CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
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Procedure<br />
Code<br />
<strong>CPT</strong> <strong>Codes</strong> <strong>Requiring</strong><br />
<strong>Prior</strong> <strong>Authorization</strong><br />
Service Description PA Required by POS<br />
74183 Mri abdomen w/o & w/dye All<br />
74185 Magnetic image/abdomen (mra) w/or w/o<br />
dye<br />
All<br />
74261 ct colonography w/o dye All<br />
74262 ct colonography w/dye All<br />
74263 ct colonography screen All<br />
75557 Cardiac mri for morph All<br />
75559 Cardiac mri w/stress img All<br />
75561 Cardiac mri for morph w/dye All<br />
75563 Card mri w/stress img & dye All<br />
75565 Card mri vel flw map add-on All<br />
75571 ct hrt w/o dye w/ca test All<br />
75572 ct hrt w/3d image All<br />
75573 ct hrt w/3d image, congen All<br />
75574 ct hrt angio hrt w/3d image All<br />
75635 ct amgop abdp,oma; arteries All<br />
75989 Radiological guidance (ie, fluoroscopy,<br />
ultrasound, or computed tomography),<br />
for percutaneous drainage (eg, abscess,<br />
specimen collection), with placement of<br />
catheter, radiological supervision and<br />
interpretation<br />
All<br />
76376 3D rendering with interpretation and<br />
reporting of computed tomography, magnetic<br />
resonance imaging, ultrasound, or<br />
other tomographic modality; not requiring<br />
image postprocessing on an independent<br />
workstation<br />
All<br />
76377 3D rendering with interpretation and<br />
reporting of computed tomography,<br />
magnetic resonance imaging, ultrasound,<br />
or other tomographic modality; requiring<br />
image postprocessing on an independent<br />
workstation<br />
All<br />
76380 ct limited or localized follow up study All<br />
76497 ct procedure All<br />
76498 Mri procedure All<br />
76499 Radiographic procedure All<br />
26994OH0812
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