CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 70552 Magnetic image, brain (mri) w/dye All 70553 Magnetic image, brain w/o & w/dye All 70554 Fmri brain by tech All 70555 Fmri brain by phys/psych All 70557 Mri Brain w/o dye All 70558 Mri Brain w/ dye All 70559 Mri Brain w/o & w/dye All 71250 Computed tomography, thorax; without contrast material All 71260 Computed tomography, thorax; with contrast material(s) All 71270 Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections All 71275 CT angiography chest All 71550 Magnetic image, chest w/o dye All 71551 Mri chest w/dye All 71552 Mri chest w/o & w/dye All 71555 Magnetic imaging/chest (mra) w/or w/o dye All 72125 Computed tomography, cervical spine; without contrast material All 72126 Computed tomography, cervical spine; with contrast material All 72127 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections All 72128 Computed tomography, thoracic spine; without contrast material All 72129 Computed tomography, thoracic spine; with contrast material All 72130 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections All 72131 Computed tomography, lumbar spine; without contrast material All 72132 Computed tomography, lumbar spine; with contrast material All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 72133 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections All 72141 Magnetic image, neck spine w/o dye All 72142 Magnetic image, neck spine w/dye All 72146 Magnetic image, chest spine w/o dye All 72147 Magnetic image, chest spine w/dye All 72148 Magnetic image, lumbar spine w/o dye All 72149 Magnetic image, lumbar spine w/dye All 72156 Magnetic image, neck spine w/o & w/dye All 72157 Magnetic image, chest spine w/o & w/dye All 72158 Magnetic image, lumbar spine w/o & w/ dye All 72159 Magnetic imaging/spine (mra) w/o & w/ dye All 72191 CT angiograph pelv w/o & w dye All 72192 Computed tomography, pelvis; without contrast material All 72193 Computed tomography, pelvis; with contrast material(s) All 72194 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections All 72195 Mri pelvis w/o dye All 72196 Magnetic image, pelvis w/dye All 72197 Mri pelvis w/o & w/dye All 72198 Magnetic imaging/pelvis(mra) w/o & w/ dye All 73200 Computed tomography, upper extremity; without contrast material All 73201 Computed tomography, upper extremity; with contrast material(s) All 73202 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections All 73206 CT angio upr extrm w/o & w/dye All 73218 Mri upper extremity w/o dye All 73219 Mri upper extremity w/dye All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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