Prior Authorization Guide
Effective January 1, 2015
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Medical Observation admits greater than 23 hours.
Surgical Observation admits where the procedure requires Prior Authorization, or greater than
23 hours
All Inpatient Hospital, Behavioral Health, Chemical Dependency, Skilled Nursing, Longterm Acute care and Rehabilitation admissions require Prior Referral/Authorization.
Maternity admissions for Vaginal Delivery greater than 48 hours and for Cesarean Delivery
greater than 96 hours.
Mental health services
Neuropsychological testing
Nutritional Support (enteral feeding)
Home Health, except for Physical Therapy, Occupational Therapy and Speech Therapy.
Hospice
Durable Medical Equipment (DME) over $1000.00 single line item purchase price, or
cumulative rental of a single item (does not include oxygen and oxygen equipment). In addition
the following items, including but not limited to:
o CPAP units (not supplies)
o TENS units (not supplies)
o Bone growth or neuromuscular stimulators
o Hospital beds
o Wheelchairs
o All custom made items
o Insulin pumps (not supplies)
o Continuous Glucose Monitors
Orthotics over $1000, all foot orthotics or any custom orthotic
Non emergent ambulance transfers
Air ambulances
Phototherapy
Clinical trials
Transplants
Prosthetic > $1000
Accidental dental services
All CPT codes ending in “99”
All CPT codes ending in “T”
Genetic testing (except codes 83890-83912)
All CPT codes in the below tables
CPT/HCPCS Code
11920-11921
Revised 09/11/14
Integumentary System
Description
Tattooing, intradermal
HADH Prior Authorization List
Page 1
11960
11970
11971
11976
11981-11982
**15822-15823
15830, 15847
15840-15845
19300
19316
19318
19324-19325
19328
19330
19340-19342
19350
19357-19369
19380-19396
Insertion of tissue expander(s) for other than breast, including subsequent expansion
Replacement of tissue expander with permanent prosthesis
Removal of tissue expander(s) without insertion of prosthesis
Removal, implantable contraceptive capsules
Insertion, removal, non-biodegradable drug delivery implant
Blepharoplasty, upper eyelid
Excision, excessive tissue skin and subcutaneous tissue
Graft for facial nerve paralysis; free muscle graft; free muscle flap; regional muscle
transfer
Mastectomy for gynecomastia
Mastopexy
Reduction mammaplasty
Mammaplasty, augmentation; with and without prosthetic implant
Removal of intact mammary implant
Removal of mammary implant material
Immediate/ delayed insertion of breast prosthesis following mastopexy, mastectomy,
or in reconstruction
Nipple reconstruction
Breast reconstruction
Revision of reconstructed breast; preparation of moulage for custom breast implant
21137-21139
21141-21160
21172-21196
21198-21199
Musculoskeletal System
Description
Electrical stimulation to aid bone healing; noninvasive; invasive
Low intensity ultrasound stimulation to aid bone healing
Arthrotomy, temporomandibular joint
Condylectomy/ Menisectomy; temporomandibular joint
Coronoidectomy
Impression and custom preparation; maxillofacial prosthesis
Unlisted maxillofacial prosthetic procedure
Application of halo type appliance for maxillofacial fixation, includes removal
Interdental fixation for other than fracture
Injection procedure for temporomandibular joint arthrography
Genioplasty
Augmentation, mandibular body or angle; prosthetic material, with bone graft, onlay,
or interpositional
Reduction forehead
Reconstruction midface, LeFort I, II, III
Reconstruction of orbital rims, forehead, cranial bones, mandibular rami
Osteotomy, mandible, segmental; with genioglossus advancement
21206-21208
Osteoplasty, facial bones; augmentation
21210-21235
Graft bone; nasal, maxillary or malar areas; rib cartilage, autogenous, to
face, chin, nose, or ear; ear cartilage, autogenous, to nose or ear
Arthroplasty, temporomandiular joint; autograft, allograft, prosthetic joint
replacement
CPT/HCPCS Code
20974-20975
20979
21010
21050-21060
21070
21076-21088
21089
21100
21110
21116
21120-21123
21125-21127
21240-21243
Revised 09/11/14
HADH Prior Authorization List
Page 2
21244-21249
21255
21256-21268
21270
21275
21740-21743
22100-22116
22206-22226
22520-22525
22526-22527
22548-22812
22818-22819
22830
22840-22855
22856-22865
23473-23474
24370-24371
Reconstruction of mandible or maxilla
Reconstruction of zygomatic arch and glenoid fossa
Reconstruction of orbit with osteotomies; periorbital osteotomies; orbital
repositioning
Malar augmentation, prosthetic material
Secondary revision of orbitocraniofacial reconstruction
Reconstructive repair of pectus excavatum or carinatum
Partial excision vertebral component or vertebral body
Osteotomy spine
Percutaneous vertebroplasty, kyphoplasty
IDET (Intradiscal electrothermal therapy)
Arthrodesis, spine
