PA Category Name Code(s) Additional Notes ABA. Applied Behavioral Analysis stage 3*
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1 ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0373T H G0396 Treatment provided to beneficiaries diagnosed with Autism Spectrum Disorder other Developmental Disorder between the ages of ICD10 Mental, Behavioral and Neurodevelopmental disorders G0397 ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders
2 CHEMICAL DEPENDENCY Chemical Dependency/Substance Abuse* (MA Only) ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders ICD10 Mental, Behavioral and Neurodevelopmental disorders CLINICAL TRIALS Clinical Trials Not specific to codes, must be indicated on submitted request. May have 8 digit trial ID, or primary or secondary Dx of Z00.6 DME Bone growth stimulators E0747 E0748 E0760 Chest compression devices E0483 C Pap* E0561 E0562 E0601 Bi Pap* E0470 E0471 E0472 Enteral/Parenteral Feedings* B4100 For individuals 21 and over B4102 Enteral Nutrition Thickeners required for members under one year old. B4103 B4149 B4150 B4152 B4153
3 DME Enteral/Parenteral Feedings* B4154 For individuals 21 and over Enteral Nutrition Thickeners required for members under one year old. B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 Hospital beds & accessories* B4199 B4216 B4220 B4222 B4224 B5000 B5100 B9000 B9002 B9004 B9006 B9998 B9999 E0193 E0194 E0250 E0251 E0255 E0256 E0260 E0261 E0266 E0277 E0290 E0291
4 DME Hospital beds & accessories* E0292 E0293 E0294 E0295 E0296 E0297 E0300 E0301 E0302 E0303 E0304 E0316 E0328 E0329 E0371 E0372 E0373 Oxygen* E1390 E1391 E1392 E0441 E0442 E0443 E0444 E0445 Ventilators* A4611 A4612 A4613 E0465 E0466 Wheelchair/Scooters* E1002 E1007 E1008 E1010 E1029 E1030 E1031 E1060 E1070 E1161 E1229 E1230 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238
5 DME Wheelchair/Scooters* E1239 E2300 E2325 E2373 E8001 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0009 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852
6 DME Wheelchair/Scooters* K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0890 K0891 K0898 Wound Vac A6550 E2402 All DME > $500 allowed amount per line item or > $1000 total allowed amount. For specific codes refer to the plan's fee schedule. Prosthetics and Orthotics L0170 L0456 L0464 L0480 L0482 L0486 L0631 L0637 L0640 L1005 L1200 L1300 L1499 L1730 L1834 L1844 L1845 L1846 L1945 L1950 L1970 L2020 L2034 L2036 L2037 L2038 L2108 L2136 L2350 L3230 L3720
7 DME Prosthetics and Orthotics L3730 L3740 L3764 L3900 L3905 L5020 L5050 L5100 L5220 L5301 L5321 L5400 L5510 L5530 L5540 L5590 L5646 L5651 L5661 L5703 L5790 L5812 L5814 L5828 L5848 L5930 L5950 L5964 L5968 L5976 L5980 L5981 L5984 L5987 L5988 L6000 L6050 L6100 L6300 L6687 L6689 L6694 L6704 L6707 L6884 L7405 L8619 L8691 L8692 Custom made Mandibular Advancement Devices (MAD) EO486
8 DME MISC. Speech Generating Device E2510 GENETIC TESTING Pathology and Laboratory 0022U 0023U 0027U 0028U 0031U 0032U 0033U 0034U 0037U 0047U 0048U 0049U 0050U 0053U 0056U 0057U 0060U
9 GENETIC TESTING Pathology and Laboratory
10 GENETIC TESTING
11 GENETIC TESTING
12 GENETIC TESTING G9143 HOME HEALTH / PRIVATE DUTY NURSING T1000 T1030 T G0151 G0152 G0153 G0155 G0156 INJECTABLE DRUGS Abatacept (Orencia) J0129 Adalimumab (Humira) J0135 Ado trastuzumab Emtansine (Kadcyla) J9354 Alemtuzumab (Lemtrada) J0202 Atezolizumab J9022 Avelumab J9023 Ziv Afibercept (Zaltrap) J9400 Belimumab (Benlysta) J0490 Botulinum Toxin (Botox/Myobloc/Dysport/Xeomin) J0585 J0586 J0587 J0588 Brentuximab (Adcetris) J9042 Buprenorphine implant (Probuphine) J0570 Buprenorphine xr subcutaneous injection Q9991 Q9992 Canakinumab (Ilaris) J0638 Cetuxumab (Erbitux) J9055 Denosumab (Prolia/ Xgeva) J0897 Ecallantide (Kalbitor) J1290 Epoprostenol (Flolan, Veletri) J1325 Erythropoiesis Stimulating Agents (Darbepoetin/Epoetin) J0881 J0882 J0885 J0887 J0888 Q4081
