PROCEDURES & SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION
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1 Prior Authorization Phone: Prior Authorization Fax: PROCEDURES & SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION This grid applies only to providers who participate with Arizona Priority Care. Prior Authorization is ALWAYS required for providers who are not in our network. Benefits and eligibility must ALWAYS be verified with the health plan. Failure to obtain prior authorization for procedures or services not on this grid may result in denial of coverage; as a result financial responsibility may be yours. This grid applies to all members; it is intended to be a guide and does not guarantee coverage or payment. Medical benefit plan language supersedes the general information provided on this grid. The presence or absence of an item on this list does not define whether or not coverage or benefits exist for the service or procedure and/or CPT Code. SERVICE DESCRIPTION Abdominal Paracentesis Administration of Chemotherapy** **Coverage is subject to medical necessity and approval/authorization of drug Annual depression screening 51720, 52287, , , , , 96450, G0444 Aspiration and Steroid Injection of Joints (non-guided) 20600, 20605, Basic Wound Care , , G0168 Biopsies: lip, external ear, tongue 40490, 41100, 41105, Brief emotional/behavioral assessment 96127, B-12 Injections 96372, J3420 Canes* E0100, E0105 Chemical Cauterization of Granulation Tissue Chest Tube/Catheter Commodes* E0163-E0168 Compression Devices* E0650-E0675 UM89 Services that Do Not Require Authorization_ Page 1 of 7
2 * CPAP (Continuous Positive Airway Pressure) Device and Supplies* E0601, A4604, A7027-A7046 CPM (Continuous Passive Motion) Device; knee only* Crutches and Crutch Substitute* Decubitus Care Equipment* E0935 E0110-E0118, E0153 E0181-E0191, E0196-E0199 Destruction any method; malignant lesions Destruction any method; premalignant lesions Destruction any method; benign lesions (other than skin tags or cutaneous vascular proliferative lesions) 17110, Diabetic Foot Care, Basic (diabetic shoes not included) G0127, G0245-G0247, , Diagnostic Anoscopies 46600, Dialysis Services , , , 90999, Q4081 Diffusing Capacity Dressings A6010-A6403, A6410-A6412, A6441-A6457 DXA Scan Ear Wax Removal 69209, 69210, G0268 ECG , Enteral and Parenteral Nutrition and Supplies* B4034-B4088, B4102-B4162, B4164-B5200, B9002-B9998 Evaluation and Monitoring of Cardiovascular Devices , Excision of Chalazion (Meibomian Cyst) External Cardiographic Recording (48 hours 21 days) 0295T-0298T Fine Need Aspiration without Imaging Guidance Foreign Body Removal 10120, 10121, 24200, 65205, UM89 Services that Do Not Require Authorization_ Page 2 of 7
3 Fracture Management (confirmed, non-surgical) Follow up X-ray, Initial & Follow up Office Visits, Splinting, Casting and Cast Removal Ganglion Cyst Aspiration/Injection (non-guided) Gastric Suction Pump* Hemodialysis Insertion, Repair/De-clotting, and/or Removal of Dialysis Catheter Humidifiers/Compressors/Nebulizers* E , , 36593, , E0560-E0585 Incision and Drainage , , 10140, 10160, 10180, , Incision/Excision of Thrombosed External Hemorrhoids 46320, Incontinence Supplies * A4310-A4360, A5102-A5200 Infusion Port-a-Cath, or Power-Ports (central line access catheters ) including Insertion, Removal, Repair and Catheter Care , , Ingrown Toenail Removal, Biopsy, Repair 11730, 11732, 11740, 11750, 11755, 11760, Inhalation Treatments 94640, , Injection of Tendon Sheaths, Bursa and Trigger Points (non-guided) , 20600, 20605, In Office Injections: Toradol, Benadryl, Dexamethasone, Phenergan, Carbocaine, Depo-Medrol, Marcaine, betamethasone acetate/sodium phosphate, Kenalog, furosemide, midazolam, alteplase recombinant, bupivicaine J1885, J1200, J1100, J2550, J0670, J1030, J2930, J3490, J0702, J3301, J1940, J2250, J2997, S0020 INR Monitoring , G0250, Instillation Drug/Chemical by Chest Tube Intraperitoneal Catheter Insertion and Removal 49418, Intrathoracic Placement Radiation Therapy Devices IV Hydration Normal saline, D5W and/or LR Mammography and Breast Tomosynthesis 96360, 96361, J7030, J7040, J , G0279 UM89 Services that Do Not Require Authorization_ Page 3 of 7