Kyphectomy
Exploration of spinal fusion
Spinal instrumentation
Total disc arthroplasty
Revision total shoulder
Revision total elbow
31660-31662
Respiratory System
Description
Rhinoplasty, primary or secondary, including major septal repair
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate
Repair of nasal vestibular stenosis
Septoplasty or submucous resection; repair choanal atresia; lysis
intranasal synechia; repair fistula; dermatoplasty; repair nasal septal perforations
Bronchoscopy with bronchial thermoplasty
CPT/HCPCS Code
32664
33361-33369
33990-33991
33782-33783
33975-33983
38243
93228-93229
G0166
Cardiovascular System
Description
Thoracoscopy with thoracic sympathectomy
Transcatheter aortic valve replacement (TAVH/TAVI)
Insertion of ventricular assist device
Nikaidoh procedure
Insertion/Replace VAD
HPC Boost
External mobile cardiovascular telemetry
Enhanced External Counterpulsation (35 treatments over 9 weeks)
CPT/HCPCS Code
30400-30450
30460-30462
30465
30520-30630
Digestive System
Description
CPT/HCPCS Code
41512
Tongue suspension
41530
Tongue base volume reduction
41800-41806
Drainage of abscess, cyst, hematoma; removal of embedded foreign body from
dentoalveolar structures
Revised 09/11/14
HADH Prior Authorization List
Page 3
41820-41874
41899
42140
42145
42280
42281
43206
43252
43281-43282
43659
43647, 43881-43882
43644-43645,
43770-43775,
43842-43848
43886-43888
S2083
Gingivectomy; operculectomy; excision of tuberosities dentoalveolar structures;
gingivoplasty
Unlisted procedure, dentoalveolar structures
Uvulectomy
Palatopharyngoplasty
Maxillary impression for palatal prosthesis
Insertion of pin-retained palatal prosthesis
Esophagoscopy with optical endomicroscopy
Upper GI endoscopy with optical endomicroscopy
Laprascopic paraesophageal hernia repair
Unlisted laproscopy procedure, stomach
Gastric neurostimulator electrodes, implanatation, revision, replacement, removal
Bariatric surgery
44705
49411
Allowed 6 in first 12 months following procedure, 3 in second 12 months following
procedure without prior authorization All other visits for S2083 require prior
authorization
Preparation of fecal microbotia for instillation
Placement of interstitial devices for radiation therapy guidance
CPT/HCPCS Code
52287
Male/Female
Description
Cystourethoscopy with injection(s) fro chemodenervation of the bladder
53860
54400-54417
58150-58240
58951
Transurethral radiofrequency micro-remodeling of the female bladder neck and
proximal urethra for stress incontinence
Penile prosthesis
Total abdominal hysterectomy, with or without removal of tube(s) and/or ovary(s)
Resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingooopherectomy and omentectomy; with total abdominal hysterectomy, pelvic and
limited para-aortic lymphadenectomy
59525
Hysterectomy after cesarean delivery
CPT/HCPCS Code
61793
61796-61800
61850-61888
62263 - 62264
63620-63621
63650-63688
64550-64595
64611-64615
64633-64636
64910-64911
Revised 09/11/14
Nervous System
Description
Stereotactic radiation
Stereotactic radiosurgery, cranial lesion
Insertion/removal/revision neurostimulator
Percutaneous lysis of epidural adhesions
Stereotactic radiosurgery, spinal lesion
Neurostimulators, spinal
Neurostimulator, peripheral
Chemodenervation of muscle(s); cervical spinal muscle(s)
Destruction by neurolytic agent, paravertebral facet joint nerves
Nerve repair with synthetic conduit or vein allograft
HADH Prior Authorization List
Page 4
64405
64450
Nerve block greater occiputal nerve (injection of anesthetic agent)
Injection of other peripheral nerves or branch (usually billed with the above code)
64640
RFA - inject rx other peripheral nerve - destruction by neurolytic agent,
chemodervervation
CPT/HCPCS Code
65760
65771
67221-67225
67345
67909
67911
67912
67914-67924
69714-69717
69930
J3396
Eye and Ocular Adnexa
Description
Keratomileusis
Radial keratotomy
Photodynamic therapy
Chemodenervation of extraocular muscle
Reduction of ptosis
Correction of lid retraction
Ocular surface reconstruction
Repair of ectropian
Osseointegrated implant, implantation, removal, replacement
Cochlear device implantation, with or without mastoidectomy
Visudyne
Radiology
CPT/HCPCS Code
70332
70554-70555
72291-72292
74261-74263
74742
75557-75565
75571-75574
76390
76498
76977, 78350
77078-77083
61793, 77371-77373,
G0339-G0340
77058-77059
77338
78459
78491-78492
78608-78609
78811 -78816
G0219, G0235,
G0252
Revised 09/11/14
Description
Temporomandibular joint arthrography
Functional MRI brain
Radiological supervision, vertebroplasty
CT colonography
Xray fallopian tubes
Cardiac MRI
CT Heart
Magnetic resonance spectroscopy
Unlisted MRI
Bone density testing when performed on a woman < 65 yrs age or a
man <70 yrs age, or when more than once every 2 years.