13 INJECTABLE DRUGS Erythropoiesis Stimulating Agents (Darbepoetin/Epoetin) Q5105 Q5106 Filgrastim biosimilar Zarxio Q5101 GnRH Agonists (Lupron) J1950 Golimumab (Simponi Aria) J1602 Granisetron extended release J1627 Granulocyte Colony Stimulating Factor (G Csf) (e.g., Pegfilgrastim, J1447 Filgastrim, Sargramostim) J1442 J2505 J2820 Q5108 Q5110 Growth Hormone (Somatropin) J2941 Hyaluronic Acid Derivatives (Synvisc, Hyalgan) J7320 J7321 J7322 J7323 Hyaluronic Acid Derivatives (Synvisc, Hyalgan) J7324 J7325 J7326 J7327 J7328 Hydroxyprogesterone Caproate (Makena) J1726 Medicaid: Pharmacy Benefit Please direct prescription to Accredo Specialty Pharmacy, phone Medicare: Prior Authorization is required. Hydroxyprogesterone Caproate J1729 Medicaid: Pharmacy Benefit Please direct prescription to Accredo Specialty Pharmacy, phone Medicare: Prior Authorization is required. Ibandronate (Boniva) Infliximab (Remicade) Infliximab biosimilar, Inflectra Infliximab abda, biosimilar, (Renflexis) Injection, somatrem, 1 mg Intravenous Immunoglobulin Ipilimumab (Yervoy) Lymphocyte immune globulin, Atgam J1740 J1745 Q5103 Q5104 J2940 J0588 J1459 J1557 J1561 J1566 J1568 J1569 J1572 J7504 J1556 J1559 J1555 J1562 J1599 J1575 J9228 J7504
14 INJECTABLE DRUGS Mempolizumab (Nacala) J2182 Natalizumab (Tysabri) J2323 Nivolumab (Opdivo) J9299 Ocrelizumab, 1 mg J2350 Omalizumab (Xolair) J2357 Paclitaxel protein bound (Abraxane) J9264 Paclitaxel (Taxol) J9267 Palivizumab (Synagis) Panitumumab (Vectibix) J9303 Pegloticase (Krystexxa) J2507 Pembrolizumab (Keytruda) J9271 Pemetrexed (Alimta) J9305 Pertuzumab (Perjeta) J9306 Ramucirumab (Cyramza) J9308 Ranibizumab (Lucentis) J2778 Reslizumab (Cinqair) J2786 Trastuzumab (Herceptin) J9355 Tocilizumab (Actemra) J3262 Treprostinil (Remodulin) J3285 Treprostinil (Remodulin) J7686 Ustekinumab (Stelara) J3357 Ustekinumab (Stelara) J3358 Vedolizumab (Entyvio) J3380 Zoledronic Acid (Zometa, Reclast) J3489 Injection, dexamethasone 9% C9034 Injection, aristada initio C9035 Injection, patisiran C9036 Injection, risperidone C9037 Inj mogamulizumab kpkc C9038 Inj., aprepitant, 1 mg J0185 Inj., benralizumab, 1 mg J0517 Inj., haegarda 10 units J0599 Injection, dexamethasone 9% J1095 Inj fosnetupitant, palonoset J1454 Inj., guselkumab, 1 mg J1628 Inj., ibalizumab uiyk, 10 mg J1746 Riboflavin 5' phosphate, ophthalmic solution, up to 3 ml J2787 Inj., rolapitant, 0.5 mg J2797 Inj., tildrakizumab, 1 mg J3245 Inj triamcinolone ace xr 1mg J3304 Inj., triptorelin xr 3.75 mg J3316 Inj., vestronidase alfa vjbk J3397 Esrd on dialysi drug/bio noc J3591 Injection, Emicizumab kxwh, 0.5 mg J7170 Inj, durolane 1 mg J7318 Inj, trivisc 1 mg J7329 Inj., copanlisib, 1 mg J9057 Inj daunorubicin, cytarabine J9153 Inj., durvalumab, 10 mg J9173 Inj inotuzumab ozogam 0.1 mg J9229
