE & DELIV
I&D THYROGLOSSAL CYST INFEC
ASPIRAT &/OR INJ THYROID CYST
BX THYROID PERCUT CORE NEEDLE
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
PARATHYROIDECT; W/MEDIASTINAL EXPLO
PARATHYROID AUTOTRANSPL
THYMECT PART/TOT; TRNCERV (SEP PRO)
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
60521
60522
60540
60545
60600
60605
60650
60659
60699
61000
61001
61020
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Description
THYMECT PART/TOT; STERN SPLIT (SP)
THYMECT; W/RAD MEDIAST DISSEC (SP)
ADRENALECTOMY (SEPART PROC)
ADRENALECT (SEP PRO); W/EXC TUMOR
EXC CAROTID BODY TUMOR; WO EXC ART
EXC CAROTID BODY TUMOR; W/EXC ART
LAP SURG W/ADRENALECT PART/COMPLT
UNLISTED LAP PROC-ENDOCRINE SYSTEM
UNLISTED PROC ENDOCRINE SYST
SUBDURAL TAP-FONTANEL INFANT; INIT
SUBDURAL TAP-FONTANEL; SUBSQT TAPS
VENTRICULAR PUNCT-SUTURE; WO INJ
VENTRICULAR PUNCT; W/INJ DRUG-DX/TX
CISTERNAL PUNCT; WO INJ (SEP PRO)
CISTERNAL PUNCT; W/INJ DRUG-DX/TX
PUNCT SHUNT TUBE/RESERVOIR-ASPIRAT
TWIST DRILL HOLE SUBDUR/VENT PUNCT;
TWIST DRILL HOLE; IMPLNT VENT CATH
TWIST DRILL HOLE; EVACUAT HEMATOMA
BURR HOLE VENT PUNCT
BURR HOLE/TREPHINE; W/BX-BRAIN/LES
BURR HOLE; W/DRAIN BRAIN ABSCESS
BURR HOLE; W/SUBSQT TAPPING ABSCESS
BURR HOLE W/EVACUATION HEMATOMA
BURR HOLE; W/ASPIRAT-INTRACEREBRAL
BURR HOLE; IMPLNT CATH (SEP PRO)
INSRT SUBQ RESERVOIR/PUMP
BURR HOLE SUPRATENTOR-NO OTHER SURG
BURR HOLE-INFRATENTORIAL-UNI/BILAT
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
CRANIECT DRAIN ABSCESS; SUPRATENT
CRANIECT DRAIN ABSCESS; INFRATENT
CRANI/CRANIOT DECOMP W/O EVAC HEMAT; W/O LOBECT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61537
61538
61539
61540
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
CRANIECTOMY-SUBOCCIPIT W/LAMINEC
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 MENINGOMA-SUPRATENT
CRANIECTOMY; EXC ABSCESS-SUPRATENT
CRANIECTOMY; EXC CYST-SUPRATENT
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
CRANIOTOMY W/FLAP; LOBECTOMY TEMPORAL LOBE
CRANIOTOMY W/FLAP; LOBECTOMY NOT TEMPORAL LOBE
CRANIOT; LOBECT NO TEMPORL LOBE PART/TOT NO ECOG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
61541
61542
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
CRANIOTMY; TRANSECT CORPUS CALLOSUM
CRANIOTOMY; TOT HEMISPHERECTOMY
CRANIOT W/ELEV BN FLP; PART/SUBTOTAL HEMISPHERCT
CRANIOT; COAGULATION CHOROID PLEXUS
CRANIOTOMY; CRANIOPHARYNGIOMA
CRANIOTOMY-HYPOPHYSECTOMY-INTRACRAN
HYPOPHYSECTOMY-TRANSNASAL NONSTEREO
CRANIEC-CRANIOSYNOSTOSIS; 1 SUTURE
CRANIEC-CRANIOSYNOSTOSIS; MX SUTURE
CRANIOT-CRANIOSYNOSTOSIS; FRONTAL
CRANIOT CRANIOSYNOSTOSIS; BIFRONTAL
EXTEN CRANIEC-CRANIOSYNOS; NO GFT
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
TRANSORAL APPROACH SKULL BASE-BX
TRANSORAL-SKULL BASE; W/SPLIT TONGU
CRANIOFAC-ANT CRAN; WO MAXILLECTMY
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
INFRATEMP APPROACH INCL PAROTIDECT
INFRATEMP APPROACH INCL MASTOIDECT
ORBITOCRAN ZYGOMAT APPROACH OSTEOT
TRANSTEMP APPROACH INCL MASTOIDECT
TRANSCOCHLR APPROACH INCL LABYRINTH
TRNSCONDYL APPRO INCL RESECT C1-C3
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61630
61635
61640
61641
61642
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
RESECT/EXC LES PARASELLAR; EXTRDURL
RESECT/EXC LES PARASELLAR; INTRDURL
TRANSECT/LIG CAROTID ART; WO REPR
TRANSECT/LIG CAROTID ART; W/REPR
TRANSECT CAROTID-PETROUS; WO REPR
TRANSEC CAROTID-PETROUS; W/REPR-GFT
OBLIT CAROTID ANEURY/FIST-DISSECT
RESECT/EXC LES POST FOSSA; XTRADURL
RESECT/EXC LES POST FOSSA; NTRADURL
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; NON-CNS
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
SURG AV MALFORM; SUPRATENT-SIMPL
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
SURG VERTEBROBASILAR CIRCULATION
SURG ANEURY INTRACRAN; CAROTID CIRC
SURG ANEURY INTRACRAN; VERTEB-BASIL
SURG ANEURY-CERV-APPLIC CLAMP-CAROT
SURG ANEURY; INTRACRAN OCCLUD CAROT
SURG ANEURY; INTRACRAN ELECTROTHROM
SURG ANEURY; INTRA-ART EMBOLIZATION
ANASTOM ART EXTRA-INTRACRAN ART
CREAT LES-STEREOTAC; GLOBUS PALLIDS
CREAT LES-STEREOTACTIC; SUBCORTICAL
STEREOTACTIC BX/EXC INTRACRAN LES
STEREOTAC BX INTRACRAN LES; CT/MRI
STEREOTAC IMPLNT-ELECTRODE-CEREBRUM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
61770
61790
61791
61793
61795
61850
61860
61863
61864
61867
61868
61870
61875
61880
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
STEREOTAC LOCALIZ W/CATH BRACHYTHR
CREAT LES-STEREOTAC; GASSERIAN GANG
CREAT LES-STEREOTAC; TRIGEM MEDULRY
STEREOTACTIC RADIOSURG-1/> SESSIONS
STEREOTAC VOL-INTRA/EXTRACRAN/SPINL
IMPLNT NEUROSTIM ELECTRODES-CORTICL
CRANIEC-IMPLNT NEUROSTIM-CEREB-CORT
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
CRANIECT-ELECTROD CEREBELLAR; CORTI
CRANIECT-ELECTROD CEREBELLAR; SUBCO
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
ELEVAT SKULL FX; SIMPL EXTRADURAL
ELEVAT SKULL FX; COMPOUND EXTRADURL
ELEVAT SKULL FX; W/REPR DURA
CRANIOT-REPR CSF LEAK W/SURG-OTORRH
REDUCT CRANIOMEGALIC SKULL; WO GFT
REDUCT CRANIOMEGALIC SKULL; W/PLSTY
REDUCT CRANIOMEGALIC; W/CRANIOT
REPR ENCEPHALOCELE INCL CRANIOPLSTY
CRANIOT-REPR ENCEPHALOCE SKULL BASE
CRANIOPLASTY SKULL DEFECT; TO 5 CM
CRANIOPLASTY SKULL DEFECT; > 5 CM
REMOV BONE FLAP/PROSTH PLATE-SKULL
REPLAC BONE FLAP/PROSTH PLATE-SKULL
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
62256
62258
62263
62264
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
62290
62291
62292
62294
62310
62311
62318
62319
62350
62351
62355
62360
62361
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
NEUROENDO IC; W/EXC PITUIT TUMR TRANSNASL APPRCH
VENTRICULOCISTERNOSTOMY
CREAT SHUNT; SUBARACHNOID/SUBDURAL
CREAT SHUNT; SUBDURAL-PERITONEAL
REPLAC/IRRIGA SUBARACHNOID CATH
VENTRICULOCISTERNOSTMY 3RD VENTRICL
VENTRICULOCISTERNOST-3RD; STEREOTAC
CREAT SHUNT; VENTRICULO-ATRIAL
CREAT SHUNT; VENTRICULO-PERITONEAL
REPLAC/IRRIGA VENTRICULAR CATH
REPLAC/REVIS CSF SHUNT/OBSTRUC VALV
REPROGRAMMING OF PROGRAMMABLE CSF SHUNT
REMOV COMPLT CSF SHUNT; WO REPLAC
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
INJ NEUROLY W/WO OTH SUB; SUBARACH
INJ NEUROLY W/WO OTH SUBST; EPI C/T
INJ NEUROLY W/WO OTH SUBST; EPI L/S
INJ PROC-MYELOGRPHY &/OR CAT-SPINAL
ASPIR/DECOMPRESS-NUC PULPOS-LUMB
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
IMPLNT/REPLC DEVIC-EPIDUR; NONPROGM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
62362
62365
62367
62368
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
No
No
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
IMPLNT/REPLAC DEVIC-EPIDUR; PROGMBL
REMOV PREV IMPLNT SUBQ RESVOIR/PUMP
ELEC ANALY PROGRM PUMP; WO REPROGRM
ELEC ANALYS PROGRM PUMP; W/REPROGRM
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 FACETS-LUMBAR
LAMINECT W/EXPLOR > 2 SEGMT; CERV
LAMINECT W/EXPLOR > 2 SEGMT; THORAC
LAMINECT W/EXPLOR > 2 SEGMT; LUMBAR
LAMINOT W/DECOMP; 1 INTERSPACE CERV
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
LAMINECT 1 VERT SEGMT-UNI/BIL; CERV
LAMINECT 1 VERT SEGMT-UNI/BIL; THOR
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
COSTOVERTEB THORACIC; EA ADD SEGMT
DISKECT ANT; CERV SNGL INTERSPACE
DISKECT ANT; CERV EA ADD INTERSPACE
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
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
LAMINECT-2 STAGES W/IN 14 DA; CERV
LAMINECT-2 STAGE W/IN 14 DA; THORAC
LAMINECTOMY W/RELEASE CORD LUMBAR
LAMINECTOMY-EXC AV MALFORM; CERV
LAMINECT-EXC AV MALFORM; THORACIC
LAMINECT-EXC AV MALFORM; THORACOLUM
LAMINECT-EXC LES-EXTRADURAL; CERV
LAMINECT-EXC LES-EXTRADURAL; THORAC
LAMINECT EXC LES-EXTRADURAL; LUMBAR
LAMINECT-EXC LES-EXTRADURAL; SACRAL
LAMINECT-EXC LES-INTRADURAL; CERV
LAMINECT-EXC LES-INTRADURAL; THORAC
LAMINECT-EXC LES-INTRADURAL; LUMBAR
LAMINECT-EXC LES-INTRADURAL; SACRAL
LAMINECT BX NEOPLSM; EXTRADURL-CERV
LAMINECT BX NEOPLSM; EXTRADURL-THOR
LAMINECT BX NEOPLSM; EXTRADURL-LUMB
LAMINECT BX NEOPLSM; EXTRADUR-SACRL
LAMINECT; INTRADUR EXTRAMEDUL CERV
LAMINECT; INTRADUR EXTRAMED THORAC
LAMINECT; INTRADUR EXTRAMEDUL LUMB
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63615
63650
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408
64410
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Description
LAMINECT-BX NEOPLSM; INTRADUR SACRL
LAMINECT; INTRADUR INTRAMEDUL CERV
LAMINECT; INTRADUR INTRAMEDUL THORA
LAMINECT; INTRAMEDULLARY THORACULUM
LAMINECTOMY; COMBO EXTRA-INTRADURL
OSTEOPLASTIC RECON DORS SP FLW PRIM INTRASP PROC
VERTEBRAL CORPECT; EXTRADURAL CERV
VERTEB CORPECT; TRANSTHORACIC
VERTEB CORPECT; THORACOLUMBAR
VERTEB CORPECT; TRANSPERITONEAL
VERTEBRAL CORPECT; INTRADURAL CERV
VERTEB CORPECT; INTRADUR-TRANSTHORA
VERTEB CORPEC; INTRADUR-THORACOLUMB
VERTEB CORPECT; INTRADUR-TRANSPERIT
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
REVIS IMPLNT SPINAL NEUROSTIM GEN
REPR MENINGOCELE; < 5 CM DIAMETER
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
REPLAC LUMBOSUBARACHNOID SHUNT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64470
64472
64475
64476
64479
64480
64483
64484
64505
64508
64510
64517
64520
64530
64550
64553
64555
64560
64561
64565
64573
64575
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
INJ ANES AGENT; SPINAL ACCES NERV
INJ ANES AGENT; CERV PLEXUS
INJ ANES AGENT; BRACHIAL PLEXUS
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 NERV-MX
INJ ANES AGENT; ILIOINGUINAL NERV
INJ ANES AGENT; PUDENDAL NERV
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
INJ ANES FACET JT; CERV/THOR-1LEVEL
INJ ANES FACET JT; CERV/THOR-EA ADD
INJ ANES FACET JT; LUMB/SAC-1LEVEL
INJ ANES FACET JT; LUMB/SAC-EA ADD
INJ ANES EPIDUR; CERV/THOR 1 LEVEL
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
INJ ANES AGENT; CAROTID SINUS (SEP)
INJ ANES AGENT; STELLATE GANGLION
INJECTION ANESTHETIC AGT; SUP HYPOGASTRIC PLEXUS
INJ ANES AGENT; LUMBAR/THORACIC
INJ ANES AGENT; CELIAC PLEXUS
APPLIC SURFACE NEUROSTIMULATOR
PERQ IMPLNT ELECTRODE; CRANIAL NERV
PERQ IMPLNT ELECTRODES; PERIPHERAL
PERQ IMPLNT ELECTRODES; AUTONOMIC
PERQ IMPL NEUROSTIM ELEC; SAC NERV
PERQ IMPLNT ELECTRODES; NEUROMUSCUL
INCS IMPLNT ELECTRODE; CRANIAL NERV
INCS IMPLNT ELECTRODES; PERIPHERAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
64577
64580
64581
64585
64590
64595
64600
64605
64610
64612
64613
64614
64620
64622
64623
64626
64627
64630
64640
64650
64653
64680
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
INCS IMPLNT ELECTRODES; AUTONOMIC
INCS IMPLNT ELECTRODES; NEUROMUSCUL
INCI IMPL NEUROSTIM ELEC; SAC NERVE
REVIS/REMOV PERIPHERAL ELECTRODE
INSRT/REPL PERIPHERAL NEUROSTIM PULSE GEN/RECV
REVIS/REMOV PERIPHERAL PULSE GEN
DESTRCT TRIGEMINAL; SUPRAORBITAL
DESTRCT TRIGEMOMAL; 2ND & 3RD DIV
DESTRCT TRIGEMINAL; W/RADIOLOGIC
DESTRUC; MUSC INNERV-FACIAL NRV
DESTRCT NEUROLYT; CERV SPINAL MUSCL
DESTRUC; EXTRMTY &/OR TRUNK MUSC
DESTRUC-NEUROLYTIC INTERCOST NRV
DESTRUC FACET JT NRV; L/S-1 LEVEL
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
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
NEUROPLSTY PERIPHERL; LUMBAR PLEXUS
NEUROPLSTY/TRANSPOSIT; CRANIAL NERV
NEUROPLASTY; ULNAR NERV @ ELBOW
NEUROPLASTY; ULNAR NERV @ WRIST
NEUROPLASTY; MEDIAN @ CARPAL TUNNEL
DECOMP; UNSPECIFIED NERV (SPECIFY)
DECOMP; PLANTAR DIGITAL NERV
INT NEUROLYSIS W/USE OR MICRO
TRANSECT/AVULSION SUPRAORBITAL NERV
TRANSECT/AVULSION INFRAORBITAL NERV
TRANSECTION/AVULSION MENTAL NERV
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
TRANSECT INFERIOR ALVEOLAR NERV
TRANSECT/AVULSION LINGUAL NERV
TRANSECT FACIAL NERV DIFF/COMPLT
TRANSECT/AVULSION GREATR OCCIP NERV
TRANSECT/AVULSION PHRENIC NERV
TRANSECT VAGUS NERV TRANSTHORACIC
TRANSECT/VAGI LTD TO PROX STOMACH
TRANSECT/AVULSION VAGUS NERV ABD
TRANSECT/AVULSION PUDENDAL NERV
TRANSECT OBTURATOR NERV EXTRAPELVIC
TRANSECT OBTURATOR NERV INTRAPELVIC
TRANSECT OTHR CRANIAL NERV EXTRADUR
TRANSECT OTHER SPINAL NERV EXTRADUR
EXC NEUROMA; CUT NERV SURG IDENT
EXC NEUROMA; DIGIT NERV 1/BOTH SAME
EXC NEUROMA; DIGIT NERV EA ADD DIGT
EXC NEUROMA; HAND/FT EX DIGIT NERV
EXC NEUROMA; HAND/FT EA ADD NERV
EXC NEUROMA; MAJOR NERV EX SCIATIC
EXC NEUROMA; SCIATIC NERV
IMPLNT NERV END INTO BONE/MUSCL
EXC NEUROFIBROMA; CUT NERV
EXC NEUROFIBROMA; MAJ PERIPHERAL
EXC NEUROFIBROMA; EXTEN
BX NERV
SYMPATHECTOMY CERV
SYMPATHECTOMY CERVICOTHORACIC
SYMPATHECTOMY THORACOLUMBAR
SYMPATHECTOMY LUMBAR
SYMPATHECTOMY DIG ARTS W/MAGNIFI-EA
SYMPATHECTOMY; RADIAL ARTERY
SYMPATHECTOMY; ULNAR ARTERY
SYMPATHECTOMY; SUP PALMAR ARCH
SUTURE DIGITAL NERV HAND/FT; 1 NERV
SUTURE DIGITAL NERV HAND/FT; EA ADD
SUTURE 1 NERV HAND/FT; COMMON SENSO
SUTURE 1 NERV HAND/FT; MED MOTOR
SUTURE 1 NERV HAND/FT; ULNAR MOTOR
SUTURE EA ADD NERV HAND/FT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64910
64911
64999
65091
65093
65101
65103
65105
65110
65112
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
SUTURE POST TIBIAL NERV
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
SUTURE FACIAL NERV; EXTRACRANIAL
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
NERV GFT HEAD/NECK; TO 4 CM LENGTH
NERV GFT HEAD/NECK; > 4 CM LENGTH
NERV GFT 1 STRAND HAND/FT; TO 4 CM
NERV GFT 1 STRAND HAND/FT; > 4 CM
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
NERV GFT MX STRAND HAND/FT; > 4 CM
NERV GFT MX STRAND ARM/LEG; TO 4 CM
NERV GFT MX STRAND ARM/LEG; > 4 CM
NERV GFT EA ADD NERV; SNGL STRAND
NERV GFT EA ADD NERV; MX STRANDS
NERV PEDICLE TRANSF; FIRST STAGE
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 ATTACH-IMPLT
ENUCLEAT EYE; MUSCL ATTACHED-IMPLNT
EXENTERATION ORBITAL CONTENTS; ONLY
EXENTERAT ORBITAL CONTENTS; W/BONE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
65114
65125
65130
65135
65140
65150
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65760
65765
65767
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
EXENTERAT ORBITAL CONTENTS; W/FLAP
MODIF OCULAR IMPLNT W/PLC PEGS (SP)
INSRT OCULAR IMPLNT 2ND; AFTR EVISC
INSRT OCULAR IMPLNT 2ND; AFTR ENUCL
INSRT OCULAR IMPLNT; MUSCL ATTACH
REINSRT OCULAR IMPLNT; W/WO GFT
REINSRT OCULAR IMPLNT; W/REINFORCE
REMOV OCULAR IMPLNT
REMOV FB EXT EYE; CONJUNC SUPERF
REMOV FB EXT EYE; CONJUNC EMBEDDED
REMOV FB EXT EYE; CORNEAL WO LAMP
REMOV FB EXT EYE; CORNEAL W/LAMP
REMOV FB IO; ANT CHAMBER/LENS
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
DESTRCT LES CORNEA-CRYOTHERAPY
MX PUNCTURES ANT CORNEA
KERATOPLASTY; LAMELLAR
KERATOPLASTY; PENETRAT (EX APHAKIA)
KERATOPLASTY; PENETRATING (APHAKIA)
KERATOPLSTY; PENETRAT (PSEUDOAPHAK)
KERATOMILEUSIS
KERATOPHAKIA
EPIKERATOPLASTY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
65770
65771
65772
65775
65780
65781
65782
65800
65805
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900
65920
65930
66020
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66600
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
KERATOPROSTHESIS
RADIAL KERATOTOMY
CORNEAL RELAXING INCS-ASTIGMATISM
CORNEAL WEDGE RESECT-ASTIGMATISM
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
PARACENTESIS; W/REMOV VITREOUS
PARACENTESIS (SEP PRO); W/REMOV BLD
GONIOTOMY
TRABECULOTOMY AB EXT
TRABECULOPLSTY-LASER-1/MORE SESSION
SEVERING ADHESIONS (SEPART PROC)
SEVERING ADHESIONS; GONIOSYNECHIAE
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
FISTULIZ SCLERA; TREPHINAT W/IRIDEC
FISTULIZAT SCLERA; THERMOCAUTERIZAT
FISTULIZAT SCLERA; SCLERECT W/PUNCH
FISTULIZAT SCLERA; IRIDENCLEISIS
FISTULIZ SCLER; TRABECULECT AB EXT
FISTULIZAT SCLERA; TRABECULECT
AQUEOUS SHUNT-EXTRAOCULAR RESERVOIR
REVIS AQUEOUS SHUNT-EXTOCULAR RESER
REPR SCLERAL STAPHYLOMA; WO GFT
REPR SCLERAL STAPHYLOMA; W/GFT
REVIS OPERATIVE WOUND ANT SEGMT
IRIDOTOMY (SEP PRO); EX TRANSFIXION
IRIDOTOMY (SEP PRO); W/TRANSFIXION
IRIDECTOMY W/CORNEO SECT; REMOV LES
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
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
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
66605
66625
66630
66635
66680
66682
66700
66710
66711
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015
67025
67027
67028
67030
67031
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
