CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 96999 Dermatological procedure All 97001 Physical therapy evaluation All - after eval and 12 visits 97002 Physical therapy re-evaluation All - after eval and 12 visits 97003 Occupational therapy evaluation All - after eval and 12 visits 97004 Occupational therapy re-evaluation All - after eval and 12 visits 97012 Mechanical traction therapy All - after eval and 12 visits 97016 Vasopneumatic device therapy All - after eval and 12 visits 97018 Paraffin bath therapy All - after eval and 12 visits 97022 Whirlpool therapy All - after eval and 12 visits 97024 Diathermy treatment All - after eval and 12 visits 97032 Electrical stimulation All - after eval and 12 visits 97034 Contrast bath therapy All - after eval and 12 visits 97035 Ultrasound therapy All - after eval and 12 visits 97036 Hydrotherapy All - after eval and 12 visits 97110 Therapeutic exercises All - after eval and 12 visits 97112 Neuromuscular reeducation All - after eval and 12 visits 97113 Aquatic therapy/exercises All - after eval and 12 visits 97116 Gait training therapy All - after eval and 12 visits 97124 Massage therapy All - after eval and 12 visits 97140 Manual therapy techniques All - after eval and 12 visits 97150 Group therapeutic procedures All - after eval and 12 visits 97530 Kinetic therapy All - after eval and 12 visits 97597 Active Wound care 20/cm or < All 97598 Active Wound care > 20CM All 99183 Hyperbaric oxygen therapy All 99304 Nursing facility care, init 31, 32, 33 99305 Nursing facility care, init 31, 32, 33 99306 Nursing facility care, init 31, 32, 33 99500 Home visit- prenat assess 12 99510 Home visit-indiv,fam couns 12 99511 Home visit-fecal impaction 12 99512 Home visit for hemodialysis 12 G0151 Phyisical Therapist in the home All G0152 Occupational Therapist in the home All G0153 Speech Therapist in the home All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS G0154 Home Health Nursing All G0156 Home Health Aide All H1000 Prenatal care: at risk assessment Prenatal Risk Assessment form required J0129 Abatacept injection All J0180 Agalsidase beta, 1 mg All J0205 Alglucerase ,Per 10 Units All J0220 Inj. Alglucosidase 10 mg All J0221 Injection, alglucosidase alfa, (lumizyme), 10 mg All J0256 Alpha 1-Proteinase Inhib-Human, 10 mg All J0257 Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg All J0270 Alprostadil inj, 1.25 mcg (admin under direct phys super) All J0490 Injection, belimumab, 10 mg All J0585 Botulium Toxin Type A, per unit All J0586 AbobotulinumtoxinA All J0587 Botulinum Toxin Type B, per 100 units All j0588 Injection, incobotulinumtoxinA, 1 unit All J0598 C1 esterase inhibitor inj All J0600 Edetate Calcium Disodium Up To 1000 mg All J0712 Injection, ceftaroline fosamil, 10 mg All J0725 Chorionic Gonadotropin Up To 5 Mu All J0800 Corticotropin, Up To 40 Units All J0897 Injection, denosumab, 1 mg All J1070 Testosterone Cypionate ,Up To 100 Mg All J1080 Testosterone Cypionate, 1Cc, 200 Mg All J1260 Dolasetron 10mg All J1300 Inj. Eculizumab 10 mg All J1453 Fosaprepitant injection All J1458 Galsulfase injection All J1459 Inj IVIG privigen 500 mg All J1557 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized All J1561 Immune Globulin, per 500 Mg All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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