15 INJECTABLE DRUGS Inj rituximab, hyaluronidase J9311 Inj., rituximab, 10 mg J9312 Injection, inflectra Q5103 Injection, renflexis Q5104 Inj retacrit esrd on dialysi Q5105 Inj retacrit non esrd use Q5106 Injection, fulphila Q5108 Injection, ixifi, 10 mg Q5109 Nivestym Q5110 Injection, udenyca 0.5 mg Q5111 Buprenorph xr 100 mg or less Q9991 Buprenorphine xr over 100 mg Q9992 Romiplostim, 10 MCG (Medicaid only) J2796 Corticotropin J0800 Taliglucerase J3060 Eculizumab J1300 Unclassified Biologics J3590 OUTPATIENT SPECIALTY SERVICES Chiropractic* (greater than 12 visits MA and qualifying AH under age 20) Hyperbaric Oxygen Treatment G Orthoptic/Pleoptic Training: therapy services associated with orthoptic and pleoptic will require a PA. See PT and OT therapy notes below Physical Therapy* (after 12 visits MA; after 12 visits age 20 and under WAH; after 6 hours (24 units) WAH age 21 and over) **EXCEPTION TO THE ABOVE: Optometrist billing for therapy services will require a PA regardless of diagnosis before services begin
16 OUTPATIENT SPECIALTY SERVICES Occupational Therapy* (after 12 visits MA; after 12 visits age 20 and under WAH; after 6 hours (24 units) WAH age 21 and over) **EXCEPTION TO THE ABOVE: Optometrist billing for therapy services will require a PA regardless of diagnosis before services begin Speech Therapy* (after 12 visits MA; after 6 visits WAH 21 and over) OTHER PSYCHIATRIC SERVICES Electroconvulsive therapy/therapeutic repetitive transcranial magnetic stimulation (TMS) treatment (WAH only) Mental Health (Medicine) IMAGING/RADIOLOGY Medical Radiation Physics, dosimetry, treatment devices and special services (WAH only) Medical Radiation Physics, dosimetry, treatment devices and special G6016 services (WAH only) MRI
17 IMAGING/RADIOLOGY MRI C8903 C8904 C8905
18 IMAGING/RADIOLOGY MRI C8906 C8907 C8908 MRA C8900 C8901 C8902 C8909 C8910 C8911 C8912 C8920 C8931 C8932 C8933 C8934 C8935 C8936 Proton Beam Treatment (WAH only) S8030 SURGICAL PROCEDURES Bariatric surgery
19 SURGICAL PROCEDURES Bariatric surgery Cochlear implant Endovenous laser/radiofrequency ablation Hysterectomy
20 SURGICAL PROCEDURES Knee Arthroscopy Mammoplasty (Augmentation/Reduction) **excludes ICD 10 cancer dx Nervous system (facet neurotomy) Reconstructive plastic surgery & supplies S2066 S2067 S
21 SURGICAL PROCEDURES Reconstructive plastic surgery & supplies Rhinoplasty and septoplasty Sclerotherapy, leg veins Shoulder Arthroscopy Spinal Injections
22 SURGICAL PROCEDURES Spinal Injections Spinal surgeries
23 SURGICAL PROCEDURES Spinal surgeries
24 SURGICAL PROCEDURES Spinal surgeries
25 SURGICAL PROCEDURES Spinal surgeries (Medicaid only) (Medicaid only) (Medicaid only) 27134
26 SURGICAL PROCEDURES (Medicaid only) (Medicaid only) (Medicaid only) (Medicaid only) TRANSPLANTS Transplant T Transplant Eval and WorkUp Transplant evaluation and workup includes standard office visits for determining patients viability for services. Tests and treatments outside of the approved evaluation and treatment will be subject to review under the remainder of the PA List
27 TRANSPLANTS Transplant Eval and WorkUp Transplant evaluation and workup includes standard office visits for determining patients viability for services. Tests and treatments outside of the approved evaluation and treatment will be subject to review under the remainder of the PA List
PA Category Name Code(s) Additional Notes ABA 0364T 0365T 0366T 0367T 0373T 0374T H G0396. Applied Behavioral Analysis stage 3*
ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
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Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
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IMPORTANT NOTICES. To search this document, use [Ctrl + F] keys. Enter Service or Code in Navigation pane; press Enter.
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