IRIDECTOMY W/CORNEO SECT; W/CYCLECT
IRIDECT; PERIPHERAL GLAU (SEP PRO)
IRIDECTOMY; SECTOR GLAU (SEP PRO)
IRIDECTOMY; "OPTICAL" (SEPART PROC)
REPR IRIS CILIARY BODY
SUTURE IRIS CILIARY BODY (SEP PRO)
CILIARY BODY DESTRCT; DIATHERMY
CILIARY BDY DESTRUC; CYCLOPHOTOCOAG TRANSSCLERAL
CILIARY BODY DESTRCTION; CYCLOPHOTOCOAGULAT ENDO
CILIARY BODY DESTRCT; CRYOTHERAPY
CILIARY BODY DESTRCT; CYCLODIALYSIS
IRIDOTOMY/IRIDECTOMY BY LASER SURG
IRIDOPLASTY BY PHOTOCOAGULATION
DESTRCT CYST/LES IRIS/CILIARY BODY
DISCISSION 2ND CATARACT; STAB INCS
DISCISSION 2ND CATARACT; LASER SURG
REPOSIT IO LENS REQ INCS (SEP PRO)
REMOV 2ND CATARACT W/CORNEO-SCLERAL
REMOV LENS MAT; ASPIRT TECH 1/MORE
REMOV LENS MAT; PHACOFRAGMENTAT
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
REMOV VITREOUS ANT; SUBTL REMOV
ASPIRAT/VITREOUS/SUBRETINAL FLUID
INJ VITREOUS SUBSTITUTE (SEP PRO)
IMPLNT INTRAVITREAL DRUG DELIV SYST
INTRAVITREAL INJ-AGENT (SEP PRO)
DISCISSION VITREOUS STRANDS
SEVERING VITREOUS STRANDS-LASER
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
67036
67038
67039
67040
67041
67042
67043
67101
67105
67107
67108
67110
67112
67113
67115
67120
67121
67141
67145
67208
67210
67218
67220
67221
67225
67227
67228
67229
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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
REPR RETINAL DETACH; CRYOTHERAPY
REPR RETINAL DETACH; PHOTOCOAGULAT
REPR RETINAL DETACH; SCLERAL BUCKL
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
PROPHYLAXIS RETINAL DETACH; PHOTOCO
DESTRCT LES RETINA; CRYOTHERAPY
DESTRCT LES RETINA; PHOTOCOAGULAT
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
SCLERAL REINFORCE (SEP PRO); W/GFT
UNLISTED PROC POST SEGMT
STRABISMUS SURG; 1 HORIZONTAL MUSCL
STRABISMUS SURG; 2 HORIZONTAL MUSCL
STRABISMUS SURG; 1 VERTICAL MUSCL
STRABISMUS SURG; 2/MORE VERTICAL
STRABISMUS SURG SUPER OBLIQUE
TRANSPOSITION EXTRAOCULAR MUSCL
STRABISMUS SURG-PT W/PREV EYE SURG
STRABISMUS SURG-PT W/SCARRING MUSCL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
67334
67335
67340
67343
67345
67346
67350
67399
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700
67710
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Description
STRABISMUS SURG-POST FIXA SUTURE
PLCMT ADJUSTABLE SUTURE-STRABISMUS
STRABISMUS SURG EXPLOR &/OR REPR
RELEASE EXTEN SCAR TISS (SEP PRO)
CHEMODENERVATION EXTRAOCULAR MUSCL
BIOPSY, EYE MUSCLE
BX EXTRAOCULAR MUSCL
UNLISTED PROC OCULAR MUSCL
ORBITOTOMY WO BONE FLAP; W/WO BX
ORBITOTOMY WO BONE FLAP; W/DRAIN
ORBITOTOMY WO BONE FLP; W/REMOV LES
ORBITOTOMY WO BONE FLP; W/REMOV FB
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
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
EXC CHALAZION; GEN ANES &/OR HOSP
BX EYELID
CORRECT TRICHIASIS; EPILAT-FORCEPS
CORREC TRICHIASIS; EPILA NOT FORCPS
CORRECT TRICHIASIS; INCS LID MARGIN
CORRECT TRICHIASIS; INCS LID W/GFT
EXC LES LID WO CLO/W SMPL DIREC CLO
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
Yes
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
68110
68115
68130
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Description
DESTRCT LES LID MARGIN
TEMPORARY CLO EYELIDS BY SUTURE
CONSTRUCT INTERMARGINAL ADHESIONS
CONSTRCT ADHESIONS; W/TRANSPOSIT
REPR BROW PTOSIS
REPR BLEPHAROPTOSIS; W/SUTURE/OTHER
REPR BLEPHAROPTOSIS; W/FASCIAL SLNG
REPR BLEPHAROPTOSIS; RESECT-INT
REPR BLEPHAROPTOSIS; RESECT-EXT
REPR BLEPHAROPTOSIS; SUPER RECTUS
REPR BLEPHAROPTOSIS; CONJUNC-TARSO
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68371
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
68760
68761
68770
68801
68810
68811
68815
68816
68840
68850
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
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
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
Description
DESTRCT LES CONJUNC
SUBCONJUNCTIVAL INJ
CONJUNCTIVOPLASTY; W/CONJUNC GFT
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
HARVESTING CONJUNCTIVAL ALLOGRAFT LIVING DONOR
UNLISTED PROC CONJUNC
INCS DRAINAGE LACRIMAL GLAND
INCS DRAINAGE LACRIMAL SAC
SNIP INCS LACRIMAL PUNCTUM
EXC LACRIMAL GLAND EX TUMOR; TOT
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
CLO LACRIMAL PUNCTUM; BY PLUG EA
CLO LACRIMAL FISTULA (SEPART PROC)
DILAT LACRIMAL PUNCTUM W/WO IRRIGA
PROBE NASOLACRIM DUCT W/WO IRRIG;
PROBE NASOLACRIM DUCT; REQ GEN ANES
PROBE NASOLAC DUCT; W/INSERT TUBE
PROBE NL DUCT W/BALLOON
PROBING LACRIMAL CANALICULI
INJ CONTRAST MEDIUM DACRYOCYSTOGPHY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
68899
69000
69005
69020
69090
69100
69105
69110
69120
69140
69145
69150
69155
69200
69205
69210
69220
69222
69300
69310
69320
69399
69400
69401
69405
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
No
No
No
Not Reimbursable
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Not Reimbursable
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Description
UNLISTED PROC LACRIMAL SYST
DRAIN EXT EAR ABSCESS; SIMPL
DRAIN EXT EAR ABSCESS; COMPLIC
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
EXC EXOSTOSIS EXT AUDITORY CANAL
EXC SOFT TISS LES EXT AUDITRY CANAL
RAD EXC AUDITRY CANAL LES; WO DISSC
RAD EXC AUDITRY CANAL LES; W/DISSEC
REMOV FB-EXT AUDIT CANAL; WO ANES
REMOV FB-EXT AUDIT CANAL; W/ANES
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)
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
VENTILAT TUBE REMOV-INSRT BY ANOTHR
TYMPANOSTOMY LOCAL/TOPICAL ANES
TYMPANOSTOMY GEN ANES
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
Not Reimbursable
No
No
No
No
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
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
69550
69552
69554
69601
69602
69603
69604
69605
69610
69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
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
Yes
Yes
Yes
Yes
Description
EXC AURAL GLOMUS TUMOR; TRANSCANAL
EXC AURAL GLOMUS TUMR; TRANSMASTOID
EXC AURAL GLOMUS TUMOR; EXTEN
REVIS MASTOIDEC; RESULT-COMPLT
REVIS MASTOIDEC; RESULT-MODIF RAD
REVIS MASTOIDEC; RESULT-RAD MASTOID
REVIS MASTOIDEC; RESULT-TYMPANOPLST
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
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
REPLAC; OSSEOINTEGRATED IMPLANT
REPLAC; W/MASTOIDECTOMY
DECOMP FACIAL NERV; LAT-GENICULATE
DECOMP FACIAL NERV; MED-GENICULATE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
69740
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
69970
69979
69990
70010
70015
70030
70100
70110
70120
70130
70134
70140
70150
70160
70170
70190
70200
70210
70220
70240
70250
70260
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
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
Description
SUTURE FACIAL NERV; LAT-GENICULATE
SUTURE FACIAL NERV; MED-GENICULATE
UNLISTED PROC MID EAR
LABYRINTHOTOMY; TRANSCANAL
LABYRINTHOTOMY; W/MASTOIDEC
ENDOLYMPHATIC SAC OR; WO SHUNT
ENDOLYMPHATIC SAC OR; W/SHUNT
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 SECT-TRANSCRANIAL
TOT FACIAL NERV DECOMP &/OR REPR
DECOMP INT AUDITORY CANAL
REMOV TUMOR TEMPORAL BONE
UNLISTED-TEMPORAL BONE-MID FOSSA
USE OPER MICROSCOPE
MYELOGRAPHY POST FOSSA-RAD S & I
CISTERNOGRAPHY + CONTRAST-RAD S & I
RAD EXAM EYE DETECTION FB
RAD EXAM MANDIB; PART < 4 VIEWS
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70370
70371
70373
70380
70390
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
70543
70544
70545
70546
70547
70548
70549
70551
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
RAD EXAM TEETH; SNGL VIEW
RAD EXAM TEETH; PART < FULL MOUTH
RAD EXAM TEETH; COMPLT FULL MOUTH
RAD EXAM TMJ OPEN & CLO MOUTH; UNI
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
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
CAT ORBIT/SELLA/EAR; WO CONTRAST
CAT ORBIT/SELLA/EAR; W/CONTRAST
CAT ORBIT; WO CONTRAST THEN CONTRST
CAT MAXILLOFACIAL AREA; WO CONTRAST
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
70552
70553
70554
70555
70557
70558
70559
71010
71015
71020
71021
71022
71023
71030
71034
71035
71040
71060
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
71555
72010
72020
72040
72050
72052
72069
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Description
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
MRI BRAIN DUR INTRACRAN;NO CONTRST FLWED CONTRST
RAD EXAM CHEST; SNGL VIEW FRONTAL
RAD EXAM CHEST; STEREO FRONTAL
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
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
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
RAD EXAM; STERNOCLAVICULAR JT/JTS
CAT THORAX; WO CONTRAST MAT
CAT THORAX; W/CONTRAST MAT
CAT THORAX; WO THEN W/CONTRAST
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
72070
72072
72074
72080
72090
72100
72110
72114
72120
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72170
72190
72191
72192
72193
72194
72195
72196
72197
72198
72200
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Description
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
RAD EXAM SPINE LUMBOSACR; AP & LAT
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
72202
72220
72240
72255
72265
72270
72275
72285
72291
72292
72295
73000
73010
73020
73030
73040
73050
73060
73070
73080
73085
73090
73092
73100
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
RAD EXAM SACROILIAC JT; 3/MORE VIEW
RAD EXAM SACRUM & COCCYX MIN 2 VIEW
MYELOGRAPHY CERV-RAD S & I
MYELOGRAPHY THORACIC-RAD S & I
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
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
RAD EXAM; FOREARM AP & LAT VIEWS
RAD EXAM; UPPER EXTREM INFANT MIN 2
RAD EXAM WRIST; AP & LAT VIEWS
RAD EXAM WRIST; COMPLT MINI 3 VIEWS
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
73225
73500
73510
73520
73525
73530
73540
73542
73550
73560
73562
73564
73565
73580
73590
73592
73600
73610
73615
73620
73630
73650
73660
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
74000
74010
74020
74022
74150
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Description
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
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
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
74160
74170
74175
74181
74182
74183
74185
74190
74210
74220
74230
74235
74240
74241
74245
74246
74247
74249
74250
74251
74260
74270
74280
74283
74290
74291
74300
74301
74305
74320
74327
74328
74329
74330
74340
74350
74355
74360
74363
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
RAD EXAM; PHARYNX &/OR CERV ESOPH
RAD EXAM; ESOPH
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
RAD EXAM GI UP-AIR CONTRAST; W/KUB
RAD EXAM GI-AIR CONTRST; W/SM BOWEL
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 CONTRAST-BARIUM
THERAP ENEMA-CM/AIR REDUC OBSTRUCTN
CHOLECYSTOGRAPHY ORAL CONTRAST
CHOLECYSTOGRPY ORAL CONTRST; REPEAT
CHOLANGIOGRAPHY; INTRAOP-RAD S & I
CHOLANGIOGRPHY; ADD SET-INTRAOP-S&I
CHOLANGIOGRAPHY; POSTOP-RAD S & I
CHOLANGIOG PERQ TRANSHEPATIC-S & I
POSTOP BILI DUCT STONE REMOV-S & I
ENDO CATH-BILI DUCT SYST-RAD S & I
ENDO CATH-PANCREAT DUCT SYST-S & I
COMBO ENDO CATH-BILI/PANCREAT-S & I
INTRO LONG GI TUBE W/MX FILMS-S & I
PERCUT PLCMT GASTRO TUBE-RAD S & I
PERQ PLCMT ENTEROCLYSIS TUBE-S & I
INTRALUMINAL DILAT STRICT-RAD S & I
PERQ TRANSHEPAT DILAT STRICT-S & I
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
74400
74410
74415
74420
74425
74430
74440
74445
74450
74455
74470
74475
74480
74485
74710
74740
74742
74775
75552
75553
75554
75555
75556
75557
75558
75559
75560
75561
75562
75563
75564
75600
75605
75625
75630
75635
75650
75658
75660
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
YES
YES
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
No
No
Description
UROGRAPHY IV W/WO KUB W/WO TOMOGPHY
UROGRAPHY INFUSION DRIP &/OR BOLUS
UROGRAPHY DRIP/BOLUS; W/NEPHROTOM
UROGRAPHY RETROGRADE W/WO KUB
UROGRAPHY ANTEGRADE-RAD S & I
CYSTOGRAPHY MINI 3 VIEWS-RAD S & I
VASOGRPHY/VESICULOGRPHY-RAD S & I
CORPORA CAVERNOSOGRAPHY-RAD S & I
URETHROCYSTOGRAPHY RETROGRADE-S & I
URETHROCYSTOGRPHY VOIDING-RAD S & I
RAD EXAM-RENAL CYST-TRNSLUMB-S & I
INTRO INTRACATH-RENAL PELVIS-S & I
INTRO URETERAL CATH-RENAL PELV-S&I
DILAT NEPHROST/URETERS/URETHRA-S&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
CARDIAC MRI-FUNCT; LTD STUDY
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 SERIALOG-S&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 SELECT-S&I
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
75662
75665
75671
75676
75680
75685
75705
75710
75716
75722
75724
75726
75731
75733
75736
75741
75743
75746
75756
75774
75790
75801
75803
75805
75807
75809
75810
75820
75822
75825
75827
75831
75833
75840
75842
75860
75870
75872
75880
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANGIO EXT CAROTID BILAT SELECT-S&I
ANGIO CAROTID CEREBRAL UNILAT-S & I
ANGIO CAROTID CEREBRAL BILAT-S & I
ANGIO CAROTID CERV UNILAT-RAD S & I
ANGIO CAROTID CERV BILAT-RAD S & I
ANGIO VERTEBRAL CERV/INTRACRAN-S&I
ANGIO SPINAL SELECT-RAD S & I
ANGIO EXTREM UNILAT-RAD S & I
ANGIO EXTREM BILAT-RAD S & I
ANGIO RENAL UNILAT SELECT-RAD S & I
ANGIO RENAL BILAT SELECT-RAD S & I
ANGIO VISCERAL SELEC/SUPRASELEC-S&I
ANGIO ADRENAL UNILAT SELECT-RAD S&I
ANGIO ADRENAL BILAT SELEC-RAD S & I
ANGIO PELVIC SELEC/SUPRASELEC-S & I
ANGIO PULM UNILAT SELECT-RAD S & I
ANGIO PULM BILAT SELECT-RAD S & I
ANGIO PULM-NONSELECT CATH-RAD S & I
ANGIO INT MAMMARY-RAD S & I
ANGIO SELECT EA ADD VESSEL-S&I
ANGIO AV SHUNT-RAD S & I
LYMPHANGIOG EXTREM ONLY UNILAT-S&I
LYMPHANGIOG EXTREM ONLY BILAT-S & I
LYMPHANGIO PELVIC/ABD UNILAT-S & I
LYMPHANGIOG PELVIC/ABD BILAT-S & I
SHUNTOGM INVESTIGAT PREV PLACED-S&I
SPLENOPORTOGRAPHY-RAD S & I
VENOGRAPHY EXTREM UNILAT-RAD S & I
VENOGRAPHY EXTREM BILAT-RAD S & I
VENOGRAPHY CAVAL INFERIOR-RAD S & I
VENOGRAPHY CAVAL SUPER-RAD S & I
VENOGRPHY RENAL UNILAT SELECT-S & I
VENOGRAPHY RENAL BILAT SELECT-S & I
VENOGRPHY ADRENAL UNILAT SELECT-S&I
VENOGRAPHY ADRENAL BILAT SELECT-S&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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
75885
75887
75889
75891
75893
75894
75896
75898
75900
75901
75902
75940
75945
75946
75952
75953
75954
75956
75957
75958
75959
75960
75961
75962
75964
75966
75968
75970
75978
75980
75982
75984
75989
75992
75993
75994
75995
75996
75998
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
PERQ TRANSHEPAT PORTOG W/EVAL-S & I
PERQ TRANSHEPAT PORTOG WO EVAL-S&I
HEPAT VENOG WEDGED/FREE W/EVAL-S&I
HEPAT VENOG WEDGED/FREE WO EVAL-S&I
VENOUS SAMPL-CATH W/WO ANGIO-S & I
TRANSCATH THERAP EMBOLIZAT-RAD S&I
TRANSCATH THERAP INFUSION-RAD S & I
ANGIO-EXIST CATH F/U STUDY-THERAP
EXCHG PREV PLCD ART CATH-RAD S & I
MECH REMV PERICATH OBST CV DEV SEP ACSS RAD S&I
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 PERIPH-S&I
TRANSLUM BALLOON ANGIOPL EA ADD-S&I
TRANSLUM BALOON ANGIOPL RENAL-S & I
TRNSLUM BALN ANGIOPL EA ADD VISCER
TRANSCATH BX-RAD S & I
TRANSLUM BALLOON ANGIOPL VENOUS-S&I
PERQ TRANSHEP BILI DRAIN-RAD S&I
PERQ PLCMT CATH-INOPER OBSTRCT-S&I
CHANGE PERQ DRAIN CATH W/MONIT-S&I
RAD GUID PERC DRAIN ABSC W/CATH-S&I
TRANSLUM ATHERECT PERIPHER ART-S&I
TRANSLUM ATHERECT EA ADD PERIPH-S&I
TRANSLUMNL ATHERECT RENAL-RAD S & I
TRANSLUM ATHERECT VISCERAL-RAD S&I
TRANSLUM ATHERECT EA ADD VISCER-S&I
FLUORO GUID CVAD PLACEMENT REPLACEMENT/REMOVAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
76000
76001
76003
76005
76006
76010
76012
76013
76020
76040
76061
76062
76065
76066
76070
76071
76075
76076
76077
76078
76080
76082
76083
76086
76088
76090
76091
76092
76093
76094
76095
76096
76098
76100
76101
76102
76120
76125
76140
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
Not Reimbursable
Description
FLUORO (SEP) TO 1HR-NOT 71023/71034
FLUORO-TIME > 1HR-ASSIST NON-RAD MD
FLUORO LOCALIZ NEEDLE BX/ASPIRAT
FLUORO GUID NEEDLE-SPINE INJ PROC
RAD EXAM STRESS VIEW(S) ANY JT
RAD EXAM NOSE-RECTUM FB-SNGL-CHILD
RAD SUPERVSN/INTERPRE PERCUTANEOUS VERTEBROPLASTY
RAD SUPERVSN/INTERPRE UNDER CT GUIDANCE
BONE AGE STUDIES
BONE LENGTH STUDIES
RAD EXAM OSSEOUS SURVEY; LTD
