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 />
77058 Mri, one breast All<br />
77059 Mri, both breasts All<br />
77078 ct bone density, axial All<br />
77338 Design mlc device for imrt All<br />
78205 Liver imaging (3d) All<br />
78206 Liver imaging Spect All<br />
78320 Bone Imaging 3D All<br />
78451 Ht muscle image spect, sing All<br />
78452 Ht muscle image spect, mult All<br />
78453 Ht muscle image, planar, sing All<br />
78454 Ht musc image, planar, mult All<br />
78459 Heart muscle imaging, PET All<br />
78469 Heart infarct image (3d) All<br />
78491 Myocardial imaging, PET All<br />
78492 Myocardial imaging, PET All<br />
78494 Cardiac blood pool imaging All<br />
78579 Pulmonary ventilation imaging (eg, aerosol<br />
or gas)<br />
All<br />
78582 Pulmonary ventilation (eg, aerosol or gas)<br />
and perfusion imaging<br />
All<br />
78597 Quantitative differential pulmonary perfusion,<br />
including imaging when performed<br />
All<br />
78607 Brain imaging (3d) All<br />
78608 Brain imaging (pet) All<br />
78609 Brain imaging (pet) UB Facility billing only<br />
78647 Cerebrospinal fluid scan All<br />
78710 Kidney imaging (3d) All<br />
78803 Tumor imaging (3d) All<br />
78807 Nuclear localization/abscess All<br />
78811 Tumor imaging (pet), limited All<br />
78812 Tumor image (pet)/skul-thigh All<br />
78813 Tumor image (pet) full body All<br />
78814 Tumor image pet/ct, limited All<br />
78815 Tumorimage pet/ct skul-thigh All<br />
78816 Tumor image pet/ct full body All<br />
26994OH0812