CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 73220 Magnetic image, arm, hand w/o & w/dye All 73221 Magnetic image, joint of arm w/o dye All 73222 Mri joint upr extrem w/dye All 73223 Mri joint upr extr w/o & w/dye All 73225 Magnetic imaging/upper (mra) w/o & w/ dye All 73700 Computed tomography, lower extremity; without contrast material All 73701 Computed tomography, lower extremity; with contrast material(s) All 73702 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections All 73706 ct angio lwr extr 2/o & w dye All 73718 Mri lower extremity w/o dye All 73719 Mri lower extremity w/dye All 73720 Magnetic image, leg, foot w/o & w/dye All 73721 Magnetic image, joint of leg w/o dye All 73722 Mri joint of lwr extr w/dye All 73723 Mri joint lwr extr w/o & w/dye All 73725 Magnetic imaging/lower (mra) w/or w/o dye All 74150 Computed tomography, abdomen; without contrast material All 74160 Computed tomography, abdomen; with contrast material(s) All 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections All 74174 Ct angio abd&pelv w/o&w/dye All 74175 ct angio abdom w/o & w dye All 74176 ct abd & pelvis w/o contrast All 74177 ct abd & pelvis w/contrast All 74178 CT abd & pelvis w/o contrst 1+ body regions All 74181 Magnetic image, abdomen (mri w/o dye All 74182 Mri abdomen w/dye All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 74183 Mri abdomen w/o & w/dye All 74185 Magnetic image/abdomen (mra) w/or w/o dye All 74261 ct colonography w/o dye All 74262 ct colonography w/dye All 74263 ct colonography screen All 75557 Cardiac mri for morph All 75559 Cardiac mri w/stress img All 75561 Cardiac mri for morph w/dye All 75563 Card mri w/stress img & dye All 75565 Card mri vel flw map add-on All 75571 ct hrt w/o dye w/ca test All 75572 ct hrt w/3d image All 75573 ct hrt w/3d image, congen All 75574 ct hrt angio hrt w/3d image All 75635 ct amgop abdp,oma; arteries All 75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation All 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation All 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation All 76380 ct limited or localized follow up study All 76497 ct procedure All 76498 Mri procedure All 76499 Radiographic procedure All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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