RAD EXAM OSSEOUS SURVEY; COMPLT
RAD EXAM OSSEOUS SURVEY INFANT
JT SURVEY SNGL VIEW 1/MORE JT
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
DXA BONE DENSITY STUDY 1/> SITES; VERT FX ASSESS
RADIOGRAPH ABSORPTIOMETRY 1/> SITES
RAD EXAM ABSC/FISTUL/SINUS TRAC-S&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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
76150
76350
76355
76360
76362
76370
76376
76377
76380
76390
76393
76394
76400
76496
76497
76498
76499
76506
76510
76511
76512
76513
76514
76516
76519
76529
76536
76604
76645
76700
76705
76770
76775
76776
76778
76800
76801
76802
76805
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Yes
No
No
No
No
No
No
No
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
No
No
No
Description
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
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 A-SCAN SAME ENCNTR
OPHTHALMIC US DX; QUANTITATIVE A-SCAN ONLY
OPHTHALMIC US DX; B-SCAN W/WO NON-QUAN A-SCAN
OPHTHALMIC US DX; ANT SEG US B-SCAN/BIOMICROSCPY
OPHTHALMIC US DX; CORNEAL PACHYMETRY UNI/BIL
OPHTH BIOMETRY-ULTRASND ECHO A-SCAN
OPHTH BIOMET A-SCAN; W/IO LENS POWR
OPHTH ULTRASONIC FB LOCALIZ
ECHO-SOFT TISS HEAD B-SCAN W/IMAGE
ECHO CHEST B-SCAN W/IMAGE DOCUMEN
ECHO BREAST(S) B-SCAN W/IMAGE DOCUM
ECHO ABD B-SCAN W/IMAGE DOC; COMPLT
ECHO ABD B-SCAN W/IMAGE DOC; LTD
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Yes
No
No
No
No
No
No
No
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
76810
76811
76812
76813
76814
76815
76816
76817
76818
76819
76820
76821
76825
76826
76827
76828
76830
76831
76856
76857
76870
76872
76873
76880
76885
76886
76930
76932
76936
76937
76940
76941
76942
76945
76946
76948
76950
76965
76970
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
ECHO PG UTERUS B-SCAN W/DOC; REPEAT
US PG UTERUS REAL TIME W/IMAGE DOC TRANSVAGINAL
FETAL BIOPHYSICAL PROFILE
PROFILE FETAL BIOPHYSICAL W/NON-STRESS 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
ECHO PELVIC B-SCAN W/DOCUMEN; LTD
ECHO SCROTUM & CONTENTS
ULTRASOUND TRANSRECTAL;
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 BX-S&I
US GUID COMPRESS REPR PSEUDO-ANEURY
US GUID VASC ACSS PTNTL ACSS SITE W/PERM REC&RPT
ULTRASOUND GUID&MONITORING VISCERAL TISSUE ABLAT
US GUID IN UTERO FETAL TRNSFUS-S&I
ULTRASON GUIDAN NEEDLE BX-RAD S & I
US GUID CHORIONIC VILLUS SAMPL-S&I
ULTRASON GUIDAN AMNIOCENTESIS-S & I
ULTRASON GUIDAN ASPIRAT OVA-S & I
ECHO PLCMT-RAD THERAP FIELDS B-SCAN
US GUID INTERST RADIOELEMENT APPLIC
ULTRASOUND STUDY F/U
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
76975
76977
76986
76998
76999
77001
77002
77003
77011
77012
77013
77014
77021
77022
77031
77032
77051
77052
77053
77054
77055
77056
77057
77058
77059
77071
77072
77073
77074
77075
77076
77077
77078
77079
77080
77081
77082
77083
77084
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Description
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
COMPUTER DX MAMMOGRAM ADD-ON
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
77261
77262
77263
77280
77285
77290
77295
77299
77300
77301
77305
77310
77315
77321
77326
77327
77328
77331
77332
77333
77334
77336
77370
77371
77372
77373
77399
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Description
THERAP RAD TX PLANNING; SIMPL
THERAP RAD TX PLANNING; INTERMED
THERAP RAD TX PLANNING; COMPLX
THERAP RAD SIMULAT-AIDED FIELD; SIM
THERAP RAD SIMULAT-AID FLD; INTERMD
THERAP RAD SIMULAT-AID FLD; COMPLX
TX RAD SIM-AIDED FIELD SETTING; 3-D
UNLIST PROC THERAP RAD TX PLANNING
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
SRS, MULTISOURCE
SRS, LINEAR BASED
SBRT DELIVERY
UNLIST PROC MED RAD PHYSICS DOSIMET
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
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
RAD TX DELIV-2 TX AREAS; 20 MEV/GRT
RAD TX DELIV-3/MORE AREAS; TO 5 MEV
RAD TX DELIV-3/MORE AREAS; 6-10 MEV
RAD TX DELIV-3/MORE AREAS; 11-19MEV
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
77416
77417
77418
77427
77431
77432
77435
77470
77499
77520
77522
77523
77525
77600
77605
77610
77615
77620
77750
77761
77762
77763
77776
77777
77778
77781
77782
77783
77784
77789
77790
77799
78000
78001
78003
78006
78007
78010
78011
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Description
RAD TX DELIV-3/MORE AREAS; 20 MEV
THERAP RAD PORT FILM
INTENS MOD TX DEL VIA TEMPORLLY MOD BEAM-TX SESS
RADIATION TX MGMT-FIVE TREATMENTS
RADIAT THERAP MGMT W/COMPLT COURSE
STEREOTACT RAD TX MGMT CEREBRAL LES
SBRT MANAGEMENT
SPECIAL TX PROC
UNLISTED PROC THERAP RAD TX MGMT
PROTON BEAM DELIV-1 TX AREA-W/SETUP
PROTON BEAN DELIV; SIMPLE W/COMP
PROTON BEAM DELIV 1-2 AREAS-W/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
INTRACAVIT RADIOELEM APPLIC; SIMPL
INTRACAVIT RADIOELEM APPLIC; INTERM
INTRACAVIT RADIOELEM APPLIC; COMPLX
INTERSTITIAL RADIOELEM APPLIC; SMPL
INTERSTIT RADIOELEM APPLIC; INTERMD
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 LOAD-RADIOELEMENT
UNLIST PROC CLINICAL BRACHYTHERAP
THYROID UPTAKE; SNGL DETERM
THYROID UPTAKE; MX DETERM
THYROID UPTAKE; STIM SUPRESS/DISCHG
THYROID IMAGING W/UPTAKE; 1 DETERM
THYROID IMAGING W/UPTAKE; MX DETERM
THYROID IMAGING; ONLY
THYROID IMAGING; W/VASCULAR FLOW
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78015
78016
78018
78020
78070
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78185
78190
78191
78195
78199
78201
78202
78205
78206
78215
78216
78220
78223
78230
78231
78232
78258
78261
78262
78264
78267
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
THYROID CA METASTAS IMAG; LTD AREA
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
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
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
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
SALIVARY GLAND IMAG; W/SERIAL IMAG
SALIVARY GLAND FUNCT STUDY
ESOPH MOTILITY
GASTRIC MUCOS IMAGING
GASTROESOPHAGEAL REFLUX STUDY
GASTRIC EMPTYING STUDY
UREA BREATH TEST C14 ISOTOPIC; ACQN ANALYSIS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78268
78270
78271
78272
78278
78282
78290
78291
78299
78300
78305
78306
78315
78320
78350
78351
78399
78414
78428
78445
78456
78457
78458
78459
78460
78461
78464
78465
78466
78468
78469
78472
78473
78478
78480
78481
78483
78491
78492
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Description
UREA BREATH TEST C14 ISOTOPIC; ANALYSIS
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
UNLISTED GI PROC DX NUCLEAR MEDS
BONE &/OR JT IMAGING; LTD AREA
BONE &/OR JT IMAGING; MX AREAS
BONE &/OR JT IMAGING; WHOLE BODY
BONE &/OR JT IMAGING; 3 PHASE STUDY
BONE &/OR JT IMAGING; TOMO (SPECT)
BONE DENSITY-1/> SITES; SNGL PHOTON
BONE DENSITY-1/>SITES; DUAL PHOTON
UNLISTED MS PROC DX NUCLEAR MEDS
DETERM CENTRAL C-V HEMODYNAMIC 1/MX
CARDIAC SHUNT DETECTION
NON-CARDIAC VASCULAR FLOW IMAGING
ACUTE VEN THROMBOSIS IMAG-PEPTIDE
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
MYOCARDIAL IMAG PLANAR; QUAL/QUAN
MYOCARDIAL IMAG; W/EJECT FRACT
MYOCARDIAL IMAG; TOMOGRPH SPECT
CARDIAC BLD POOL IMAG; SNGL STUDY
CARDIAC BLD POOL IMAG; MX STUDIES
MYOCARDIAL PERFUS STUDY QUAL/QUAN
MYOCARD PERFUS STUDY W/EJECT FRACT
CARDIAC BLD POOL 1ST PASS; SNGL
CARDIAC BLD POOL IMAG 1ST PASS; MX
MYOCARD IMAG-PET-PERFUS; SNGL STUDY
MYOCARD IMAG-PET-PERFUS; MX STUDIES
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78494
78496
78499
78580
78584
78585
78586
78587
78588
78591
78593
78594
78596
78599
78600
78601
78605
78606
78607
78608
78609
78610
78615
78630
78635
78645
78647
78650
78660
78699
78700
78701
78704
78707
78708
78709
78710
78715
78725
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Description
CARD BLD POOL IMAG-GATED SPECT-REST
CARD BLD POOL IMAG-GATED-1 STUDY
UNLISTED CARDIOVASC PROC DX NUCLEAR
PULM PERFUSION IMAGING PARTICULATE
PULM PERFUS PARTICULATE; 1 BREATH
PULM PERFUS PARTICULATE; REBREATH
PULM VENTILAT IMAG AEROSOL; 1 PROJ
PULM VENTILAT IMAG AEROSOL; MX PROJ
PULM PERF IMAG-PARTIC W/VENT-AEROSL
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
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
KIDNEY FUNT NON-IMAGE RADIOISOTOPIC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
78730
78740
78760
78761
78799
78800
78801
78802
78803
78804
78805
78806
78807
78811
78812
78813
78814
78815
78816
78890
78891
78999
79005
79101
79200
79300
79403
79440
79445
79999
80047
80048
80050
80051
80053
80055
80061
80069
80074
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Bundled
Bundled
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Description
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
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
ELECTROLYTE PANEL
COMP METABOLIC PANEL
OBSTETRIC PANEL
LIPID PANEL
RENAL FUNCTION PANEL
ACUTE HEPATITIS PANEL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Bundled
Bundled
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
80076
80100
80101
80102
80103
80150
80152
80154
80156
80157
80158
80160
80162
80164
80166
80168
80170
80172
80173
80174
80176
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 January 2009
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
No
No
No
Description
HEPATIC FUNCTION PANEL
DRUG SCREEN; MX DRUG CLASSES EA
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
80402
80406
80408
80410
80412
80414
80415
80416
80417
80418
80420
80422
80424
80426
80428
80430
80432
80434
80435
80436
80438
80439
80440
80500
80502
81000
81001
81002
81003
81005
81007
81015
81020
81025
81050
81099
82000
82003
82009
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ACTH STIM PANEL; 21 HYDROXYLASE DEF
ACTH STIM PANEL; 3 BETA-HYDROXYDEHY
ALDOSTERONE SUPPRESSION EVAL PANEL
CALCITONIN STIM PANEL
CORTICOTROPIC RELEAS HORMONE STIM
CHORION GONADOTRO STIM; TESTOSTERON
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
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 NON-AUTO
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
URIN PG TEST VISUAL COLOR COMPAR
VOLUM MEASUR TIMED COLLEC EA
UNLISTED UA PROC
ACETALDEHYDE BLD
ACETAMINOPHEN
ACETONE/OTHER BODIES SERUM; QUAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82010
82013
82016
82017
82024
82030
82040
82042
82043
82044
82055
82075
82085
82088
82101
82103
82104
82105
82106
82107
82108
82120
82127
82128
82131
82135
82136
82139
82140
82143
82145
82150
82154
82157
82160
82163
82164
82172
82175
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ACETONE/OTHER BODIES SERUM; QUAN
ACETYLCHOLINESTERASE
ACYLCARNITINES; QUAL EA SPEC
ACYLCARNITINES; QUAN EA SPEC
ADRENOCORTICOTROPIC HORMONE
ADENOSINE 5'-MONOPHOSPHATE CYCLIC
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
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
ANDROSTENEDIONE
ANDROSTERONE
ANGIOTENSIN II
ANGIOTENSIN I- CONVERTING ENZYME
APOLIPOPROTEIN EA
ARSENIC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82180
82190
82205
82232
82239
82240
82247
82248
82252
82261
82270
82271
82272
82274
82286
82300
82306
82307
82308
82310
82331
82340
82355
82360
82365
82370
82373
82374
82375
82376
82378
82379
82380
82382
82383
82384
82387
82390
82397
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
CALCITONIN
CALCIUM; TOT
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
CARNITINE (TOT & FREE) QUAN EA SPEC
CAROTENE
CATECHOLAMINES; TOT URIN
CATECHOLAMINES; BLD
CATECHOLAMINES; FRACTIONATED
CATHEPSIN-D
CERULOPLASMIN
CHEMILUMINESCENT ASSAY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82415
82435
82436
82438
82441
82465
82480
82482
82485
82486
82487
82488
82489
82491
82492
82495
82507
82520
82523
82525
82528
82530
82533
82540
82541
82542
82543
82544
82550
82552
82553
82554
82565
82570
82575
82585
82595
82600
82607
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
CHLORAMPHENICOL
CHLORIDE; BLD
CHLORIDE; URIN
CHLORIDE; OTHER SOURCE
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
CHROMATOG/SPECTROM-ANALYT NES; QUAN
CHROMATOG ANALYT NES; ISOTOPE DIL-1
CHROMATOG ANALYT NES; ISOTOP DIL-MX
CREATINE KINASE; TOT
CREATINE KINASE; ISOENZYMES
CREATINE KINASE; MB FRACTION ONLY
CREATINE KINASE; ISOFORMS
CREATININE; BLD
CREATININE; OTHER SOURCE
CREATININE; CLEARANCE
CRYOFIBRINOGEN
CRYOGLOBULIN
CYANIDE
CYANOCOBALAMIN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82608
82610
82615
82626
82627
82633
82634
82638
82646
82649
82651
82652
82654
82656
82657
82658
82664
82666
82668
82670
82671
82672
82677
82679
82690
82693
82696
82705
82710
82715
82725
82726
82728
82731
82735
82742
82746
82747
82757
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
CYANOCOBALAMIN; UNSATURATED BINDING
CYSTATIN C
CYSTINE & HOMOCYSTINE URIN QUAL
DEHYDROEPIANDROSTERONE
DEHYDROEPIANDROSTERONE-SULFATE
DESOXYCORTICOSTERONE 11DEOXYCORTISOL 11DIBUCAINE NUMBER
DIHYDROCODEINONE
DIHYDROMORPHINONE
DIHYDROTESTOSTERONE
DIHYDROXYVITAMIN D 1 25DIMETHADIONE
ELASTASE PANCREATIC FECAL QUALITATIVE/SEMIQUAN
ENZYM ACTIV-CELLS/TISS NES; NONRAD
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
FLUORIDE
FLURAZEPAM
FOLIC ACID; SERUM
FOLIC ACID; RBC
FRUCTOSE SEMEN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
82759
82760
82775
82776
82784
82785
82787
82800
82803
82805
82810
82820
82926
82928
82938
82941
82943
82945
82946
82947
82948
82950
82951
82952
82953
82955
82960
82962
82963
82965
82975
82977
82978
82979
82980
82985
83001
83002
83003
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
GLU; BLD REAGENT STRIP
GLU; POST GLU DOSE
GLU; TOLERANCE TEST 3 SPECMN
GLU; TOLERANCE EA ADD BEYOND 3 SPEC
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83008
83009
83010
83012
83013
83014
83015
83018
83020
83021
83026
83030
83033
83036
83037
83037
83045
83050
83051
83055
83060
83065
83068
83069
83070
83071
83080
83088
83090
83150
83491
83497
83498
83499
83500
83505
83516
83518
83519
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
GUANOSINE MONOPHOSPHATE CYCLIC
H PYLORI BLOOD TEST UREASE NON-RADIOACTV ISOTOPE
HAPTOGLOBIN; QUAN
HAPTOGLOBIN; PHENOTYPES
H PYLORI; BREATH TEST UREASE NON-RADACTV ISOTOPE
HELICOBACTER PYLORI; DRUG ADMINISTRATION
HEAVY METAL; SCREEN
HEAVY METAL; QUAN EA
HGB FRACTION-QUANTITAT: ELEC-PHORE
HEMOGLOB FRACT & QUAN; CHROMATOGR
HGB; COPPER SULFATE METHD NON-AUTO
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83520
83525
83527
83528
83540
83550
83550
83570
83582
83586
83593
83605
83615
83625
83630
83631
83632
83633
83634
83655
83661
83662
83663
83664
83670
83690
83695
83698
83700
83701
83704
83718
83719
83721
83727
83735
83775
83785
83788
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
IMMUNOASSAY ANALYTE QUAN; NOS
INSULIN; TOT
INSULIN; FREE
INTRINSIC FACTOR
IRON
CALCIUM; IONIZED
IRON BINDING CAPACITY
ISOCITRIC DEHYDROGENASE
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83789
83805
83825
83835
83840
83857
83858
83864
83866
83872
83873
83874
83880
83883
83885
83887
83890
83891
83892
83893
83894
83896
83897
83898
83900
83901
83902
83903
83904
83905
83906
83907
83908
83909
83912
83913
83914
83915
83916
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
NICKEL
NICOTINE
MOLECULAR DX; MOLEC ISOLAT/EXTRACT
MOLEC DX; ISOLA/EXTRAC NUCLEIC ACID
MOLECULAR DX; ENZYMATIC DIGESTION
MOLEC DX; DOT/SLOT BLOT PRODUCTION
MOLEC DX; SEPARAT GEL ELECT-PHORE
MOLECULAR DX; NUCLEIC ACID PROBE EA
MOLEC DX; NUCLEIC ACID TRANSF
MOLEC DX; AMPLIF NUC ACID 1 PAIR-EA
MOLEC AMP NUCLEIC ACID MLTX 1ST 2 SEQ
MOLEC DX; AMPL NUCLEIC ACID-MXPLEX
MOLECULAR DX; REVERSE TRANSCRIPTION
MOLEC DX; MUTATION SCAN-PHYS PROP-1
MOLEC DX; MUTATION ID-SEQUENC-1-EA
MOLEC DX; MUTAT ID-ALLELE TRANSCRIP
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
83918
83919
83921
83925
83930
83935
83937
83945
83950
83970
83986
83992
83993
84022
84030
84035
84060
84061
84066
84075
84078
84080
84081
84085
84087
84100
84105
84106
84110
84119
84120
84126
84127
84132
84133
84134
84135
84138
84140
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ORGANIC ACIDS QUAN EA SPEC
ORGANIC ACIDS; QUAL EA SPEC
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
PHENYLKETONES QUAL
PHOSPHATASE ACID; TOT
