Oregon CPT Preapproval Grid
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- Carol Powers
- 6 years ago
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1 * The following grid only identifies items that require preapproval from Excision benign lesion Blepharoplasty Notes: If Opthamologist requesting, pre-auth is not required Breast repair or reconstruction Mammaplasty, augmentation with or without prosthetic implant Notes: If breast cancer diagnosis, pre-auth is not required Breast repair or reconstruction Electrical stimulation non-invasive Electrical stimulation operative Low intensity ultrasound (US) for bone stimulation Spinal procedures Spinal procedures Spinal procedures Arthrodesis Heart/lung transplant Endovenous Ablation Therapy Treatment of varicose veins Laparoscopic Gastric Bypass with Small Bowel Resection Page 1 of 5
2 * The following grid only identifies items that require preapproval from Other Laparoscopic Gastric Procedures Laparoscopic Bariatric Procedures Open Bariatric, Gastric Procedures Freeing of intestinal adhesions Pancreas Transplant Hernia repair Laparoscopy Kidney Transplant Plastic surgery on penis; insertion and repair of prosthesis Plastic repair of introitus, clitoroplasty, perineoplasty Hysterectomy, abdominal and vaginal enterocele repair Vaginal hysterectomy Vaginal hysterectomy with laparoscopy Unlisted laparoscopy procedures, uterus Laparoscopy/Lysis of Adhesions Laparoscopy/Lysis of Adhesions Oophrectomy/Laparotomy Page 2 of 5
3 * The following grid only identifies items that require preapproval from Reduction of craniomegaly Cranioplasty procedures Neurolysis & Injection/Aspiration of Spine, Diagnostic/Therapeutic Injection/Infusion Diagnostic/Therapeutic Material Procedures Related to Epidural and Interthecal Catheters Posterior Midline Laminectomy/Laminotomy/Decompression & Cervical Laminoplassty Procedures Spinal cord procedures Spinal Neurostimulation Transforaminal Injection Peripheral nerve neurostimulators Decompression and/or Transposition of Nerve Decompression and/or Transposition of Nerve Decompression and/or Transposition of Nerve Corneal transplant Corneal procedures Implantation of hearing device Cochlear implant & unlisted Page 3 of 5
4 * The following grid only identifies items that require preapproval from Magnetic Resonance Imaging (MRI) Temporomandibular Joint Notes: If for dentofacial anomalies, osteoarthrosis, dislocation of jaw, pre-auth is not required Magnetic Resonance Imaging (MRI) Orbit, Face, or Neck Magnetic Resonance Imaging (MRI) Brain Magnetic Resonance Imaging (MRI) Chest Magnetic Resonance Imaging/Magnetic Resonance Angiography (MRI/MRA) spinal canal Magnetic Resonance Imaging (MRI) Pelvis Magnetic Resonance Imaging (MRI) Upper Extremity Magnetic Resonance Imaging (MRI) Lower Extremity Magnetic Resonance Imaging (MRI) Abdomen - General Magnetic Resonance Imaging (MRI) Heart Structure and Physiology Unlisted Ultrasound Procedure Magnetic Resonance Imaging (MRI) breast Magnetic Resonance Imaging (MRI) Bone Marrow Blood Supply Nuclear cardiac testing Heart Positron Emission Tomography (PET) Brain Positron Emission Tomography (PET) Tumor Positron Emission Tomography (PET) Page 4 of 5
5 * The following grid only identifies items that require preapproval from Biofeedback Biofeedback Speech/language services Speech/language services Unlisted neurological or neuromuscular diagnostic procedure Neuro-psych testing Health and Behavior Assessment and Intervention Notes: Effective 10/1/2011, pre-auth required for units > 10 per member per year Physical medicine & rehabiliation Medical Nutrition Therapy Notes: If diabetes diagnosis, pre-auth is not required Chiropractic manipulation Hyperbaric Page 5 of 5
Oregon CPT Preapproval Grid
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ADI Procedure Codes. August 2016 Revised April 2017 Page 1 of 7 ADI Procedure Codes
Code Description 70450 CT Head without contrast 70460 CT Head with contrast 70470 CT Head with & without contrast 70480 CT Orbit, et al without contrast 70481 CT Orbit, et al with contrast 70482 CT Orbit,
Radiology Codes Requiring Authorization*
70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) 70450 Computed tomography, head or brain; without contrast material 70460 Computed tomography, head or brain; with contrast material(s)
05/02/ CPT Preauthorization Groupings Effective May 2, Computerized Tomography (CT) Abdomen 6. CPT Description SEGR CT01
Computerized Tomography (CT) 6 & 101 5 Upper Extremity 11 Lower Extremity 12 Head 3 Orbit 1 Sinus 2 Neck 4 7 Cervical Spine 8 Thoracic Spine 9 Lumbar Spine 10 Colon 13 CPT Preauthorization Groupings CPT
