* The following grid only identifies items that require preapproval from. 11400-11471 Excision benign lesion 15820-15823 Blepharoplasty Notes: If Opthamologist requesting, pre-auth is not required 19316-19318 Breast repair or reconstruction 19324-19325 Mammaplasty, augmentation with or without prosthetic implant Notes: If breast cancer diagnosis, pre-auth is not required 19328-19330 Breast repair or reconstruction 20974-20974 Electrical stimulation non-invasive 20975-20975 Electrical stimulation operative 20979-20979 Low intensity ultrasound (US) for bone stimulation 22100-22226 Spinal procedures 22505-22534 Spinal procedures 22548-22899 Spinal procedures 27284-27286 Arthrodesis 33930-33945 Heart/lung transplant 36475-36479 Endovenous Ablation Therapy 37700-37799 Treatment of varicose veins 43644-43645 Laparoscopic Gastric Bypass with Small Bowel Resection Page 1 of 5
* The following grid only identifies items that require preapproval from. 43647-43653 Other Laparoscopic Gastric Procedures 43770-43775 Laparoscopic Bariatric Procedures 43842-43888 Open Bariatric, Gastric Procedures 44055-44055 Freeing of intestinal adhesions 48550-48999 Pancreas Transplant 49491-49611 Hernia repair 49650-49659 Laparoscopy 50300-50380 Kidney Transplant 54360-54417 Plastic surgery on penis; insertion and repair of prosthesis 56800-56810 Plastic repair of introitus, clitoroplasty, perineoplasty 58150-58180 Hysterectomy, abdominal and vaginal enterocele repair 58260-58290 Vaginal hysterectomy 58550-58554 Vaginal hysterectomy with laparoscopy 58578-58578 Unlisted laparoscopy procedures, uterus 58660-58662 Laparoscopy/Lysis of Adhesions 58672-58770 Laparoscopy/Lysis of Adhesions 58940-58960 Oophrectomy/Laparotomy Page 2 of 5
* The following grid only identifies items that require preapproval from. 62115-62117 Reduction of craniomegaly 62140-62148 Cranioplasty procedures 62280-62292 Neurolysis & Injection/Aspiration of Spine, Diagnostic/Therapeutic 62310-62319 Injection/Infusion Diagnostic/Therapeutic Material 62350-62368 Procedures Related to Epidural and Interthecal Catheters 63001-63051 Posterior Midline Laminectomy/Laminotomy/Decompression & Cervical Laminoplassty Procedures 63055-63199 Spinal cord procedures 63650-63688 Spinal Neurostimulation 64479-64484 Transforaminal Injection 64550-64595 Peripheral nerve neurostimulators 64702-64716 Decompression and/or Transposition of Nerve 64719-64719 Decompression and/or Transposition of Nerve 64726-64727 Decompression and/or Transposition of Nerve 65710-65755 Corneal transplant 65760-65782 Corneal procedures 69710-69799 Implantation of hearing device 69930-69949 Cochlear implant & unlisted Page 3 of 5
* The following grid only identifies items that require preapproval from. 70336-70336 Magnetic Resonance Imaging (MRI) Temporomandibular Joint Notes: If for dentofacial anomalies, osteoarthrosis, dislocation of jaw, pre-auth is not required 70540-70543 Magnetic Resonance Imaging (MRI) Orbit, Face, or Neck 70551-70555 Magnetic Resonance Imaging (MRI) Brain 71550-71552 Magnetic Resonance Imaging (MRI) Chest 72141-72159 Magnetic Resonance Imaging/Magnetic Resonance Angiography (MRI/MRA) spinal canal 72195-72197 Magnetic Resonance Imaging (MRI) Pelvis 73218-73223 Magnetic Resonance Imaging (MRI) Upper Extremity 73718-73723 Magnetic Resonance Imaging (MRI) Lower Extremity 74181-74183 Magnetic Resonance Imaging (MRI) Abdomen - General 75557-75565 Magnetic Resonance Imaging (MRI) Heart Structure and Physiology 76999-76999 Unlisted Ultrasound Procedure 77058-77059 Magnetic Resonance Imaging (MRI) breast 77084-77084 Magnetic Resonance Imaging (MRI) Bone Marrow Blood Supply 78414-78499 Nuclear cardiac testing 78459-78459 Heart Positron Emission Tomography (PET) 78608-78609 Brain Positron Emission Tomography (PET) 78811-78816 Tumor Positron Emission Tomography (PET) Page 4 of 5
* The following grid only identifies items that require preapproval from. 90875-90876 Biofeedback 90901-90911 Biofeedback 92506-92510 Speech/language services 92526-92526 Speech/language services 95999-95999 Unlisted neurological or neuromuscular diagnostic procedure 96100-96117 Neuro-psych testing 96150-96155 Health and Behavior Assessment and Intervention Notes: Effective 10/1/2011, pre-auth required for units > 10 per member per year 97001-97799 Physical medicine & rehabiliation 97802-97804 Medical Nutrition Therapy Notes: If diabetes diagnosis, pre-auth is not required 98940-98943 Chiropractic manipulation 99183-99183 Hyperbaric Page 5 of 5