PHOSPHATASE ACID; FORENSIC EXAM
PHOSPHATASE ACID; PROSTATIC
PHOSPHATASE ALKALINE
PHOSPHATASE ALKALINE; HEAT STABLE
PHOSPHATASE ALKALINE; ISOENZYMES
PHOSPHATIDYLGLYCEROL
PHOSPHOGLUCONATE 6- DEHYDROGENA 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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84143
84144
84146
84150
84152
84153
84154
84155
84156
84157
84160
84163
84165
84166
84181
84182
84202
84203
84206
84207
84210
84220
84228
84233
84234
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305
84307
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
17-HYDROXYPREGNENOLONE
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 PROBE-BAND ID EA
PROTOPORPHYRIN RBC; QUAN
PROTOPORPHYRIN RBC; SCREEN
PROINSULIN
PYRIDOXAL PHOSPHATE
PYRUVATE
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84311
84315
84375
84376
84377
84378
84379
84392
84402
84403
84425
84430
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
84479
84480
84481
84482
84484
84485
84488
84490
84510
84512
84520
84525
84540
84545
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
UREA NITRO; QUAN
UREA NITRO; SEMIQUANTITATIVE
UREA NITRO URIN
UREA NITRO CLEARANCE
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
84550
84560
84577
84578
84580
84583
84585
84586
84588
84590
84591
84597
84600
84620
84630
84681
84702
84703
84704
84830
84999
85002
85004
85007
85008
85009
85013
85014
85018
85025
85027
85032
85041
85044
85045
85046
85048
85049
85055
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
85060
85097
85130
85170
85175
85210
85220
85230
85240
85244
85245
85246
85247
85250
85260
85270
85280
85290
85291
85292
85293
85300
85301
85302
85303
85305
85306
85307
85335
85337
85345
85347
85348
85360
85362
85366
85370
85378
85379
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
BLD SMEAR PERIPHRL INTRPT W/REPORT
BONE MARROW; SMEAR INTERPT ONLY
CHROMOGENIC SUBSTRATE ASSAY
CLOT RETRACTION
CLOT LYSIS TIME WHOLE BLD DILUT
CLOTTING; FACT II PROTHROMBIN SPEC
CLOTTING; FACTOR V LABILE FACTOR
CLOTTING; FACTOR VII
CLOTTING; FACTOR VIII 1 STAGE
CLOTTING; FACTOR VIII RELATED ANTIG
CLOT; VIII VW RISTOCETIN COFACTOR
CLOTTING; FACT VIII VW FACTOR ANTIG
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
CLOT INHIB/ANTCG;ANTTHRMB III ANTIG
CLOT INHIB/ANTICOAG; PROT C ANTIG
CLOT INHIB/ANTICOAG;PROT C ACTIVITY
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; AGGLUT-SEMIQUAN
FIBRIN DEGRADAT PRODUCTS; PARACOAG
FIBRIN DEGRADATION PRODUCTS; QUAN
FIBRN DEGRAD PROD D-DIMER; SEMIQUAN
FIBRIN DEGRADAT PROD D-DIMER; QUAN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
85380
85384
85385
85390
85396
85400
85410
85415
85420
85421
85441
85445
85460
85461
85475
85520
85525
85530
85536
85540
85547
85549
85555
85557
85576
85597
85610
85611
85612
85613
85635
85651
85652
85660
85670
85675
85705
85730
85732
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
FDP D-DIMER; ULTRASENSITIVE QUAL/SEMIQUAN
FIBRINOGEN; ACTIVITY
FIBRINOGEN; ANTIG
FIBRINOLYSN/COAGULOPATHY SCREEN
FIBRINOLYSINS;
FIBRINOLYTIC FACT & INHIB; PLASMIN
FIBRNOLYTC FACT/INHIB;ALPHA-2ANTIPL
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
RUSSELL VIPER VENOM TIME; UNDILUTED
RUSSELL VIPER VENOM TIME; DILUTED
REPTILASE TEST
SED RATE ERYTHROCYTE NON-AUTOMATED
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
85810
85999
86000
86001
86003
86005
86021
86022
86023
86038
86039
86060
86063
86077
86078
86079
86140
86141
86146
86147
86148
86155
86156
86157
86160
86161
86162
86171
86185
86200
86215
86225
86226
86235
86243
86255
86256
86277
86280
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
ANTINUCLEAR ANTIB; TITER
ANTISTREPTOLYSIN 0; TITER
ANTISTREPTOLYSIN 0; SCREEN
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
ANTI-PHOSPHATIDYLSERINE ANTIBODY
CHEMOTAXIS ASSAY SPEC METHD
COLD AGGLUTININ; SCREEN
COLD AGGLUTININ; TITER
COMPLEMENT; ANTIG EA COMPONENT
COMPLEMENT; FUNCT ACTIVIT EA COMPON
COMPLEMENT; TOT HEMOLYTIC
COMPLEMENT FIXA TESTS EA ANTIG
COUNTERIMMUNOELECTROPHORESIS EA
CYCLIC CITRULLINATED PEPTIDE ANTB
DEOXYRIBONUCLEASE ANTIB
DNA ANTIB; NATIVE/DOUBLE STRANDED
DNA ANTIB; SNGL STRANDED
EXTRACT NUCLR ANTIG ANTIB ANY METHD
FC RECEPTOR
FLUORES NONINFECT AGENT ANTIB; EA
FLUORESCENT ANTIB; TITER EA ANTIB
GROWTH HORMONE HUMAN ANTIB
HEMAGGLUTINATION INHIBIT TEST
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86294
86300
86301
86304
86308
86309
86310
86316
86317
86318
86320
86325
86327
86329
86331
86332
86334
86335
86336
86337
86340
86341
86343
86344
86353
86355
86356
86357
86359
86360
86361
86367
86376
86378
86382
86384
86403
86406
86430
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
IMMUNOELECTROPHORESIS; SERUM
IMMUNOELEC-PHORE; OTHER FLDS CONCEN
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
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 CNT-RATIO
T CELLS; ABSOLUTE CD4 COUNT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86431
86480
86485
86486
86490
86510
86580
86586
86590
86592
86593
86602
86603
86606
86609
86611
86612
86615
86617
86618
86619
86622
86625
86628
86631
86632
86635
86638
86641
86644
86645
86648
86651
86652
86653
86654
86658
86663
86664
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
ANTIB; ENCEPHALITIS EASTERN EQUINE
ANTIB; ENCEPHALITIS ST. LOUIS
ANTIB; ENCEPHALITIS WESTERN EQUINE
ANTIB; ENTEROVIRUS
ANTIB; EPSTEIN-BARR EARLY ANTIG
ANTIB; EPSTEIN-BARR NUCLEAR ANTIG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86665
86666
86668
86671
86674
86677
86682
86684
86687
86688
86689
86692
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
86713
86717
86720
86723
86727
86729
86732
86735
86738
86741
86744
86747
86750
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANTIB; EPSTEIN-BARR VIRAL CAPSID
ANTIB; EHRLICHIA
ANTIB; FRANCISELLA TULARENSIS
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
ANTIB; LYMPHOCYTIC CHORIOMENINGITIS
ANTIB; LYMPHOGRANULOMA VENEREUM
ANTIB; MUCORMYCOSIS
ANTIB; MUMPS
ANTIB; MYCOPLASMA
ANTIB; NEISSERIA MENINGITIDIS
ANTIB; NOCARDIA
ANTIB; PARVOVIRUS
ANTIB; PLASMODIUM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86753
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
86781
86784
86787
86788
86789
86790
86793
86800
86803
86804
86805
86806
86807
86808
86812
86813
86816
86817
86821
86822
86849
86850
86860
86870
86880
86885
86886
86890
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ANTIB; PROTOZOA NES
ANTIB; RESPIRATORY SYNCYTIAL VIRUS
ANTIB; RICKETTSIA
ANTIB; ROTAVIRUS
ANTIB; RUBELLA
ANTIB; RUBEOLA
ANTIB; SALMONELLA
ANTIB; SHIGELLA
ANTIB; TETANUS
ANTIB; TOXOPLASMA
ANTIB; TOXOPLASMA IGM
ANTIB; TREPONEMA PALLIDUM CONFIRM
ANTIB; TRICHINELLA
ANTIB; VARICELLA-ZOSTER
WEST NILE VIRUS AB, IGM
WEST NILE VIRUS ANTIBODY
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
ANTIHUMAN GLOB TST; INDIREC QUAL EA
ANTIHUMAN GLOB; INDIRECT TITER EA
AUTOLGUS BLD/COMP; PREDEPOSIT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
86891
86900
86901
86903
86904
86905
86906
86910
86911
86920
86921
86922
86923
86923
86927
86930
86931
86932
86940
86941
86945
86950
86960
86960
86965
86970
86971
86972
86975
86976
86977
86978
86985
86999
87001
87003
87015
87040
87045
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
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
Description
AUTOLOGOUS BLD; INTRA/POSTOP SALVAG
BLD TYPING; ABO
BLD TYPING; RH
BLD TYP; ANTIG SCRN REAGENT EA UNIT
BLD TYP; ANTIG SCRN PT SERM EA UNIT
BLD TYPING; RBC ANTIG NOT ABO/RH EA
BLD TYPING; RH PHENOTYPING COMPLT
BLD TYP PATERNITY-INDIV; ABO/RH/MN
BLD TYP PATERN/INDIVI; EA ADD ANTIG
COMPAT TEST EA UNIT; IMMED SPIN
COMPAT TEST EA UNIT; INCUBATION
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
FROZEN BLD PREP FREEZE EA; W/THAW
FROZN BLD PREP FREZ EA;W/FREEZ/THAW
HEMOLYSINS & AGGLUTNS; AUTO SCRN EA
HEMOLYSINS & AGGLUTINS; INCUBATED
IRRADIATION BLD PRODUCT EA UNIT
LEUKOCYTE TRANSFUSION
VOL RDCTJ BLD/BLD PRODUX EA UNIT
VOL RDCTJ BLD/BLD PRODUX EA UNIT
POOLING PLATELETS/OTHER BLD PRODUCT
PRETX RBC; INCUBATE W/AGENTS/DRG EA
PRETX RBC; INCUBATE W/ENZYMES EA
PRETX RBC; DENSITY GRADIENT SEPART
PRETX SERUM-ANTIB ID; INCUBATION EA
PRETX SERUM-RBC ANTIB ID; DILUTION
PRETX SERM-RBC ANTIB; W/INHBITOR EA
PRETX SERM-ANTIB; DIFF RED CELL EA
SPLITTING BLD/BLD PRODUCTS EA UNIT
UNLISTED TRANSFUSION MEDS PROC
ANIMAL INOCUL SM ANIMAL; W/OBSRV
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87046
87070
87071
87073
87075
87076
87077
87081
87084
87086
87088
87101
87102
87103
87106
87107
87109
87110
87116
87118
87140
87143
87147
87149
87152
87158
87164
87166
87168
87169
87172
87176
87177
87181
87184
87185
87186
87187
87188
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
CULT BACT ANY; DEFIN ID EA ANAEROB
CULT BACT AEROBIC ISOLATE
CULT BACT SCREEN ONLY SNGL ORGAN
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
CULTURE FUNGI DEFINITIVE ID EA FUNG
CULTURE, MOLD
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
CULTURE TYPING; OTHER METHD
DARK FIELD ANY SOURCE; W/SPEC COLL
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
SENSIT ANTIBIOT; DISK METHOD/PLATE
SENSIT ANTIBIOT; ENZYME DETECTION, PER ENZYME
SENSIT ANTIBIOT; MICRTITR MIC ANY #
SENSIT ANTIBIOT; MINI BACTRCDL CONC
SENSIT ANTIBIOT; MACROTUBE DILUT EA
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87190
87197
87205
87206
87207
87209
87210
87220
87230
87250
87252
87253
87254
87255
87260
87265
87267
87269
87270
87271
87272
87273
87274
87275
87276
87277
87278
87279
87280
87281
87283
87285
87290
87299
87300
87301
87305
87320
87324
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
SENSIT ANTIBIOTIC; TB/AFB EA DRUG
SERUM BACTERICIDAL TITER
SMEAR PRIM W/INTERPT; ROUTINE STAIN
SMEAR PRIM W/INTRPT; FLUOR/ACID AFB
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
TOXIN/ANTITOXIN ASSAY TISS CULTURE
VIRUS ID; W/OBSRV & DISSECT
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
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
AG-IMMUNOASSAY; CHLAMYDIA TRCHOMATS
AG-IMMUNOASSAY; CLOSTRIDIUM-TOXIN A
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87327
87328
87329
87332
87335
87336
87337
87338
87339
87340
87341
87350
87380
87385
87390
87391
87400
87420
87425
87427
87430
87449
87450
87451
87470
87471
87472
87475
87476
87477
87480
87481
87482
87485
87486
87487
87490
87491
87492
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
AG-IMMUNOASSAY; CRYPTOCOCCUS NEOFORMANS
INF AGT ENZYME IMMUNOASSAY TECH; CRYPTOSPORIDUM
INF AGT ANTIG EIA MX STEP METH; GIARDIA
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
AG-IMMUNOASSAY; HEP DELTA AGENT
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 METHD-NOS
AG-IMMUNOASSAY; SNGL STEP METHD-NOS
AG-IMMUNOASSAY; MULTI STEP METH
AGT-DNA/RNA; BARTONELLA-DIR PROBE
AGT-DNA/RNA; BARTONELLA-AMPLI PROBE
AGT-DNA/RNA; BARTONELLA H & Q-QUAN
AGT-DNA/RNA; BORRELIA BURGDORF-DIR
AGT-DNA/RNA; BORRELIA BURGDOR-AMPLI
AGT-DNA/RNA; BORRELIA BURGDORF-QUAN
AGT-DNA/RNA; CANDIDA SPECIES-DIRECT
AGT-DNA/RNA; CANDIDA SPECIES-AMPLI
AGT-DNA/RNA; CANDIDA SPECIES-QUAN
AGT-DNA/RNA; CHLAMYDIA PNEUMON-DIR
AGT-DNA/RNA; CHLAMYDIA PNEUMO-AMPLI
AGT-DNA/RNA; CHLAMYDIA PNEUMON-QUAN
AGT-DNA/RNA; CHLAMYDIA TRACH-DIRECT
AGT-DNA/RNA; CHLAMYDIA TRACH-AMPLI
AGT-DNA/RNA; CHLAMYDIA TRACH-QUAN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87495
87496
87497
87498
87500
87510
87511
87512
87515
87516
87517
87520
87521
87522
87525
87526
87527
87528
87529
87530
87531
87532
87533
87534
87535
87536
87537
87538
87539
87540
87541
87542
87550
87551
87552
87555
87556
87557
87560
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
AGT-DNA/RNA; CYTOMEGALOVIRUS-DIRECT
AGT-DNA/RNA; CYTOMEGALOVIRUS-AMPLI
AGT-DNA/RNA; CYTOMEGALOVIRUS-QUAN
ENTEROVIRUS, DNA, AMP PROBE
VANOMYCIN, DNA, AMP PROBE
AGT-DNA/RNA; GARDNERELLA VAG-DIRECT
AGT-DNA/RNA; GARDNERELLA VAG-AMPLI
AGT-DNA/RNA; GARDNERELLA VAG-QUAN
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 SIMPLEX-DIRECT
AGT-DNA/RNA; HERPES SIMPLEX-AMPLI
AGT-DNA/RNA; HERPES SIMPLEX-QUAN
AGT-DNA/RNA; HERPES VIRUS-6-DIRECT
AGT-DNA/RNA; HERPES VIRUS-6-AMPLI
AGT-DNA/RNA; HERPES VIRUS-6-QUAN
AGT-DNA/RNA; HIV-1-DIRECT PROBE
AGT-DNA/RNA; HIV-1-AMPLI PROBE
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 PNEUMO-DIR
AGT-DNA/RNA; LEGIONELLA PNEUMO-AMPL
AGT-DNA/RNA; LEGIONELLA PNEUMO-QUAN
AGT-DNA/RNA; MYCOBACTERIA-DIR PROBE
AGT-DNA/RNA; MYCOBACTERIA-AMPL PROB
AGT-DNA/RNA; MYCOBACTERIA-QUAN
AGT-DNA/RNA; MYCOBACTERIA TB-DIRECT
AGT-DNA/RNA; MYCOBACTERIA TB-AMPLI
AGT-DNA/RNA; MYCOBACTERIA TB-QUAN
AGT-DNA/RNA; MYCOBACTERIA AVIUM-DIR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
87561
87562
87580
87581
87582
87590
87591
87592
87620
87621
87622
87640
87641
87650
87651
87652
87653
87660
87797
87798
87799
87800
87801
87802
87803
87804
87807
87808
87809
87810
87850
87880
87899
87900
87901
87902
87903
87904
87999
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
AGT-DNA/RNA; MYCOBACTERIA AVIUM-AMP
AGT-DNA/RNA; MYCOBACTER AVIUM-QUAN
AGT-DNA/RNA; MYCOPLASMA PNEUMON-DIR
AGT-DNA/RNA; MYCOPLASMA PNEUMO-AMPL
AGT-DNA/RNA; MYCOPLASMA PNEUMO-QUAN
AGT-DNA/RNA; NEISSER GONORRHEA-DIR
AGT-DNA/RNA; NEISSER GONORRHEA-AMPL
AGT-DNA/RNA; NEISSER GONORRHEA-QUAN
AGT-DNA/RNA; PAPILLOMAVIRUS-DIRECT
AGT-DNA/RNA; PAPILLOMAVIRUS-AMPLI
AGT-DNA/RNA; PAPILLOMAVIRUS-QUAN
STAPH A, DNA, AMP PROBE
MR-STAPH, DNA, AMP PROBE
AGT-DNA/RNA; STREP GROUP A-DIRECT
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
AGT-DNA/RNA; NOS-AMPLIFIED PROBE
AGT-DNA/RNA; NOS-QUAN
AGT-DNA/RNA; MULTI ORGANISMS
AGT-DNA/RNA; AMPLIFIED PROBE TECHNIQUE
INF AGT ANTIG IMMUOAS; STREP GRP B
INF AGT ANTIG IMMUNOAS;C-DIFF TOX A
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
NFCT AGT DRUG SC PHEXYP PREDICT
AGT-DNA/RNA; GENOTYPE ANALYSIS BY NUCLEIC ACID
INF AGT GENOTYPE DNA/RNA; HCV
AGT-DNA/RNA; PHENOTYPE ANALYSIS BY NUCLEIC ACID
AGT-DNA/RNA; ADD DRUG UP TO 5 DRUGS
UNLISTED MICROBIOLOGY PROC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
88104
88106
88107
88108
88112
88125
88130
88140
88141
88142
88143
88147
88148
88150
88152
88153
88154
88155
88160
88161
88162
88164
88165
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
NECROPSY GROSS EXAM ONLY; WO CNS
NECROPSY GROSS EXAM ONLY; W/BRAIN
NECROPSY GROSS ONLY; W/BRAIN-CORD
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
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 SCRN-RESCR
CYTOPATH CERV/VAG; AUTO SCRN-SUPRVS
CYTOPATH CERV; SCR-RESCRN-MD SUPR
CYTPTH SLIDE CERV/VAG; MANUAL-SUPRV
CYTPTH SLDE CERV/VAG; MANUAL-CMPUTR
CYTOPATH CERV/VAG; MAN SCRN-RESCRN
CYTOPATH CERV/VAG; SCRN-RESCRN-CELL
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
88166
88167
88172
88173
88174
88175
88182
88184
88185
88187
88188
88189
88199
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
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; 20-25
CHROMOSOME ANALY; BASELINE BREAKAGE
CHROMOSOME ANALY; CLASTOGEN STRESS
CHROMO ANALY; CT 5 CEL 1 KAROTYPE
CHROMO ANALY; CT 15-20 CELL 2 KARYO
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
CYTOGEN; INTERPHASE HYBRID 100-300
CHROMOSOME ANALY; ADD KARYOTYPES EA
CHROMO ANALY; ADD SPECIALIZED BAND
CHROMO ANALY; ADD CELLS COUNTED EA
CHROMO ANALY; ADD HIGH RESOLUTION
CYTOGEN & MOLEC CYTOGEN INTER & RPT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
88299
88300
88302
88304
88305
88307
88309
88311
88312
88313
88314
88318
88319
88321
88323
88325
88329
88331
88332
88333
88334
88342
88346
88347
88348
88349
88355
88356
88358
88360
88361
88362
88365
88367
88368
88371
88372
88380
88381
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
88384
88385
88386
88399
88400
89049
89050
89051
89055
89060
89100
89105
89125
89130
89132
89135
89136
89140
89141
89160
89190
89220
89225
89230
89235
89240
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
89272
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
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
Description
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
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;