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Cigna - Prior Authorization Procedure List: Radiology & Cardiology
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AMERICAN IMAGING MANAGEMENT
2012 CPT Codes Computerized Tomography (CT) CPT Description Abdomen 74150 CT abdomen; w/o 74160 CT abdomen; with 74170 CT abdomen; w/o followed by Chest 71250 CT thorax; w/o 71260 CT thorax; with 71270
AMERICAN IMAGING MANAGEMENT
2010 BCBS of Georgia CPT Codes With Grouper Numbers Computerized Tomography (CT) CPT Description Abdomen 74150 CT abdomen; w/o contrast 6 74160 CT abdomen; with contrast 74170 CT abdomen; w/o contrast
screening; including image post processing CT, heart; without contrast material; with Requires authorization
0042T Cerebral perfusion analysis using CT; with ; including of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 74263 Computed tomographic (CT) colonography,
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Cigna - Prior Authorization Procedure List: Radiology & Cardiology
Cigna - Prior Authorization Procedure List: Radiology & Cardiology Product Category CPT Code CPT Code Description Radiology MR 70336 MRI Temporomandibular Joint(s), (TMJ) Radiology CT 70450 CT Head or
MOLINA HEALTHCARE OF MICHIGAN PRIOR AUTHORIZATION / PRE-SERVICE REVIEW GUIDE IMAGING CODES REQUIRING PRIOR AUTHORIZATION EFFECTIVE 1/1/2014
70336 MRI MRI, temporomandibular joint(s) 70450 CT/CTA CT, head or brain; without contrast material 70460 CT/CTA CT, head or brain; with contrast material(s) 70470 CT/CTA CT, head or brain; without contrast
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Arteriovenostomy for renal dialysis 39.27, 39.42
Surgery categories NHSN Surgery codes (Reference: NHSN Operative Procedure Category Mappings to ICD-9-CM Codes, October 2010 www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf) Operative aortic aneurysm
Diagnostic Imaging Prior Review Code List 2 nd Quarter 2018
Computerized Tomography (CT) Abdomen 6 Abdomen/Pelvis Combination 101 Service 74150 CT abdomen; w/o 74160 CT abdomen; with 74170 CT abdomen; w/o followed by 74176 Computed tomography, abdomen and pelvis;
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BlueAdvantage SM & BlueChoice SM Radiology Prior Authorization Program Code List CPT /HCPS 70336 MRI TMJ 70450 CT Head Without Contrast 70460 CT Head With Contrast 70470 CT Head Without & With Contrast
AIM 2014 CPT Radiology & Cardiac Codes Requiring Review
AIM 2014 CPT Radiology & Cardiac Codes Requiring Review Modality Body Part CT Head 1 70480 CT orbit, sella or posterior fossa; w/o contrast 1 CT Head 1 70481 CT orbit, sella or posterior fossa; with CT
2014 CPT Radiology Codes Requiring Review
CT Head 1 70480 CT orbit, sella or posterior fossa; w/o contrast 1 CT Head 1 70481 CT orbit, sella or posterior fossa; with CT orbit, sella or posterior fossa; w/o contrast CT Head 1 70482 followed by
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2012 CPT Radiology Codes Requiring Review Blue Cross and Blue Shield of Louisiana CT Head 70480 CT orbit, sella or posterior fossa; w/o CT Head 70481 CT orbit, sella or posterior fossa; with CT Head 70482
22110 vertebral segment; cervical vertebral segment; thoracic vertebral segment; lumbar
The following codes are authorized by Palladian Health for applicable product lines. Visit palladianhealth.com to request authorization and to access guidelines. Palladian Musculoskeletal Program Codes
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EFFECTIVE OCTOBER 1, 2012 70336 MAGNETIC RESONANCE IMAGING TMJ 70450 COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT 70460 COMPUTED TOMOGRAPHY HEAD/BRAIN WITH 70470 COMPUTED TOMOGRAPHY HEAD/BRAIN WITHOUT AND WITH
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Description MRI, TMJ C T Head Without Contrast C T Head With Contrast C T Head Without & With Contrast
s Requiring Prior Authorization for the Advanced Imaging 70336 MRI, TMJ 70450 C T Head Without Contrast 70460 C T Head With Contrast 70470 C T Head Without & With Contrast 70480 C T Orbit Without Contrast
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2010 Radiology Prior Authorization List for UnitedHealthcare s HealthChoice Members
70336 MR TEMPOROMANDIBULAR JOINT 70450 CT, HEAD OR BRAIN; WITHOUT MATERIAL 70460 CT HEAD/BRAIN W/ 70470 CT HEAD/BRAIN W/O & W/ 70480 CT, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MID 70481 CT ORBIT W/
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