CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 64865 Repair of facial nerve All 64866 Fusion of facial/other nerve All 64868 Fusion of facial/other nerve All 64870 Fusion of facial/other nerve All 64872 Subsequent repair of nerve All 64874 Repair & revise nerve All 64876 Repair nerve; shorten bone All 64885 Nerve graft, head or neck All 64886 Nerve graft, head or neck All 64890 Nerve graft, hand or foot All 64891 Nerve graft, hand or foot All 64892 Nerve graft, arm or leg All 64893 Nerve graft, arm or leg All 64895 Nerve graft, hand or foot All 64896 Nerve graft, hand or foot All 64897 Nerve graft, arm or leg All 64898 Nerve graft, arm or leg All 64901 Additional nerve graft All 64902 Additional nerve graft All 64905 Nerve pedicle transfer All 64907 Nerve pedicle transfer All 64910 Nerve repair w/allograft All 64911 Neurorraphy w/vein autograft All 64999 Nervous system surgery All 65091 Revise eye All 65093 Revise eye with implant All 65101 Removal of eye All 65103 Remove eye/insert implant All 65105 Remove eye/attach implant All 65110 Removal of eye All 65112 Remove eye, revise socket All 65114 Remove eye, revise socket All 65125 Revise ocular implant All 65130 Insert ocular implant All 65135 Insert ocular implant All 65140 Attach ocular implant All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 65150 Revise ocular implant All 65155 Reinsert ocular implant All 65175 Removal of ocular implant All 65710 Corneal transplant All 65730 Corneal transplant All 65750 Corneal transplant All 65755 Corneal transplant All 65756 Corneal trnspl, endothelial All 65757 Prep corneal endo allograft All 65770 Revise cornea with implant All 65772 Correction of astigmatism All 65775 Correction of astigmatism All 65778 Place amniotic memb ocular surface self retain All 65779 Place amniotic membrane ocular surface sutured All 65780 Ocular Reconst, Transplant All 65781 Ocular Reconst, Transplant All 65782 Ocular Reconst, Transplant All 66174 Trluml dilat aqueous canal w/o dev/stnt All 66175 Trluml dilat aqueous canal w/dev/stnt All 66180 Implant eye shunt All 66185 Revise eye shunt All 66220 Repair eye lesion All 66225 Repair/graft eye lesion All 66250 Follow-up surgery of eye All 66500 Incision of iris All 66505 Incision of iris All 66600 Remove iris and lesion All 66605 Removal of iris All 66625 Removal of iris All 66630 Removal of iris All 66635 Removal of iris All 66680 Repair iris & ciliary body All 66682 Repair iris and ciliary body All 66700 Destruction, ciliary body All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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