CULT OOCYTE/EMBRYO <4 DAY; CO-CULT OOCYTE/EMBRYO
ASSISTED EMBRYO HATCHING-MICROTECH
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 TISS-FRESH/CRYOPRES
INSEMINATION OF OOCYTES
EXTENDED CULTURE OF OOCYTE/EMBRYO 4-7 DAYS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
89280
89281
89290
89291
89300
89310
89320
89321
89322
89325
89329
89330
89331
89335
89342
89343
89344
89346
89352
89353
89354
89356
90281
90283
90284
90287
90288
90291
90296
90371
90375
90376
90378
90379
90384
90385
90386
90389
90393
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
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
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
Yes
No
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
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
BOTULINUM ANTITOX-EQUINE-ANY ROUTE
BOTULISM IMMUNE GLOBULIN HUMAN-IV
CYTOMEGALOVIRUS IMMUNE GLOBULIN-IV
DIPHTHERIA ANTITOX EQUINE ANY ROUTE
HEPATITIS B IMMUNE GLOBULIN-IM USE
RABIES IMMUNE GLOBULIN-IM &/SUBCUT
RABIES IG HEAT-TREATED IM &/SUBCUT
RESP SYNCYTIAL VIRUS IMMUN GLOBULIN
RESP SYNCYTIAL VIR IMMUNE GLOB IV
RHO IMMUNE GLOBULIN FULL DOSE-IM
RHO IMMUNE GLOBULIN MINI DOSE-IM
RHO IMMUNE GLOBULIN HUMAN-IV USE
TETANUS IMMUNE GLOBULIN HUMAN-IM
VACCINIA IMMUNE GLOBULIN HUMAN-IM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
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
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
No
No
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90396
90399
90465
90466
90467
90468
90471
90472
90473
90474
90476
90477
90581
90585
90586
90632
90633
90634
90636
90645
90646
90647
90648
90649
90650
90655
90656
90657
90658
90660
90661
90662
90663
90665
90669
90675
90676
90680
90681
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
No
No
Not Reimbursable
No
No
No
No
No
Yes
Not Reimbursable
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
No
No
No
Not Reimbursable
Not Reimbursable
Description
VARICELLA-ZOSTER IMMUNE GLOBULIN IM
UNLISTED IMMUNE GLOBULIN
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 LIVE-ORAL
ADENOVIRUS VACCINE TYPE 7 LIVE-ORAL
ANTHRAX VACCINE-SUBCUT USE
BCG VACCINE FOR TB LIVE-PERCUT USE
BCG VACC BLADDER CA LIVE-INTRAVES
HEPATITIS A VACCINE ADULT DOSE-IM
HEP A VACCINE PED/ADOLES DOSE-2-IM
HEP A VACCINE PED/ADOLES DOSE-3-IM
HEP A-HEP B VACCINE ADULT DOSE-IM
HEMOPHILUS FLU B VACC HBOC CONJU-IM
HEMOPHIL FLU B VACC PRPD-D BOOST IM
HEMOPHIL FLU B VACC PRP-OMP CONJ-IM
HEMOPHIL FLU B VACC PRP-T CONJUG-IM
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 6-35 MO IM USE
INFLUENZA VIRUS VACC-SPLIT VIRUS 3 YR AGE & > IM
FLU VIRUS VACC-LIVE-INTRANASAL USE
FLU VACC CELL CULT PRSV FREE
FLU VACC PRSV FREE INC ANTIG
FLU VACC PANDEMIC
LYME DISEASE VACC-ADULT DOSE-IM USE
PNEUMOCOCCAL VACC-POLYVALENT-IM USE
RABIES VACCINE-IM USE
RABIES VACCINE-INTRADERMAL USE
ROTAVIRUS VACC TETRAVLNT-LIVE-ORAL
ROTAVIRUS VACC 2 DOSE ORAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
No
No
No
No
No
YES
Not Reimbursable
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90690
90691
90692
90693
90696
90698
90700
90701
90702
90703
90704
90705
90706
90707
90708
90710
90712
90713
90714
90715
90716
90717
90718
90719
90720
90721
90723
90725
90727
90732
90733
90734
90735
90736
90740
90743
90744
90746
90747
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
No
Yes
Yes
No
Yes
No
Yes
Yes
Yes
No
Description
TYPHOID VACCINE-LIVE-ORAL
TYPHOID VACCINE-VICPS-IM USE
TYPHOID VACC-HEAT INACTIV-SUBQ/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
RUBELLA VIRUS VACCINE LIVE SUBCUTANEOUS USE
MEASLES MUMPS & RUBELLA VIRUS VACC LIVE-SUBQ USE
MEASLES & RUBELLA VIRUS VACCINE LIVE SUBQ USE
MEASLES/MUMPS/RUBELLA/VARCELLA-SUBQ
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
DIPTH/TET/ACELL PERTUSSIS/INFLU B V
DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HE
CHOLERA VACCINE-INJ USE
PLAGUE VACCINE INTRAMUSCULAR USE
PNEUMOCOCCAL POLYSACCH VAC-ADULT
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
HEPATITIS B VAC ADULT DOSE-IM USE
HEP B VAC DIALYSIS/IMMUNOSUPPRES-IM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90748
90749
90760
90761
90765
90766
90767
90768
90769
90770
90771
90772
90773
90774
90775
90776
90779
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Yes
No
Yes
Yes
Yes
No
No
Not Reimbursable
Not Reimbursable
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Yes
Description
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
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;
PSYCHOTHER OP 20-30 MIN; W/MED E&M
PSYCHOTHER OV/OP-BEHV MOD 45-50 MN;
PSYCHOTHER OP 45-50 MIN; W/MED E&M
PSYCHOTHER OV/OP-BEHV MOD 75-80 MN;
PSYCHOTHER OP 75-80 MIN; W/MED E&M
PSYCHOTHER OV/OP-INTERACT 20-30 MN;
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;
PSYCHOTHER IP-BEHV 20-30 MIN; W/E&M
PSYCHOTHER IP/PH/RCS-BEHV 45-50 MN;
PSYCHOTHER IP-BEHV 45-50 MIN; W/E&M
PSYCHOTHER IP/PH/RCS-BEHV 75-80 MN;
PSYCHOTHER IP-BEHV 75-80 MIN; W/E&M
PSYCHOTHER IP/RCS-INTRAC 20-30 MIN;
PSYCHOTHER IP-INTRAC 20-30 MIN; E&M
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Yes
No
Yes
Yes
Yes
No
No
Not Reimbursable
Not Reimbursable
Yes
Yes
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
90862
90865
90870
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90918
90919
90920
90921
90922
90923
90924
90925
90935
90937
90940
90945
90947
90989
90993
90997
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
No
Not Reimbursable
Yes
Yes
No
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Bundled
Yes
Not Reimbursable
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
PSYCHOTHER IP/RCS-INTRAC 45-50 MIN;
PSYCHOTHER IP-INTRAC 45-50 MIN; E&M
PSYCHOTHER IP/RCS-INTRAC 75-80 MIN;
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 MX-FAMILY)
INTERACTIVE GROUP PSYCHOTHERAPY
PHARM MGMT W/SCRIPT USE & REVIEW
NARCOSYNTHESIS FOR PSYCH DX & THER
ELEC-CONVULS THERAP; SNGL SEIZURE
INDIV PSYCHPHYSIOL THER; 20-30 MIN
INDIV PSYCHOPHYSIOL THER; 45-50 MIN
HYPNOTHERAPY
ENVIRONM INTERVEN-W/AGENCIES/INSTIT
PSYCH EVAL HOSP RECRD-MED DX PURPOS
INTERPT/EXPLAN RESULTS EXAM/DATA
PREP REPORT PT STATUS/TX FOR OTHER
UNLISTED PSYCH SERV/PROC
BIOFEEDBACK TRAINING-ANY MODALITY
BIOFEEDBACK TRAIN-ANORECTAL W/EMG
ESRD FULL MO <2 YR
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
ESRD RELAT SERV PER DA; PT 2-11 YR
ESRD RELAT SERV PER DA; PT 12-19 YR
ESRD RELAT SERV PER DA; PT 20/> YR
HEMODIALYSIS PROC W/SNGL PHYS EVAL
HEMODIALYSIS PROC W/REPEAT EVAL
HEMODIALYSIS ACCESS FLOW STUDY
DIALYSIS OTHER THAN HEMO W/1 EVAL
DIALYSIS NOT HEMO W/REPEAT EVAL
DIALYSIS TRAIN-PT-INCL HELPR-COMPLT
DIALYSIS TRAIN-PT-PER SESSION
HEMOPERFUSION
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Yes
Yes
Not Reimbursable
Not Reimbursable
Yes
Not Reimbursable
No
Not Reimbursable
Yes
Yes
No
Yes
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Bundled
Not Reimbursable
Bundled
Yes
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
90999
91000
91010
91011
91012
91020
91022
91030
91034
91035
91037
91038
91040
91052
91055
91060
91065
91100
91105
91110
91111
91120
91122
91123
91132
91133
91299
92002
92004
92012
92014
92015
92018
92019
92020
92025
92060
92065
92070
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
No
No
Yes
No
No
No
No
No
Yes
Yes
No
No
No
Not Reimbursable
Yes
Description
UNLIST DIALYSIS PROC INPT/OUTPT
ESOPH INTUBAT & COLLEC-W/PREP (SP)
ESOPH MOTILITY STUDY;
ESOPH MOTILITY STUDY; W/MECHOLYL
ESOPH MOTILITY; W/ACID PERFUSION
GASTRIC MOTILITY STUDIES
DUOL MOTILITY STD
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
GASTRIC ANALY W/INJ STIM SECRETION
GASTRIC INTUBAT WASH (SEPART PROC)
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
No
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
92081
92082
92083
92100
92120
92130
92135
92136
92140
92225
92226
92230
92235
92240
92250
92260
92265
92270
92275
92283
92284
92285
92286
92287
92310
92311
92312
92313
92314
92315
92316
92317
92325
92326
92340
92341
92342
92352
92353
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Description
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
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
SCRIPT & FIT CONTACT; APHAKIA-1 EYE
SCRIPT CONTACT LENS; APHAKIA-BOTH
SCRIPT CONTACT LENS; CORNEOSCLERAL
SCRIPT W/FIT BY TECH; LENS-EX APHAK
SCRIPT W/FIT BY TECH; APHAKIA-1 EYE
SCRIPT W/FIT BY TECH; APHAKIA-BOTH
SCRIPT W/FIT BY TECH; CORNEOSCLERAL
MODIFICAT LENS (SEP PRO) W/SUPERVS
REPLAC CONTACT LENS
FIT SPECTACLES EX APHAKIA; MONOFOCL
FIT SPECTACLES EX APHAKIA; BIFOCAL
FIT SPECTACLE EX APHAKIA; MULTIFOCL
FIT SPECTACL PROSTH-APHAK; MONOFOCL
FIT SPECTACL PROSTH-APHAK; MULTIFOC
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
92354
92355
92358
92370
92371
92499
92502
92504
92506
92507
92508
92511
92512
92516
92520
92526
92531
92532
92533
92541
92542
92543
92544
92545
92546
92547
92548
92551
92552
92553
92555
92556
92557
92559
92560
92561
92562
92563
92564
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Not Reimbursable
Not Reimbursable
No
No
Yes
N0
Yes
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Yes
Yes
Yes
Yes
No
Bundled
Bundled
Bundled
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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 PROSTH-APHAK
UNLISTED OPHTH SERV/PROC
OTOLARYNGOLOGIC EXAM UNDER GEN ANES
BINOCULAR MICRO (SEPART DX PROC)
EVAL SPEECH/LANG/COMMUN/AUD PROCESS
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
SPONTANEOUS NYSTAGMUS INCL GAZE
POSIT NYSTAGMUS
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No
No
No
No
No
Bundled
Bundled
Bundled
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92592
92593
92594
92595
92596
92597
92601
92602
92603
92604
92605
92606
92607
92608
92609
92610
92611
92612
92613
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Bundled
Bundled
No
No
No
No
No
No
Bundled
Description
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
VISUAL REINFORCEMENT AUDIOMETRY
CONDITIONING PLAY AUDIOMETRY
SELECT PICTURE AUDIOMETRY
ELECTROCOCHLEOGRAPHY
AUD EVOKED POTENTIALS &/OR TEST-CNS
AUD EVOKED POTENTIAL, LIMITED
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
EVAL VOICE PROSTH/COMMUN DEVICE
DX ANALY COCHLEAR IMPL PT UND 7 YR AGE; W/PROG
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Bundled
Bundled
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
92614
92615
92616
92617
92620
92621
92625
92626
92627
92630
92630
92633
92640
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
92998
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Bundled
No
Bundled
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
FLX FO ENDO EVAL LARYNG SENSY TST CINE/VIDEO;
FLX ENDO LARYNG SENSY TST CINE/VIDEO; PHYS I&R
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
AUD RHAB POST-LNGL HEARING LOSS
AUD BRAINSTEM IMPLT PROGRAMG
UNLISTED OTORHINOLARYNGOLOGICAL SERVICE/PROC
CARDIOPULMONARY RESUSCITATION
TEMPORARY TRANSCUTANEOUS PACING
CARDIOVERS ELEC-CONVER ARRHY; EXT
CARDIOVERSION ELECT; INT (SEP PROC)
CARDIOASSIST-METHD CIRC ASSIST; INT
CARDIOASSIST-METHD CIRC ASSIST; EXT
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
ATRIAL SEPTECT/SEPTOST; TRANSVEN
ATRIAL SEPTECT/SEPTOST; BLADE METHD
PERQ TRNSLUM CORON ATHEREC; 1 VESSL
PERQ TRNSLUM CORON ATHEREC; EA ADD
PERC TRNSLUM PULM ART ANGIOPLSTY; 1
PERC PULM ART ANGIOPLSTY; EA ADD
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Bundled
No
Bundled
No
No
No
No
No
No
No
No
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
93025
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93303
93304
93307
93308
93312
93313
93314
93315
93316
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
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
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
ECG-ROUTINE 12 LEAD; W/INTRPT & RPT
ECG-ROUTINE 12 LEAD; TRACING ONLY
ECG-ROUTINE 12 LEAD; INTRPT & REPRT
TELEPHON POST-SX ECG/30 DA; TRACING
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/INTRPT-REPRT
RHYTHM ECG 1-3 LEADS; TRACING ONLY
RHYTHM ECG; INTERPT & REPORT ONLY
ECG-24 HR W/SCAN; REPRT-REVW-INTRPT
ECG-24 HR W/SCAN; RECORDING
ECG-24 HR W/SCAN; ANALY W/REPORT
ECG-24 HR W/SCAN; MD REVW & REPRT
ECG-24 HR W/PRINT; REPT-REVW-INTRPT
ECG-24 HR W/PRINTOUT; RECORDING
ECG-24 HR; MICROPROCESS ANALY W/RPT
ECG-24 HR W/PRINT; MD REVW & INTRPT
ECG-24HR COMPUTR MONIT; W/ANAL-REPT
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; HOOK-UP/RECRD
PT DEMND RECRD/30 DA; MONITOR/ANALY
PT DEMND RECRD/30 DA; REVIEW/INTERP
SIGNAL-AVG ELECTROCARDIOGRAPHY
TRANSTHOR ECHO-CONG CARD ANOM; COMP
TRANSTHOR ECHO-CONG CARD ANOM; LTD
ECHO TRNSTHORAC REAL-TIME; COMPLT
ECHO TRNSTHORAC REAL-TIME; F/U-LTD
ECHO TRNSESOPH; W/PROBE PLCMT-REPRT
ECHO TRANSESOPH; PLCMT PROBE ONLY
ECHO TRANSESOPH; INTERPT & REPORT
TRANSESOPH ECHO-CONG CARD ANOM; TOT
TRANSESOPH ECHO-CONG CARD; PLC PROB
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93317
93318
93320
93321
93325
93350
93501
93503
93505
93508
93510
93511
93514
93524
93526
93527
93528
93529
93530
93531
93532
93533
93539
93540
93541
93542
93543
93544
93545
93555
93556
93561
93562
93571
93572
93580
93581
93600
93602
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Description
TRNSESOPH ECHO-CONG CARD; IMAGE-I&R
ECHO TEE FOR MONITORING PURPOSES
DOPPLER ECHO CONT WAVE; COMPLT
DOPPLER ECHO CONT WAVE; F/U-LTD
DOPPLR ECHO COLOR FLOW VELOCITY MAP
ECHO W/REST & STRESS-INTERP & REPRT
RT HEART CATH
INSRT & PLCMT FLO DIREC CATH-MONITR
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
COMBO RT HRT & RETRO LT HRT CATH
COMBO RT HRT-LT HRT CATH THRU SEPTM
COMBO RT HRT CATH W/LT VENT PUNCT
COMBO RT & LT HRT CATH VIA SEP OPEN
RT HEART CATH-CONGEN CARD ANOMALIES
RT & RETRO LT HRT CATH-CONGEN ANOM
RT-LT TRNSSEPT-INTACT-HRT CATH-CONG
RT-LT TRNSSEP-EXIST OP-HRT CTH-CONG
INJ PROC CARDIAC CATH; ART CONDUITS
INJ PROC CARDIAC CATH; AORTOCORON
INJ PROC CARDIAC CATH; PULM ANGIO
INJ PROC-CATH; RT VENT/ATRIAL ANGIO
INJ PROC-CATH; LT VENT/ATRIAL ANGIO
INJ PROC CARDIAC CATH; AORTOGRAPHY
INJ PROC-CATH; SELECT CORONRY ANGIO
IMAG SUPERVS I&R-CATH; VENT/ATRIAL
IMAG SUPERVS I&R-CATH; PULM ANGIOGR
INDICA DIL STDY; W/CARD OUTPUT (SP)
INDICAT DILUT; SUBSQT CARD OUTPUT
INTRAVASC DOPPLER DURING SCA; INIT
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93603
93609
93610
93612
93613
93615
93616
93618
93619
93620
93621
93622
93623
93624
93631
93640
93641
93642
93650
93651
93652
93660
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
93662
93668
93701
93720
93721
93722
93724
93727
93731
93732
93733
93734
93735
93736
93740
93741
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
Bundled
No
Description
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
COMP ELECTROPHYS; LT VENT RECORD
PROGRAM STIM & PACE AFTER IV DRUG
ELECTROPHYSIOL F/U W/INDUCT ARRHY
INTRA-OP PACING/MAP-SITE OF TACHY
EVAL CARDIOVERTER-DEFIB LEADS-INIT;
EVAL DEFIB LEADS-INIT; W/GEN TEST
EVAL 1/2 CHAMBER CARDIOVERTER-DEFIB
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
PERIPHERAL ARTERIAL DISEASE REHAB
BIOIMPEDANCE THORACIC ELECTRICAL
PLETHYSMOG BODY; W/INTERPT & REPORT
PLETHYSMOGRAPHY TOT BODY; TRACING
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93742
93743
93744
93745
93760
93762
93770
93784
93786
93788
93790
93797
93798
93799
93875
93880
93882
93886
93888
93890
93892
93893
93922
93923
93924
93925
93926
93930
93931
93965
93970
93971
93975
93976
93978
93979
93980
93981
93982
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Not Reimbursable
Not Reimbursable
Bundled
No
No
No
No
Not Reimbursable
No/Not covered for Basic Health Plan
Yes
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
Description
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
THERMOGRAM; CEPHALIC
THERMOGRAM; PERIPHERAL
DETERM VENOUS PRESS
AMB BP MONIT; RECORD-INTERPT-REPORT
AMB BP MONITOR; RECORDING ONLY
AMB BP MONITOR; SCAN ANALY W/REPRT
AMB BP MONITOR; REVW-INTERPT-REPRT
PHYS SERV-OUTPT CARD REHAB; WO ECG
PHYS SERV-OUTPT CARD REHAB; W/MONIT
