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 />
25073 Exc forearm tum deep = 3 cm All<br />
25075 Exc forearm les sc < 3 cm All<br />
25076 Exc forearm tum deep < 3 cm All<br />
25077 Resect forearm/wrist tum < 3cm All<br />
25078 Resect forearm/wrist tum = 3 cm All<br />
25085 Incision of wrist capsule All<br />
25100 Biopsy of wrist joint All<br />
25101 Explore/treat wrist joint All<br />
25105 Remove wrist joint lining All<br />
25107 Remove wrist joint cartilage All<br />
25109 Excise tendon forearm/wrist All<br />
25110 Remove wrist tendon lesion All<br />
25111 Remove wrist tendon lesion All<br />
25112 Reremove wrist tendon lesion All<br />
25115 Remove wrist/forearm lesion All<br />
25116 Remove wrist/forearm lesion All<br />
25118 Excise wrist tendon sheath All<br />
25119 Partial removal of ulna All<br />
25120 Removal of forearm lesion All<br />
25125 Remove/graft forearm lesion All<br />
25126 Remove/graft forearm lesion All<br />
25130 Removal of wrist lesion All<br />
25135 Remove & graft wrist lesion All<br />
25136 Remove & graft wrist lesion All<br />
25145 Remove forearm bone lesion All<br />
25150 Partial removal of ulna All<br />
25151 Partial removal of radius All<br />
25170 Resect radius/ulnar tumor All<br />
25210 Removal of wrist bone All<br />
25215 Removal of wrist bones All<br />
25230 Partial removal of radius All<br />
25240 Partial removal of ulna All<br />
25246 Injection for wrist x-ray All<br />
25248 Remove forearm foreign body All<br />
25250 Removal of wrist prosthesis All<br />
25251 Removal of wrist prosthesis All<br />
26994OH0812
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