Stereotactic radiation
Breast MRI
Multi-leaf collimator device for IMRT
Myocardial imaging, positron emission tomography (PET), metabolic evaluation
Myocardial imaging, positron emission tomography (PET), single or multiple
studies
Brain imaging, positron emission tomography (PET); metabolic evaluation,
perfusion evaluation
Tumor imaging, positron emission tomography (PET), metabolic evaluation
PET imaging
HADH Prior Authorization List
Page 5
CPT/HCPCS Code
90378
90875-90876
90901-90911
91110-91112
93228-93229
96020
96118-96120
96900
96902
96910-96913
97532
97533
97537
97545-97546
97605-97606
99183
J0585-J0588
J1745
Medicine
Description
RSV IG intramuscular
Individual psychophysiological therapy
Biofeedback
GI tract imaging, intraluminal e.g. capsule endoscopy
External mobile cardiovascular telemetry
Neurofunctional testing
Neuropsychological testing battery
Actinotherapy (ultraviolet light)
Microscopic examination of hairs plucked or clipped by the examiner
Photochemotherapy (Goeckerman and/or PUVA)
Development of cognitive skills
Sensory integrative techniques
Community/work reintegratin
Work hardening
Negative pressure wound therapy
Physician attendance and supervision of hyperbaric oxygen therapy, per session
Botox
Remicade
Cosmetic: Not Covered
CPT/HCPCS Code
Description
11950-11954
Subcutaneous injection of filling material (e.g. collagen)
15775-15776
Punch graft for hair transplant
15780-15811
Dermabrasion, abrasion, chemical peel, and salabrasion
15819
Cervicoplasty
15820-15821
Blepharoplasty, lower eyelid
15824-15829
Rhytidectomy
15830-15839
Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen
(abdominoplasty)
15876-15879
Suction assisted lipectomy
17380
Electrolysis epilation
19316
Mastopexy
19355
Correction of inverted nipples
21209
Osteoplasty, facial bones; reduction
21280-21282
Medial canthopexy; lateral canthopexy
21295-21296
Reduction of masseter muscle and bone; extraoral , intraoral approach
30120
Excision or surgical planing of skin of nose for rhinophyma
36468-36471
Single or multiple injections of sclerosing solutions (spider veins); limb, trunk, face,
legs
67715
Canthotomy
67900-67911
Repair of brow ptosis; repair of blepharoptosis; repair of overcorrection of ptosis;
correction of lid retraction
67950
Canthoplasty
69090
Ear piercing
69300
Otoplasty, protruding ear, with or without size reduction
Revised 09/11/14
HADH Prior Authorization List
Page 6
Infertility: Not Covered
CPT/HCPCS Code
Description
55400
Vasovasostomy Vasovasorrhaphy
Dental: Not Covered
CPT/HCPCS Code
Description
40840
Vestibuloplasty; Anterior
40842
Vestibuloplasty; Post Unilateral
40843
Vestibuloplasty; Post Bilateral
40844
Vestibuloplasty; Entire Arch
40845
Vestibuloplasty; COMPLX
Unlisted not ending in “99”
CPT/HCPCS Code
Description
88749
Unlisted In vivo lab service
89398
Unlisted reproductive medicine lab procedure
This list excludes xxxxT (Category III Codes). If a Category III code is available for a given service
or procedure, use the Category III code instead of a Category I Unlisted code. If billing with a
temporary code, include supporting documentation with the claim.
Revised 09/11/14
HADH Prior Authorization List
Page 7