UNLISTED CARDIOVASCULAR SERV/PROC
NONINVASIV STDIES EXTRACRAN ART BIL
DUPLEX SCAN EXTRACRAN ART; BILAT
DUPLEX SCAN EXTRACRAN ART; UNI/LTD
TRANSCRAN DOPPLER STDY ART; COMPLT
TRANSCRAN DOPPLER STDY ART; LTD
TRANSCRANIL DOPPLR INTRACRAN ART;VASOREACTV STDY
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
DUPLEX SCAN LOWR EXT ART; UNI/LTD
DUPLEX SCAN UPPR EXTREM ART; COMPLT
DUPLEX SCAN UPPR EXT ART; UNI/LTD
NON-INVAS STDY EXTREM VEIN; BILAT
DUPLEX SCAN-EXTREM VEINS; COMPLT
DUPLEX SCAN-EXTREM VEINS; UNI/LTD
DUPLEX SCAN FLO ABD ORGANS; COMPLT
DUPLEX SCAN FLO ABD/PEL ORGANS; LTD
DUPLEX SCAN AORTA/GFTS; COMPLT
DUPLEX SCAN AORTA/IVC/GFTS; UNI/LTD
DUPLEX SCAN PENILE VESSELS; COMPLT
DUPLEX SCAN PENILE VESSELS; F/U-LTD
ANEURYSM PRESSURE SENS STUDY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
Not Reimbursable
Not Reimbursable
Bundled
No
No
No
No
Not Reimbursable
NA
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
93990
94002
94003
94004
94005
94010
94014
94015
94016
94060
94070
94150
94200
94240
94250
94260
94350
94360
94370
94375
94400
94450
94452
94453
94610
94620
94621
94640
94642
94644
94645
94656
94657
94660
94662
94664
94667
94668
94680
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
Bundled
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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)
THORACIC GAS VOLUM
DETERM MALDISTRIBUTION INSPIRED GAS
DETERM RESIST AIRFLO-OSCILLATORY
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
VENTILAT ASSIST & MGMT; SUBSQT DA
CPAP VENTILAT INIT & MGMT
CNP VENTILAT INIT & MGMT
AEROSOL/VAPOR INHALA; 1ST DEMO/EVAL
MANIP CHEST WALL; 1ST DEMO/EVAL
MANIP CHEST WALL; SUBSQT
O2 UPTAKE EXPIRED GAS; DIREC SIMPL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
Bundled
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
94681
94690
94720
94725
94750
94760
94761
94762
94770
94772
94774
94775
94776
94777
94799
95004
95010
95012
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95078
95115
95117
95120
95125
95130
95131
95132
95133
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
Bundled
Bundled
No
No
No
No
No
No
No
Yes
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
O2 UPTAKE EXPIRED GAS; W/CO2 OUTPUT
O2 UPTAKE EXPIRED GAS; REST (SEP)
CO MONOXD DIFFUS CAPACITY ANY METHD
MEMBRN DIFFUS CAPACITY
PULM COMPLIANCE STUDY ANY METHD
NONINVAS OXIMETRY-O2 SAT; 1 DETERM
NONINVAS OXIMETRY-O2 SAT; MX DETERM
NONINVAS OXIMETRY; OVERNITE (SEP)
CO2 EXPIRED GAS DETERM-INFRARED
CIRCADN RESP PATTRN 12-24 HR-INFANT
PED HOME APNEA REC, COMPL
PED HOME APNEA REC, HK-UP
PED HOME APNEA REC, DOWNLD
PED HOME APNEA REC, REPORT
UNLISTED PULM SERV/PROC
PERQ W/ALLERG EXTRACT-SPEC # TEST
PERQ SEQUENT/INCREM-SPEC # TEST
EXHALED NITRIC OXIDE MEAS
INTRACUT SEQUENT/INCREM-SPEC # TEST
INTRACUT W/ALLERG EXTRCT-SPEC # TES
SKIN END POINT TITRATION
INTRACUT W/ALLERG DELAYED-# TESTS
PATCH/APPLIC TEST(S)
PHOTO PATCH TEST(S)
PHOTO TESTS
OPHTH MUCOS MEMBRN TESTS
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
PROF IMMUNOTX WO EXTRACT; 2/> INJ
PROF IMMUNOTX INCL EXTRACT; 1 INJ
PROF IMMUNOTX INCL EXTRACT; 2/> INJ
PROF IMMUNOTX W/EXTRACT; 1 INSECT
PROF IMMUNOTX W/EXTRACT; 2 INSECT
PROF IMMUNOTX W/EXTRCT; 3 INSECT
PROF IMMUNOTX W/EXTRCT; 4 INSECT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
Bundled
Bundled
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95251
95805
95806
95807
95808
95810
95811
95812
95813
95816
95819
95822
95824
95827
95829
95830
95831
95832
95833
95834
95851
95852
95857
95860
95861
95863
95864
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
No
No
No
No
No
No
No
No
No
Yes
Not Reimbursable
No
Yes
Not Reimbursable
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
PROF IMMUNOTX W/EXTRCT; 5 INSECT
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 EXTRCT-INSEC
RAPID DESENZT PROC EA HR
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 TRIAL-SLEEPINES
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 ELECTROD-EEG
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
No
No
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
95865
95866
95867
95868
95869
95870
95872
95873
95874
95875
95900
95903
95904
95920
95921
95922
95923
95925
95926
95927
95928
95929
95930
95933
95934
95936
95937
95950
95951
95953
95954
95955
95956
95957
95958
95961
95962
95965
95966
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
NDL EMG LARX
NDL EMG HEMIDPHRM
NEEDLE EMG CRAN NERV-MUSCL; UNILAT
NEEDLE EMG CRAN NERV-MUSCL; BILAT
NEEDLE EMG; THORACIC PARASPIN MUSC
NEEDL EMG; LTD-1 MUS EXTREM/NON-LIM
NEEDLE EMG W/QUAN MEAS EA MUSC STDY
ESTIM GDN CONJUNCT CHEMODNRVTJ
NDL EMG GDN CONJUNCT CHEMODNRVTJ
ISCHEM LIMB EXER W/NEEDLE EMG-LACTC
NRV CONDUC STDY EA ; MOTOR WO F-WAV
NRV CONDUC STDY EA ; MOTOR W/F-WAVE
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 CNS-CHECKERBOARD/FLASH
ORBICULARIS OCULI REFLEX BY ELEC-DX
H-REFLEX AMP STUDY; GASTNEM/SOLEUS
H-REFLEX STUDY; NOT GASTNEM/SOLEUS
NEUROMUSCL JUNCT TST EA NERV 1 METH
MONITOR-CEREBRAL SEIZ-EEG EA 24 HR
MONITOR CEREBRAL SEIZ-CABLE/RADIO
MONITOR SEIZ FOC-PORT EEG; EA 24 HR
PHARM/PHYS ACTIV-MD ATTND-EEG RECRD
EEG DURING NONINTRACRANIAL SURG
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
MEG REC&ANALY; EVOKED 1 MODALITY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
95967
95970
95971
95972
95973
95974
95975
95978
95979
95980
95981
95982
95990
95991
95999
96000
96001
96002
96003
96004
96020
96040
96101
96102
96103
96105
96110
96111
96116
96118
96119
96120
96125
96150
96151
96152
96153
96154
96155
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
YES
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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/PROG-1
ANALY NEUROSTIM; CRAN NRV W/PROG-RX
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 VIDEO-TAP;
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
HLTH&BHV ASSESS 15 MIN W/PT; INIT
HLTH&BHV ASSESS 15 MIN; RE-ASSESS
HLTH&BHV INTRVN EA 15 MIN; IND
HEALTH&BHV INTRVN EA 15 MIN; GROUP
HEALTH&BHV INTRVN EA 15 MIN; FAM
HEALTH&BHV INTRVN EA 15 MIN; FAM
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
96401
96402
96405
96406
96409
96411
96413
96415
96416
96417
96420
96422
96423
96425
96440
96445
96450
96521
96522
96523
96542
96549
96567
96570
96571
96900
96902
96904
96910
96912
96913
96920
96921
96922
96999
97001
97002
97003
97004
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Bundled
Not Reimbursable
No
No
No
Yes
Yes
Yes
Yes
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
No - unless over 24 visits
Description
CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO
CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO
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
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
CHEMOTX INTRA-ART; INFUSION TO 1 HR
CHEMOTX INTRA-ART; 1-8 HR EA ADD HR
CHEMOTX INTRA-ART; PROLONGED W/PUMP
CHEMOTX-PLEURAL CAVITY-W/THORACENTE
CHEMOTX-PERITONEAL-W/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
CHEMOTX INJ SUBARACH-1/MX AGENTS
UNLISTED CHEMOTX PROC
PHOTODYN TX EXT APPL LGHT EA EXPOS
PHOTODYNAM THER-LIGHT; 1ST 30 MIN
PHOTODYNAM TX-LIGHT; EA ADD 15 MIN
ACTINOTHERAPY
MICRO EXAM HAIRS-TELOGEN-ANAGEN CNT
WHOLE BODY PHOTOGRAPHY
PHOTOCHEMOTX; TAR-UV B/PETROL-UV B
PHOTOCHEMOTX; PSORALENS & UV A
PHOTOCHEMOTX 4-8 HR CARE BY PHYS
LASER TX INFLAM SKIN DZ; TOT AREA < 250 SQ CM
LASER TX INFLAMMATORY SKIN DZ; 250-500 SQ CM
LASER TX INFLAMMATORY SKIN DZ; OVER 500 SQ CM
UNLISTED SPECIAL DERM SERV/PROC
PHYS THERAP EVAL
PHYS THERAP RE-EVAL
OCCUPATIONAL THERAP EVAL
OCCUPATIONAL THERAP RE-EVAL
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Bundled
Not Reimbursable
No
No
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
97005
97006
97010
97012
97014
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97532
97533
97535
97537
97542
97545
97546
97597
97598
97602
97605
97606
97750
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
Bundled
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
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
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
Description
ATHLETIC TRAINING EVALUATION
ATHLETIC TRAINING RE-EVALUATION
APPLIC MODAL 1/> AREAS; HOT/CLD PKS
APPLIC MODAL 1/> AREAS; TRACTN-MECH
APPLIC MODAL 1/> AREAS; ELEC STIM
APPLIC MODAL 1/> AREAS; VASPNEU DEV
APPLIC MODAL 1/> AREAS; PARAFN BATH
APPLIC MODAL 1/> AREAS; WHIRLPOOL
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/TIME-ATTEND)
THERAP 1/> AREAS/15 MIN; EXERCISES
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
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 TRAIN-1 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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
Bundled
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
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
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
97755
97760
97761
97762
97799
97802
97803
97804
97810
97811
97813
97814
98925
98926
98927
98928
98929
98940
98941
98942
98943
98960
98961
98962
98966
98967
98968
98969
99000
99001
99002
99024
99026
99027
99050
99051
99053
99056
99058
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No - unless over 24 visits
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
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
No
Bundled
No
Bundled
Bundled
Description
ASSTIV TECH ASSESS DIR 1:1 CNTC W/RPT EA 15 MIN
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
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; IN-HOSP EA HOUR
HOSP MANDATED CALL SERVICE; OUT-OF-HOSP EA HOUR
SRVC REQUEST AFTER POSTED OFFICE HR ADD BASIC
SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS
SVC PRV BTW 10 PM&8 AM AT 24-HR FAC
SERV @ REQ OF PT @ LOCAT NOT OFFIC
OFFIC SERV PROVID-EMER BASIS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No - unless over 24 visits
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
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
No
Bundled
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99060
99070
99071
99075
99078
99080
99082
99090
99091
99100
99116
99135
99140
99143
99144
99145
99148
99149
99150
99170
99172
99173
99174
99175
99183
99185
99186
99190
99191
99192
99195
99199
99201
99202
99203
99204
99205
99211
99212
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Bundled
Bundled
Bundled
No
No
Bundled
No
Bundled
Not Reimbursable
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
No
Not Reimbursable
Bundled
Yes
No
Yes
Yes
Yes
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
Description
SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC
SUPPL/MAT PROVID-PHYS NOT W/VISIT
EDUCAT SUPPL @ COST TO PHYS
MED TESTIMONY
PHYS EDUCAT SERV RENDERED IN GRP
SPEC REPORT >INFO IN USUAL MED FORM
UNUSUAL TRAVEL
ANALYS INFORM DATA STORED-COMPUTERS
CLCT&INTEPR PHYSIOLOGIC DATA 30 MIN
ANES PT EXTREM AGE <1 YR & OVER 70
ANES COMPLIC BY UTILIZ BODY HYPOTHE
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/COLPOSCOP-CHILD
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
ASSEMBLY &/OR PUMP W/OXYGENATOR
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
OFFIC/OUTPT E&M NEW MOD-HI 45 MIN
OFFIC/OUTPT E&M NEW MOD-HI 60 MIN
OFFIC/OUTPT E&M ESTAB 5 MIN
OFFIC/OUTPT E&M ESTAB MINOR 10MIN
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Bundled
Bundled
Bundled
No
No
Bundled
No
Bundled
Not Reimbursable
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
Bundled
No
Not Reimbursable
Bundled
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99285
99288
99289
99290
99291
99292
99293
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
Description
OFFIC/OUTPT E&M ESTAB LOW-MOD 15MIN
OFFIC/OUTPT E&M ESTAB MOD-HI 25 MIN
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
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
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
HOSP D/C DA MGMT; MORE THAN 30 MIN
OFFIC CONS NEW/ESTAB MINOR 15 MIN
OFFICE CONS NEW/EST LO SEVER 30 MIN
OFFIC CONS NEW/ESTAB MOD 40 MIN
OFFIC CONS NEW/ESTAB MOD-HI 60 MIN
OFFIC CONS NEW/ESTAB MOD-HI 80 MIN
INIT INPT CONS NEW/ESTAB MINR 20MIN
INIT INPT CONS NEW/ESTAB LOW 40MIN
INIT INPT CONS NEW/ESTAB MOD 55MIN
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99294
99295
99296
99298
99299
99300
99304
99305
99306
99307
99308
99309
99310
99315
99316
99324
99325
99326
99327
99328
99334
99335
99336
99337
99339
99340
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
SUBSQT IP PED CRTL CARE E/M 29 DAY TO 24 MOS AGE
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
SBSQ IC PR D F/E/M RECOVERING INFT
1ST NF CARE PR D E/M LW SEVERITY
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
SBSQ NF CARE PR D E/M NEW PROBLEM
SBSQ NF CARE PR D E/M UNSTABLE/NEW PROBLEM
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
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 SELF-LMTD/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/>
HOME VISIT E&M NEW PT LO SEV-20 MIN
HOME VISIT E&M NEW PT MOD SEV-30 MN
HOME VISIT E&M NEW PT MOD-HI-45 MIN
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
HOME VISIT E&M ESTAB MOD-HI 40 MIN
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99358
99359
99360
99361
99362
99363
99364
99366
99367
99368
99371
99372
99373
99374
99375
99377
99378
99379
99380
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No -Reimbursed FOR WMIP line of
business ONLY
No -Reimbursed FOR WMIP line of
business ONLY
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
No
No
No
Bundled
No
Bundled
No
Bundled
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
Not Reimbursable
Description
PROLONG E/M WO PT CONTACT; 1ST HR
PROLONG E/M WO PT CONTCT; ADD 30MIN
PHYS STANDBY W/PROLONG ATTEND EA 30
MED CONFRNCE PHYS W/TEAM; 30 MIN
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
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
PHYS SUPERVS HOSPICE PT; 15-29 MIN
PHYS SUPERVS HOSPICE PT; 30 MIN/>
PHYS SUPERVS NURS FAC PT; 15-29 MIN
PHYS SUPERVS NURS FAC PT; 30 MIN/>
INIT PREVEN MEDS E&M NEW PT; INFANT
INIT PREVEN MEDS E&M NEW PT; 1-4 YR
INIT PREVEN MEDS E&M NEW PT; 5-11
INIT PREVEN MEDS E&M NEW PT; 12-17
INIT PREVEN MEDS E&M NEW PT; 18-39
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
PREVEN MEDS E&M ESTAB PT; 1-4 YR
PREVEN MEDS E&M ESTAB PT; 5-11 YR
PREVEN MEDS E&M ESTAB PT; 12-17 YR
PREVEN MEDS E&M ESTAB PT; 18-39 YR
PREVEN MEDS E&M ESTAB PT; 40-64 YR
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No -Reimbursed FOR WMIP line of
business ONLY
No -Reimbursed FOR WMIP line of
business ONLY
No
No
No
No
No
Not Reimbursable
No
Not Reimbursable
No
No
No
Bundled
No
Bundled
No
Bundled
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99406
99407
99408
99409
99411
99412
99420
99429
99431
99432
99433
99435
99436
99440
99441
99442
99443
99444
99450
99455
99456
99477
99499
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
99511
99512
99600
99601
99602
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
99605
99606
99607
0003T
0008T
0016T
0017T
0018T
0019T
0021T
0024T
0026T
0027T
0028T
0029T
0030T
0031T
0032T
0041T
0042T
0043T
0044T
0045T
0046T
0047T
0048T
0049T
0050T
0051T
0052T
0053T
0054T
0055T
0056T
0058T
0059T
0060T
0061T
0062T
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
0063T
0064T
0065T
0066T
0067T
0068T
0069T
0070T
0071T
0072T
0073T
0074T
0075T
0076T
0077T
0078T
0079T
0080T
0081T
0082T
0083T
0084T
0086T
0087T
0088T
0120T
0123T
0124T
0126T
0137T
0140T
0141T
0142T
0143T
0144T
0145T
0146T
0147T
0148T
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
0149T
0150T
0151T
0152T
0153T
0154T
0162T
0163T
0164T
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
A4601
A4614
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not Reimbursable
Not Reimbursable
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
No
No
Description
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
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
LITHIUM ION BATTERY NONPROSTHETIC USE REPLACMENT
