CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 23071 Exc shoulder les sc > 3 cm All 23073 Exc shoulder tum deep > 5 cm All 23077 Resect shoulder tumor < 5 cm All 23078 Resect shoulder tum > 5 cm All 23100 Biopsy of shoulder joint All 23101 Shoulder joint surgery All 23105 Remove shoulder joint lining All 23106 Incision of collarbone joint All 23107 Explore,treat shoulder joint All 23120 Partial removal, collarbone All 23125 Removal of collarbone All 23130 Partial removal,shoulderbone All 23140 Removal of bone lesion All 23145 Removal of bone lesion All 23146 Removal of bone lesion All 23150 Removal of humerus lesion All 23155 Removal of humerus lesion All 23156 Removal of humerus lesion All 23170 Remove collarbone lesion All 23172 Remove shoulder blade lesion All 23174 Remove humerus lesion All 23180 Remove collarbone lesion All 23182 Remove shoulderblade lesion All 23184 Remove humerus lesion All 23190 Partial removal of scapula All 23195 Removal of head of humerus All 23200 Resect clavicle tumor All 23210 Resect scapula tumor All 23220 Resect prox humerus tumor All 23332 Remove shoulder foreign body All 23350 Injection for shoulder x-ray All 23395 Muscle transfer,shoulder/arm All 23397 Muscle transfers All 23400 Fixation of shoulderblade All 23405 Incision of tendon & muscle All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 23406 Incise tendon(s) & muscle(s) All 23410 Repair of tendon(s) All 23412 Repair of tendon(s) All 23415 Release of shoulder ligament All 23420 Repair of shoulder All 23430 Repair biceps tendon rupture All 23440 Removal/transplant tendon All 23450 Repair shoulder capsule All 23455 Repair shoulder capsule All 23460 Repair shoulder capsule All 23462 Repair shoulder capsule All 23465 Repair shoulder capsule All 23466 Repair shoulder capsule All 23470 Reconstruct shoulder joint All 23472 Reconstruct shoulder joint All 23480 Revision of collarbone All 23485 Revision of collarbone All 23490 Reinforce clavicle All 23491 Reinforce shoulder bones All 23800 Fusion of shoulder joint All 23802 Fusion of shoulder joint All 23900 Amputation of arm & girdle All 23920 Amputation at shoulder joint All 23921 Amputation follow-up surgery All 23929 Shoulder surgery procedure All 24000 Exploratory elbow surgery All 24071 Exc arm/elbow les sc = 3 cm All 24073 Ex arm/elbow tum deep > 5 cm All 24079 Resect arm/elbow tum > 5 cm All 24100 Biopsy elbow joint lining All 24101 Explore/treat elbow joint All 24102 Remove elbow joint lining All 24105 Removal of elbow bursa All 24110 Remove humerus lesion All 24115 Remove/graft bone lesion All 24116 Remove/graft bone lesion All 26994OH0812
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