4 Manual Wheelchairs, Manual Wheelchair Accessories, and Wheelchair Cushions* Marsupialization of Bartholin s Cyst E0958-E0960, E0971, E0974- E0982, E0990-E0995, E1015, E1017, E1020-E1030, E1050- E1228, E1231-E1238, E1240, E1270, E1280, E1295-E1298, E2201-E2295, E2601-E2608, E2611-E2616, E2619-E2625, E2626-E2633, K0001-K0007, K0015-K0077, K0105, K0195 Measurement of post voiding residual urine and/or bladder capacity by ultrasound, non-imaging Medical Nutrition Therapy Services** **diagnosis of renal disease or diabetes ONLY Negative Pressure Wound Therapy (Wound Vac) and Supplies* E2402, A6550, A7000 Nitric Oxide Expired Gas Determination Non-invasive Vascular Studies: extremities Occipital Nerve Block Office Visits Ophthalmology Exam and Evaluation Orthopedic Devices* E0910-E0930, E0940-E0948 Osteopathic Manipulative Treatment (OMT) Ostomy Pouches and Supplies* A4361-A4435, A5051-A5093 Outpatient PT/OT/ST Initial Evaluation and 1 (one) Treatment (free standing facility only) , , UM89 Services that Do Not Require Authorization_ Page 4 of 7
5 Oxygen and Respiratory Equipment and Supplies* Patient Lifts* A4614-A4626, A4628-A4629, A7001-A7018, A7047 E0424-E0445, E0466-E0480, E0482-E0484, E0600, E1353- E1355, E1372, E1390-E1392, K0738, K0739 E0621, E0630, E0635 Percutaneous Drainage 75984, Plain Film X-Ray , , , 70380, , , , , , , , , , , , , , , , Plethysmography for Lung Volume Pleural Aspiration and Drainage PPD Tuberculosis Test Prostate Screenings G0102 Pulmonary Stress Test, simple Pulse Oximetry 94760, Removal of Foreign Substance and Infected/Devitalized Tissue Routine Medicare-covered Vaccinations 90630, , , 90670, , 90682, , 90732, 90739, 90740, 90743, 90744, 90746, 90747, 90756, G0008-G0010, Q2034-Q2039 Shave, Punch or Excisional Skin Biopsies , , Skin Lesion removal; confirmed malignant Smoking and Tobacco Cessation Counseling UM89 Services that Do Not Require Authorization_ Page 5 of 7
6 Spinal Manipulation 98940, 98941, Spirometry Test 94010, TENS (Transcutaneous Electrical Nerve Stimulation) device* Tracheostomy Supplies and Speaking Valve* Transfer Bench/Device* E0720-E0730, A4556-A4557, A5695 A4605, A4608, A4481, A7501- A7527, L8501 E0247, E0248, E0705 Treatment of Genital Warts 56501, 56515, 57061, 57065, Treatment of hidradenitis; excision and repair Treatment of Lesions; injection Ultrasound 76506, , , , , , , 76975, Ultrasound Guidance for Needle Placement and Vascular Access 76942, Urinary Catheterization (insertion/removal) , A4351, A4358 Vein Mapping for Fistula 93970, Walkers* For OB/Gyn Specialists Only: In-Office GYN Procedures: Endometrial Biopsies, Colposcopies with Biopsy For ENT Specialists Only: Control of Nosebleed, Nasal Endoscopy Dx, Nasal/Sinus Endoscopy Surg, Diagnostic Laryngoscopy, Diagnostic Laryngoscopy, Ear Microscopy Examination, Basic Vestibular Evaluation, Spontaneous Nystagmus Test For ENT & Audiology Specialists Only: Tympanometry & Reflex Threshold, Pure Tone Audiometry Air, Audiometry Air and Bone, Speech Threshold Audiometry, Speech Audiometry Complete, Comprehensive Hearing Test, Tympanometry, Acoustic Reflex Threshold Test E0130-E0149, E0154-E , 58110, 58555, 58558, , , 56820, 56821, G0123-G0124, Q0091, Q , 30905, 30906, 31231, 31237, 31505, 31575, 92504, 92540, , 92552, 92553, 92555, 92556, 92557, 92567, UM89 Services that Do Not Require Authorization_ Page 6 of 7
7 In-Office Laboratory Services: Collection of venous blood venipuncture, Urinalysis, non-automated without microscopy, Glucose, serum glucose monitoring device(s) cleared by the FDA specifically for home use, Heterophile antibodies screening, Tuberculosis, intradermal, Urine pregnancy test, by visual color comparison methods, Infectious agent enzymatic activity other than virus (e.g., sialidase activity in vaginal fluid) 36410, 36415, , 82962, 86308, 86580, 81025, Detection Infectious Agent by Immunoassay with Direct Optical Observation East Valley Access Center In Network Laboratory Services Unique Labs 87804, 87807, 87808, 87809, All All All UM89 Services that Do Not Require Authorization_ Page 7 of 7
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