PEAK EXPIR FLOW METER HAND HELD
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
Yes
Not Reimbursable
Not Reimbursable
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 - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if under $200
No - if 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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
A4627
A4641
A4642
A5507
A9500
A9502
A9503
A9504
A9505
A9507
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Yes
No
No
No
No
No
No
Yes
A9508
Yes
A9510
A9512
A9513
A9514
A9515
A9516
A9517
A9519
A9520
A9521
A9522
A9523
A9524
A9525
A9526
A9527
A9528
A9529
A9530
A9531
A9532
A9533
A9534
A9535
A9568
A9600
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
Yes
Description
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
RP DX INDIUM IN 111 CAPROMABPENDET
SUPP RADIOPHARMACEUTICAL DIAG IMAGING AGENT-IOBENGUANE
SULFA
SUPP RADIOPHARMACEUTICAL DIAG IMAGING AGENT-TECHNETIUM
TC99M
TECHNETIUM TC 99M PER TECHNETATE
HCPCS - No Auth
HCPCS - No Auth
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 I-125 SERUM ALBUMI
HCPCS - No Auth
HCPCS - No Auth
INJECTION METHYLENE BLUE 1 ML
TECHTM TC-99M ARCITUMOMAB DX STDY DOSE TO 45 MCI
SUPP THERAP STRONTIUM-89 CL PER MCI
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No - if under $200
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
A9603
A9605
A9699
A9700
A9900
D1203
G0008
G0009
G0010
G0027
G0030
G0031
G0032
G0033
G0034
G0035
G0036
G0037
G0038
G0039
G0040
G0041
G0042
G0043
G0044
G0045
G0046
G0047
G0101
G0102
G0103
G0104
G0105
G0106
G0107
G0108
G0109
G0117
G0118
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
No
No
No
No
No
No
No
Bundled
Bundled
Description
HCPCS - No Auth
RP SAMARIUM SM 153 LEXIDRNMM 50 MCL
SUPPLY RADOPHRM THERAPEUTIC IMAGING AGT NOC
SUPP INJECT CONTRAST MATERIAL-ECHOCARDIOGRAPHY
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
CERV/VAG CA SCREEN PELVIC/BREAST
PROSTATE CA SCRN DIG RECTAL EXAM
PROSTATE CA SCRN (PSA) TOTAL
COLORECTAL CA SCREEN FLEX SCOPE
COLORECTAL CA SCREEN HI RISK IND
COLON CA SCREEN BARIUM ENEMA
CA SCREEN FECAL BLD TEST 1-3 DETERM
DIAB OUTPT SELF-MGMT INDIV /SESSION
DIAB SELF-MGMT GRP TRAIN PER INDIV
GLAUC SCR HI RISK BY OPT/OPHTHLGIST
GLAUC SCR HI RISK UND DIR SUP DR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
Not Reimbursable
No
No
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0120
G0121
G0122
G0123
G0124
G0127
G0128
G0129
G0130
G0141
G0143
G0144
G0145
G0147
G0148
G0151
G0152
G0153
G0154
G0155
G0156
G0166
G0168
G0173
G0179
G0180
G0181
G0182
G0186
G0202
G0204
G0206
G0210
G0211
G0212
G0213
G0214
G0215
G0216
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
Not Reimbursable
Not Reimbursable
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
COLORECT CA SCRN ALT G0105 SCOPE BE
COLORECTAL CA SCRN NOT HI RISK
COLORECTAL CA SCREEN BARIUM ENEMA
SCRN CERV/VAG THIN LAY W/MD SUPER
SCREEN CERV/VAG THIN LAY PHYS INTRP
TRIM DYSTROPHIC NAILS ANY NUMBER
DIR SKILL NSG RN OUTPT REHAB EA 10
SKILLS OCCUP THERAP PT HOSP TX QD
SEXA BONE DENS STUD APPEND >=1 SITE
SCR CERV/VAG CYTO/AUTOSYS MAN RESCR
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
SERV SPEECH/LANG PATH/HOME/15 MIN
SERV SKL NURS/HOME HLTH SET/15 MIN
SERV CSW/HOME HEALTH SET/EA 15 MIN
SERV HOME HLTH AIDE/HOME/EA 15 MIN
EXT COUNTERPULSATION PER TX SES
WOUND CLO UTILIZ TISS ADHES ONLY
LINR ACCELERATOR STEREOTAC RADIOSURG CMPL 1 SESS
INTENSITY MODULATED RAD THERAP PLAN
PHY SERV-MC-HHA PROV/CERT PERIOD
PHYS SUPVSN HAA PT-CMPLX/MO-30/>MIN
PHYS SUPV HOSPIC PT-CMPLX/MO-30/>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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
Not Reimbursable
Not Reimbursable
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
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0217
G0218
G0219
G0220
G0221
G0222
G0223
G0224
G0225
G0226
G0227
G0228
G0229
G0230
G0231
G0232
G0233
G0234
G0237
G0238
G0239
G0243
G0245
G0246
G0247
G0248
G0249
G0250
G0251
G0252
G0253
G0254
G0255
G0257
G0259
G0260
G0265
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
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
NO PA in ASC ASC POS 24 Grouper 1;
Not Reimbursable other POS.
Not Reimbursable
Description
PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED
INIDICATION
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
CURRNT PERCEPT THRESHOLD/SNCT PER LIMB ANY NERVE
UNSCHD/EMERG DIALYSIS TX ESRD PT HOS OP NOT CERT
INJECTION PROCEDURE FOR SI JNT; ARTHROGRAPY
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
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
INJ PROC SI JNT;ANES STEROID&/TX AGT&ARTHROGRPH
CRYOPRES FREEZING&STOR CELLS TX USE EA CELL LINE
Not Reimbursable
Not Reimbursable
MUSCLES FACE FACE 1 ON 1 EA 15 MIN
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0266
G0267
G0268
G0269
G0270
G0271
G0275
G0278
G0281
G0282
G0283
G0288
G0289
G0290
G0291
G0293
G0294
G0295
G0296
G0297
G0298
G0299
G0300
G0302
G0303
G0304
G0305
G0306
G0307
G0308
G0309
G0310
G0311
G0312
G0313
G0314
G0315
G0316
G0317
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
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
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
THAWING&EXPAN FRZN CELLS TX USE EA ALIQUOT
BN MARROW/STEM CELL HARV MOD/TX ELIMIN CELL TYPE
REMV IMP CERUMEN PHYS SAME DATE AUDIO FUNCT TST
PLCMT OCCL DEVC VENUS/ART POST SURG/INTRVNL PROC
MED NUT TX; REASSESS FLW 2 REF YR W/PT EA 15 MIN
MED NUT TX REASSESS FLW 2 REF YR GRP EA 30 MIN
RENL ART ANGIO PRFRM AT CARD CATH RAD SUP&INTEPR
ILIAC ART ANGIO PRFRM W/CARD CATH RAD SUP&INTEPR
E-STIM 1/> AREAS CHRONIC STAGE III&IV ULCERS
E-STIM 1/MORE AREAS WND CARE OTH THAN DESC G0281
E-STIM 1/> AREAS OTH THAN WND CARE PART TX PLAN
RECON CT ANGIO AORTA SURG PLANNING VASC SURG
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 ANES-MCR QUAL TRIAL-DAY
NONCOVR PROC NO ANES/LOC ANES-MCR 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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
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
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G0318
G0319
G0320
G0321
G0322
G0323
G0324
G0325
G0326
G0327
G0328
G0329
G0332
G0337
G0339
G0340
G0341
G0342
G0343
G0344
G0364
G0365
G0366
G0367
G0368
G0375
G0376
G0389
G0390
G0392
G0393
G0394
G3001
G9001
G9002
G9003
G9004
G9005
G9006
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Yes
No
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
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
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
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
COORDINATED CARE FEE MAINT RATE
COORD CARE FEE RISK ADJUST-HI-INIT
COORD CARE FEE RISK ADJUST-LOW-INIT
COORD CARE FEE RISK ADJST MAINT
COORD CARE FEE-HOME MONITOR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
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
No
No
No
No
No
No
No
No
No
No
No
No
Bundled
Not Reimbursable
Not Reimbursable
Not Reimbursable
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
G9007
G9008
G9009
G9010
G9011
G9012
G9013
G9014
G9016
G9017
G9018
G9019
G9020
G9034
G9035
G9036
H0009
J0120
J0130
J0132
J0133
J0140
J0150
J0151
J0152
J0160
J0170
J0180
J0190
J0200
J0205
J0207
J0210
J0215
J0220
J0256
J0270
J0275
J0278
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
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
Yes
No
No
No
No
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
No
Not Reimbursable
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0280
J0282
J0285
J0286
J0287
J0288
J0289
J0290
J0295
J0300
J0330
J0340
J0350
J0360
J0365
J0380
J0390
J0395
J0400
J0456
J0460
J0470
J0475
J0476
J0480
J0500
J0510
J0515
J0520
J0530
J0540
J0550
J0560
J0570
J0580
J0583
J0585
J0587
J0590
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Description
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
INJ AMOBARBITAL TO 125 MG
SUCCINYLCHOLINE CHLORIDE TO 20 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
INJ BENZTROPINE MESYLATE, PER 1 MG
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
INJECTION BIVALIRUDIN 1 MG
BOTULINUM TOXIN TYPE A /PER UNIT
BOTULINUM TOXIN TYPE B-100 UNITS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0592
J0595
J0600
J0610
J0620
J0630
J0635
J0636
J0637
J0640
J0670
J0690
J0692
J0694
J0695
J0696
J0697
J0698
J0702
J0704
J0706
J0710
J0713
J0715
J0720
J0725
J0730
J0735
J0740
J0743
J0744
J0745
J0760
J0770
J0780
J0795
J0800
J0810
J0835
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
INJ CEFEPIME HYDROCHLORID 500 MG
INJ CEFOXITIN SODIUM 1 GM
INJ CEFTRIAXONE SODIUM PER 250 MG
INJ STER CEFUROXIME SODIUM/750 MG
CEFOTAXIME SODIUM PER GM
BETAMETHASONE ACETATE-NA PHOS/3 MG
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
CHORIONIC GONADOTROPIN/1000 USP U
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J0850
J0881
J0882
J0885
J0886
J0895
J0900
J0945
J0970
J1000
J1020
J1030
J1040
J1050
J1051
J1055
J1056
J1060
J1070
J1080
J1090
J1094
J1095
J1100
J1110
J1120
J1160
J1162
J1165
J1170
J1180
J1190
J1200
J1205
J1212
J1230
J1240
J1245
J1250
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Yes
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
No
No
Description
INJ CMV IMMUNE GLOBULIN IV/VIAL
INJECTION DARBEPOETIN ALFA 1 MCG NON-ESRD USE
INJ DARBEPOETIN ALFA 1 MCG FOR ESRD DIALYSIS
INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS
INJ EPOETIN ALFA 1000 UNITS FOR ESRD DIALYSIS
DEFEROXAMINE MESYLATE 500 MG/5 CC
TESTOS ENANTH/ESTRA VALERATE-1CC
INJ BROMPHENIRAMINE MALEATE/10 MG
INJ ESTRADIOL VALERATE TO 40 MG
DEPO-ESTRADIOL CYPIONATE TO 5 MG
METHYLPREDNISOLONE ACETATE-20 MG
METHYLPREDNISOLONE ACETATE-40 MG
METHYLPREDNISOLONE ACETATE-80 MG
INJECTION MEDROXYPROGESTERONE ACETATE 50 MG
MEDROXYPRO ACETATE-CONTRA-150 MG
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
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
CHLOROTHIAZIDE SODIUM, PER 500 MG
DMSO DIMETHYL SULFOXIDE 50%-50 ML
INJ METHADONE HCL UP TO 10 MG
INJ DIMENHYDRINATE TO 50 MG
INJ DIPYRIDAMOLE PER 10MG
INJ, DOBUTAMINE HCL, PER 250 MG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J1260
J1265
J1270
J1320
J1325
J1327
J1330
J1335
J1362
J1364
J1380
J1390
J1410
J1430
J1435
J1436
J1438
J1440
J1441
J1450
J1451
J1452
J1455
J1460
J1470
J1480
J1490
J1500
J1510
J1520
J1530
J1540
J1550
J1560
J1561
J1562
J1563
J1565
J1566
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
Yes
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
Description
INJ DOLASETRON MESYLATE 10 MG
INJECTION DOPAMINE HCL 40 MG
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
INJECTION ERTAPENEM SODIUM 500 MG
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
yes
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J1567
J1570
J1580
J1590
J1595
J1600
J1610
J1620
J1626
J1630
J1631
J1640
J1642
J1644
J1645
J1650
J1652
J1655
J1670
J1675
J1690
J1700
J1710
J1720
J1730
J1739
J1741
J1742
J1745
J1750
J1751
J1752
J1756
J1760
J1770
J1780
J1785
J1790
J1800
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
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
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
HEPARIN SODIUM-HEP LOCK FLUSH-10 U
INJ HEPARIN SODIUM PER 1000 UNITS
INJ DALTEPARIN SODIUM PER 2500 IU
INJECTION ENOXAPARIN SODIUM 10 MG
INJECTION FONDAPARINUX SODIUM 0.5 MG
INJECTION TINZAPARIN SODIUM 1000 IU
TETANUS IMMUNE GLOBULIN HUMAN-250 U
INJECTION HISTRELIN ACETATE 10 MICROGRAMS
INJ HYDROCORTISONE ACETATE TO 25 MG
HYDROCORTISONE NA PHOSPHATE-50 MG
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 January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J1810
J1815
J1817
J1820
J1825
J1830
J1835
J1840
J1850
J1885
J1890
J1910
J1930
J1940
J1945
J1950
J1955
J1956
J1960
J1970
J1980
J1990
J2000
J2001
J2010
J2020
J2060
J2150
J2175
J2180
J2185
J2210
J2240
J2250
J2260
J2270
J2271
J2275
J2278
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
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
No
No
Description
DROPERIDOL-FENTANYL CITRATE-2 ML
INJECTION INSULIN PER 5 UNITS
INSULIN ADMINISTRATION THROUGH DME PER 50 UNITS
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
INJ KANAMYCIN SULFATE UP TO 500 MG
INJ KETOROLAC TROMETHAMINE PER 15MG
INJ CEPHALOTHIN SODIUM TO 1 GM
INJ FUROSEMIDE TO 20 MG
INJECTION LEPIRUDIN 50 MG
INJ LEUPROLIDE ACETATE PER 3.75 MG
INJ LEVOCARNITINE PER 1 GM
INJ LEVOFLOXACIN 250 MG
INJ LEVORPHANOL TARTRATE TO 2 MG
INJ HYOSCYAMINE SULFATE TO .25 MG
INJ CHLORDIAZEPOXIDE HCL TO 100 MG
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
MEPERIDINE HYDROCHLORIDE/100 MG
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
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
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J2280
J2300
J2310
J2320
J2321
J2322
J2325
J2330
J2350
J2352
J2353
J2354
J2355
J2357
J2360
J2370
J2400
J2405
J2410
J2425
J2430
J2440
J2460
J2480
J2500
J2501
J2503
J2504
J2505
J2510
J2512
J2513
J2515
J2540
J2543
J2545
J2550
J2560
J2590
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
INJ OPRELVEKIN 5 MG
INJ OMALIZUMAB 5 MG
INJ ORPHENADRINE CITRATE UP TO 60MG
INJ PHENYLEPHRINE HCL TO 1 ML
INJ CHLOROPROCAINE HCL, PER 30 ML
INJ ONDANSETRON HCL PER 1 MG
INJ OXYMORPHONE HCL TO 1 MG
INJECTION PALIFERMIN 50 MICROGRAMS
INJ PAMIDRONATE DISODIUM PER 30 MG
INJ PAPAVERINE HCL TO 60 MG
INJ OXYTETRACYCLINE HCL TO 50 MG
PARICALCITOL
INJECTION PEGAPTANIB SODIUM 0.3 MG
INJECTION PEGADEMASE BOVINE 25 IU
INJECTION PEGFILGRASTIM 6 MG
PEN G PROCAINE AQUEOUS-600,000 U
INJECTION PENTASTARCH 10% SOLUTION 100 ML
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
INJ PHENOBARBITAL SODIUM TO 120 MG
INJ OXYTOCIN TO 10 UNITS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J2597
J2640
J2650
J2670
J2675
J2680
J2690
J2700
J2710
J2720
J2725
J2730
J2760
J2765
J2770
J2780
J2783
J2788
J2790
J2792
J2795
J2800
J2805
J2810
J2820
J2850
J2860
J2910
J2912
J2915
J2916
J2920
J2930
J2940
J2941
J2950
J2970
J2993
J2994
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
INJ, DESMOPRESSIN ACETATE/1 MCG
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
NEOSTIGMINE METHYLSULFATE-0.5 MG
INJ PROTAMINE SULFATE PER 10 MG
INJ PROTIRELIN PER 250 MCG
INJ PRALIDOXIME CHLORIDE TO 1 GM
INJ PHENTOLAMINE MESYLATE TO 5 MG
INJ METOCLOPRAMIDE HCL TO 10 MG
INJECTION QUINUPRISTIN/DALFOPRISTIN 500 MG
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
INJ SODIUM CHLORIDE, 0.9 % PER 2 ML
NA FERRIC GLUCONATE COMPLEX
METHYLPRED NA SUCCINATE-40 MG
METHYLPRED NA SUCCINATE TO 125MG
INJECTION, SPANESTRIN P, UP TO 1 ML
INJECTION, SOMATROPIN, 1 MG
INJ PROMAZINE HCL TO 25 MG
INJ RETEPLASE 18.8 MG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J2995
J2996
J2997
J3000
J3010
J3030
J3070
J3080
J3100
J3105
J3120
J3130
J3140
J3150
J3230
J3240
J3245
J3250
J3260
J3265
J3270
J3280
J3285
J3301
J3302
J3303
J3305
J3310
J3315
J3320
J3350
J3355
J3360
J3364
J3365
J3370
J3390
J3400
J3410
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
THIETHYLPERAZINE MALEATE TO 10 MG
INJECTION TREPROSTINIL 1 MG
TRIAMCINOLONE ACETONIDE/10 MG
TRIAMCINOLONE DIACETATE/5 MG
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J3411
J3415
J3420
J3430
J3450
J3465
J3470
J3471
J3472
J3475
J3480
J3485
J3486
J3487
J3490
J3520
J3530
J3535
J3570
J3590
J7030
J7040
J7042
J7050
J7051
J7060
J7070
J7100
J7110
J7120
J7130
J7188
J7189
J7190
J7191
J7192
J7193
J7194
J7195
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
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
No
No
No
No
No
No
No
No
No
Description
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
INE HYALURONIDASE OVINE PRES FREE 1 USP UNIT
INJ HYALURONIDASE OVINE PRES FREE-1000 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
HYPERTON SAL SOLN 50-100 MEQ, 20 CC
INJECTION VON WILLEBRAND FACTOR COMPLEX HUMAN IU
FACTOR VIIA 1 MICROGRAM
FACT VIII(ANTI-HEMOPHI HUMAN)PER IU
FACT VIII/ANTIHEMOPH/PORCINE PER IU
FACTOR VIII (ANTIHEMO RECOMB)PER IU
FACTOR IX PER I.U.
FACTOR IX COMPLX PER IU
FACTOR IX PER I.U.
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
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
No
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7197
J7198
J7199
J7300
J7302
J7303
J7306
J7308
J7310
J7315
J7316
J7317
J7320
J7330
J7340
J7341
J7342
J7350
J7500
J7501
J7502
J7504
J7505
J7506
J7507
J7508
J7509
J7510
J7511
J7513
J7515
J7516
J7517
J7520
J7525
J7599
J7608
J7610
J7615
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
Yes
Not Reimbursable
No
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
No
No
No
No
No
No
No
No
Description
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
Not Reimbursable
No
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
No
No
No
No
No
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7617
J7620
J7622
J7624
J7625
J7626
J7627
J7628
J7629
J7630
J7631
J7633
J7635
J7636
J7637
J7638
J7639
J7640
J7641
J7642
J7643
J7644
J7645
J7648
J7649
J7650
J7651
J7652
J7653
J7654
J7655
J7658
J7659
J7660
J7665
J7668
J7669
J7670
J7672
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
ALBUTEROL TO 2.5 MG & IPRATROPIUM BR TO 0.5 MG
BETHAMETHASONE INHAL SOL DME U MG
BETHAMETHASONE INHAL SOL DME U MG
BUDESONIDE INHAL SOL DME .25 MG
BUDESONIDE PWDR CMPND INHAL SOL U DOSE TO 0.5 MG
BITOLTEROL MESYLATE INHAL SOL CON
BITOLTEROL MESYLATE INHAL SOL/MG
CROMOLYN NA INHAL SOL UD PER 10 MGS
BUDESONIDE INHAL SOL ADMND THRU DME CONC-0.25 MG
ATROPINE INHAL SOL/CONCEN PER MG
ATROPINE INHAL SOL UD PER MG
DEXAMETHASONE INHAL SOL/CON PER MG
DEXAMETHASONE INHAL SOL UD PER MG
DORNASE ALPHA INHAL SOL UD PER MG
FORMOTEROL INHAL SOL UNIT DOSE 12 MICROGRAMS
FLUNISOLIDE INHAL SOL ADMNED DME-MG
GLYCOPYRROLATE INHAL SOL CON PER MG
GLYCOPYRROLATE INHAL SOL UD PER MG
IPRATROPIUM BROMIDE INHAL SOL UD/MG
ISOETHARINE HCL INHAL SOL CON/MG
ISOETHARINE HCL INHAL SOL UD PER MG
ISOPROTERENOL HCL INHAL SOL CON/MG
ISOPROTERENOL HCL INHAL SOL UD/ MG
METAPROTERENOL INHAL SOL CON/10 MGS
METAPROTERENOL INHAL SOL UD/10 MGS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J7675
J7680
J7681
J7682
J7683
J7684
J7699
J7799
J8498
J8499
J8510
J8515
J8520
J8521
J8530
J8540
J8560
J8597
J8600
J8610
J8700
J8999
J9000
J9001
J9010
J9015
J9017
J9020
J9025
J9027
J9031
J9040
J9045
J9050
J9060
J9062
J9065
J9070
J9080
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
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
No
No
No
Description
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
BUSULFAN ORAL 2 MG
CABERGOLINE ORAL 0.25 MG
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
BCG (INTRAVESICAL) PER INSTALLATION
BLEOMYCIN SULFATE 15 UNITS
CARBOPLATIN, 50 MG
CARMUSTINE, 100MG
CISPLATIN, POW/SOLN/10 MG
CISPLATIN 50 MG
INJ CLADRIBINE PER 1 MG
CYCLOPHOSPHAMIDE 100MG
CYCLOPHOSPHAMIDE 200 MG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
No
No
No
No
No
No
No
Not Reimbursable
No
No
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9090
J9091
J9092
J9093
J9094
J9095
J9096
J9097
J9098
J9100
J9110
J9120
J9130
J9140
J9150
J9151
J9160
J9165
J9170
J9175
J9178
J9180
J9181
J9182
J9185
J9190
J9200
J9201
J9202
J9206
J9208
J9209
J9211
J9212
J9213
J9214
J9215
J9216
J9217
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
CYCLOPHOSPHAMIDE 500 MG
CYCLOPHOSPHAMIDE 1 G
CYCLOPHOSPHAMIDE 2 G
CYCLOPHOSPHAMIDE LYOPHILIZED 100 MG
CYCLOPHOSPHAMIDE LYOPHILIZED 200 MG
CYCLOPHOSPHAMIDE LYOPHILIZED 500 MG
CYCLOPHOSPHAMIDE LYOPHILIZED 1 G
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
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
INJ INTERFERN ALFAC-1 RECOMB 1 MCG
INTERFERON,ALFA-2A,RECOMB/3 MIL U
INTERFERON,ALFA-2B,RECOMB,1 MIL U
INTERFERON, ALFA-N3, 250,000 IU
INTERFERON, GAMMA-1B, 3 MIL U
LEUPROLIDE ACET/DEPOT SUSP 7.5 MG
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
J9218
J9219
J9225
J9226
J9230
J9240
J9245
J9250
J9260
J9263
J9264
J9265
J9266
J9268
J9270
J9280
J9290
J9291
J9293
J9300
J9310
J9320
J9340
J9350
J9355
J9357
J9360
J9370
J9375
J9380
J9390
J9395
J9600
J9999
L0120
L0210
L0220
L1800
L1810
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Yes
Yes
Yes
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
Yes
No
No
Description
LEUPROLIDE ACETATE PER 1 MG
LEUPROLIDE ACETATE IMPLANT 65 MG
HISTRELIN IMPLANT 50 MG
HISTRELIN IMPLANT 50 MG
MECHLORETHAMINE HCL/10 MG
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
INJECTION FULVESTRANT 25 MG
PORFIMER SODIUM 75 MG
NOC ANTINEOPLASTIC DRUGS
CERV FLEX NON ADJUS (FOAM COLLAR)
THORACIC RIB BELT
THORACIC RIB BELT CUSTOM FABRICATED
KNEE ORTHOSIS ELASTIC W/STAYS
KO ELASTIC W/JOINTS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
No
Yes
Yes
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 - if under $200
No - if under $201
No - if under $202
No - if under $203
No - if under $204
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
L1815
L1820
L1830
L1902
L1906
L3000
L3030
L3100
L3140
L3150
L3170
L3215
L3219
L3230
L3310
L3320
L3334
L3340
L3350
L3360
L3400
L3410
L3420
L3650
L3700
L3807
L3908
L3909
L3928
L4350
L4360
L4380
L4386
L8000
L8010
L8600
L8603
L8606
L8614
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Yes
No
No
No
Yes
No
No
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
No
No
Yes
Yes
No
Yes
Description
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
FT INSRT MOLD UCB, BERKELEY SHELL
FT INSERT FORMED TO PT FT EA
HALLUS-VALGUS NIGHT DYNAMIC SPLINT
FT/ABDUCT ROTATION BAR INCL SHOES
FT/ABDUCT ROTATION BAR/WO SHOES
FT PLASTIC HEEL STABILIZER
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
WHFO/AIR SUPPRT W/WO THUMB EXTEN
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No - if under $205
No - if under $206
No - if under $207
No - if under $208
No - if under $209
No - if under $210
No - if under $211
No - if under $212
No - if under $213
No - if under $214
No - if under $215
No - if under $216
No - if under $217
No - if under $218
No - if under $219
No - if under $220
No - if under $221
No - if under $222
No - if under $223
No - if under $224
No - if under $225
No - if under $226
No - if under $227
No - if under $228
No - if under $229
No - if under $230
No - if under $231
No - if under $232
No - if under $233
No - if under $234
No - if under $235
No - if under $236
No - if under $237
No - if under $238
No - if under $239
No - if under $240
No - if under $241
No - if under $242
NA
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
L8619
L8623
L8624
L8690
L8691
L8695
L8699
L9900
P3000
P3001
P9010
P9011
P9012
P9016
P9017
P9019
P9020
P9021
P9022
P9023
P9031
P9032
P9033
P9034
P9035
P9036
P9037
P9038
P9039
P9040
P9041
P9042
P9043
P9044
P9045
P9046
P9047
P9048
P9050
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
No
Description
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
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
WASHED RED BLOOD CELLS EACH UNIT
PLASMA POOL SOL/DTRGNT FROZ EA UNIT
PLATELETS LEUKOCYTES REDUC EA UNT
PLATELETS IRRADIATED EA UNT
PLATELETS LEUKOCYTES REDUC IRRAD
PLATELETS PHERESIS EA UNT
PLATELETS PHERESIS LEUKOCYTES RED
PLATELETS PHERESIS IRRADIATED EA
PLTLTS PHERESIS LEUKOCYTS RED IRRAD
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
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
GRANULOCYTES PHERESIS EACH UNIT
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
NA
No - if under $242
No - if under $242
No - if under $242
No - if under $242
No - if under $242
NA
No - if under $242
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
P9612
P9615
Q0081
Q0083
Q0084
Q0085
Q0091
Q0092
Q0111
Q0112
Q0113
Q0114
Q0115
Q0144
Q0156
Q0157
Q0160
Q0161
Q0163
Q0164
Q0165
Q0166
Q0167
Q0168
Q0169
Q0170
Q0171
Q0172
Q0173
Q0174
Q0175
Q0176
Q0177
Q0178
Q0179
Q0180
Q0181
Q0515
Q1003
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Description
CATH COLLECT SPECMN 1 PT ALL POS
CATH COLLECT SPEC MULT PTS
INFUS THERAP NOT CHEMO/VISIT
CHEMO ADMIN NOT INFUS TECH/VISIT
CHEMO ADMIN INFUS TECH ONLY/VISIT
CHEMO ADMIN INFUS & OTH TECH/VISIT
SCREEN PAP OBTAIN PREP CONVEY LAB
SET-UP PORTABLE X-RAY EQUIPMENT
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
PERPHENZAINE 4 MG ORAL ANTI-EMETIC
PERPHENZAINE 8 MG ORAL ANTI-EMETIC
HYDROXYZINE PAMOATE 25 MG ORAL
HYDROXYZINE PAMOATE 50 MG ORAL
ODANSETRON HCL 8 MG ORAL
DOLASETRON MESYLATE 100 MG ORAL
UNSPEC ORAL DOSE FORM ANTI-EMETIC
INJECTION SERMORELIN ACETATE 1 MICROGRAM
NEW TECH INTRAOCULAR LENS CATEGORY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Q1004
Q1005
Q2004
Q2009
Q2017
Q3000
Q3001
Q3002
Q3003
Q3004
Q3005
Q3006
Q3007
Q3008
Q3009
Q3010
Q3011
Q3012
Q3014
Q3019
Q3020
Q3025
Q3026
Q3031
Q4001
Q4002
Q4003
Q4004
Q4005
Q4006
Q4007
Q4008
Q4009
Q4010
Q4011
Q4012
Q4013
Q4014
Q4015
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
Not Reimbursable
No
No
No
No
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Description
NEW TECH INTRAOCULAR LENS CATEGORY
NEW TECH INTRAOCULAR LENS CATEGORY
IRRIG SOLN TX OF BLDR CALCULI 500ML
INJ FOSPHENYTOIN 50 MG
INJ TENIPOSIDE 50 MG
RADIOELEMENTS FOR BRACHYTHERAP
TELEHEALTH ORIG SITE FACILITY FEE
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 F-GLSS
CAST SPL SHLDR CAST ADULT PLASTR
CAST SPL SHLDR CAST ADULT FIBRGLS
CAST SPL LONG ARM CAST ADULT PLASTR
CAST SPL LONG ARM CAST ADLT FIBRGLS
CAST SPL LNG ARM CAST PED PLASTR
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 F-GLASS
CAST SPL GAUNTLT CAST PED PLASTR
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
Not Reimbursable
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Not Reimbursable
Not Reimbursable
No
No
Bundled
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
Q4016
Q4017
Q4018
Q4019
Q4020
Q4021
Q4022
Q4023
Q4024
Q4025
Q4026
Q4027
Q4028
Q4029
Q4030
Q4031
Q4032
Q4033
Q4034
Q4035
Q4036
Q4037
Q4038
Q4039
Q4040
Q4041
Q4042
Q4043
Q4044
Q4045
Q4046
Q4047
Q4048
Q4049
Q4050
Q4051
Q4076
Q4077
Q9951
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
No
No
No
Description
CAST SPL GAUNTLET CAST PED F-GLASS
CAST SPL LNG ARM SPLINT ADLT PLASTR
CAST SPL LNG ARM SPLNT ADLT FIBRGLS
CAST SPL LNG ARM SPLINT PED PLASTR
CAST SPL LNG ARM SPLINT PED FIBRGLS
CAST SPL SHRT ARM SPLINT ADLT PLAST
CAST SPL SHRT ARM SPLNT ADLT F-GLSS
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
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
CAST SPL LNG LEG CAST PED PLASTR
CAST SPL LNG LEG CAST PED FIBRGLS
CAST LNG LEG CYCLE CAST ADLT PLAST
CAST LNG LEG CYCLE CAST ADLT F-GLSS
CAST LNG LEG CYCLE CAST PED PLAST
CAST LNG LEG CYCLE CAST PED F-GLSS
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
CAST SPL LNG LEG SPLINT PED PLASTR
CAST SPL LNG LEG SPLINT PED FIBRGLS
CAST SPL SHRT LEG SPLINT ADLT PLAST
CAST SPL SHRT LEG SPLNT ADLT F-GLSS
CAST SPL SHORT LEG SPLINT PED PLAST
CAST SPL SHRT LEG SPLNT PED FIBRGLS
FINGER SPLINT STATIC
CAST SPL UNLIST TYPES&MATL CASTS
SPLINT SUPPLIES MISCELLANEOUS
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
No
No
No
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
R0070
R0075
R0076
S0012
S0014
S0017
S0020
S0021
S0023
S0028
S0030
S0032
S0034
S0039
S0040
S0073
S0074
S0077
S0078
S0079
S0080
S0081
S0087
S0088
S0090
S0091
S0092
S0093
S0104
S0106
S0107
S0108
S0114
S0115
S0116
S0122
S0126
S0128
S0130
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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
This guide is subject to change at any time. If a member belongs to a group delegated for UM, contact that group for authorization inquiries. Claim payment is subject to eligibility and
benefits at the time of service. Claim processing edits will apply.
This prior authorization guide applies to the following lines of business: Healthy Options (HO), State Children's Health Insurance Plan (SCHIP), Basic Health Plan Plus (BH+),
Washington Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
S0132
S0135
S0136
S0137
S0138
S0139
S0140
S0141
S0147
S0155
S0156
S0157
S0158
S0159
S0160
S0161
S0162
S0164
S0170
S0171
S0172
S0173
S0174
S0175
S0176
S0177
S0178
S0179
S0181
S0182
S0183
S0187
S0189
S0190
S0191
S0194
S0195
S0201
S0207
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Yes
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
INJECTION GANIRELIX ACETATE 250 MCG
CLOZAPINE 25 MG
DIDANOSINE 25 MG
FINASTERIDE 5 MG
MINOXIDIL 10 MG
ZALCITABINE 0375 MG
INJECTION ALGLUCOSIDASE ALFA 20 MG
STERILE DILUTANT EPOPROSTENOL 50 ML
EXEMESTANE 25 MG
BECAPLERMIN GEL 0.01% 0.5 GM
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Yes
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
S0265
S0315
S0316
S0317
S0320
S0390
S1040
S2070
S2078
S2079
S2083
S2095
S2107
S2135
S2152
S2213
S2225
S2230
S2235
S2262
S2265
S2266
S2267
S2325
S2344
S2362
S2363
S2405
S2900
S3000
S3625
S3626
S3655
S3820
S3822
S3823
S3828
S3829
S3833
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Yes
Yes
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
Yes
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
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
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
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
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
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
S3834
S3840
S3841
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S3853
S3854
S3855
S3890
S4013
S4014
S4017
S4023
S4035
S4036
S4037
S4040
S4995
S5000
S5001
S5010
S5011
S5012
S5013
S5014
S5100
S5101
S5102
S5105
S5108
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
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
No
No
No
No
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
SINGLE-MUTAT ANALY SUSCEPT FAP&ATTENUATED FAP
DNA ANALYSIS GERMLINE MUTATS RET PROTO-ONCOGENE
GENETIC TESTING FOR RETINOBLASTOMA
GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE
DNA ANALYSIS F5 GENE FCT V LEIDEN THROMBOPHILIA
DNA ANALY CONNEXIN 26 GENE CONGN PFND DEAFNESS
GENETIC TESTING FOR ALPHA-THALASSEMIA
GENETIC TESTING HEMOGLOBIN E BETA-THALASSEMIA
GENETIC TESTING FOR TAY-SACHS DISEASE
GENETIC TESTING FOR GAUCHER DISEASE
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
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
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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
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 Integration Partnership (WMIP), Basic Health Plan (BHP)
Code
S5109
S5110
S5111
S5115
S5116
S5120
S5121
S5126
S5130
S5131
S5135
S5136
S5140
S5141
S5145
S5146
S5150
S5151
S5160
S5161
S5162
Prior Authorization Required
Outpatient Facility Place of Serivce
22, 24 Effective January 2009
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
Not Reimbursable
Not Reimbursable
Not Reimbursable
Not Reimbursable
Description
HOME CARE TRAINING HOME CARE CLIENT PER SESSION
HOME CARE TRAINING FAMILY; PER 15 MINUTES
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
ATTENDANT CARE SERVICES; PER DIEM
HOMEMAKER SERVICE NOS; PER 15 MINUTES
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
EMERGENCY RESPONSE SYSTEM; SERVICE FEE PER MONTH
EMERGENCY RESPONSE SYSTEM; PURCHASE ONLY
Prior Authorization Required
Office Setting Place of Service
11, 20 Effective January 2009
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
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.

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