CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 25425 Repair/graft radius or ulna All 25426 Repair/graft radius & ulna All 25430 Vascular pedicle graft for carpal bone All 25431 Repair nonunion carpal bone All 25440 Repair/graft wrist bone All 25441 Reconstruct wrist joint All 25442 Reconstruct wrist joint All 25443 Reconstruct wrist joint All 25444 Reconstruct wrist joint All 25445 Reconstruct wrist joint All 25446 Wrist replacement All 25447 Repair wrist joint(s) All 25449 Remove wrist joint implant All 25450 Revision of wrist joint All 25455 Revision of wrist joint All 25490 Reinforce radius All 25491 Reinforce ulna All 25492 Reinforce radius and ulna All 25800 Fusion of wrist joint All 25805 Fusion/graft of wrist joint All 25810 Fusion/graft of wrist joint All 25820 Fusion of hand bones All 25825 Fusion hand bones with graft All 25830 Fusion radioulnar joint/ulna All 25900 Amputation of forearm All 25905 Amputation of forearm All 25907 Amputation follow-up surgery All 25909 Amputation follow-up surgery All 25915 Amputation of forearm All 25920 Amputate hand at wrist All 25922 Amputate hand at wrist All 25924 Amputation follow-up surgery All 25927 Amputation of hand All 25929 Amputation follow-up surgery All 25931 Amputation follow-up surgery All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 25999 Forearm or wrist surgery All 26040 Release palm contracture All 26045 Release palm contracture All 26055 Incise finger tendon sheath All 26060 Incision of finger tendon All 26100 Biopsy hand joint lining All 26105 Biopsy finger joint lining All 26110 Biopsy finger joint lining All 26111 Exc hand les sc > 1.5 cm All 26113 Exc hand tum deep > 5 cm All 26115 Exc hand les sc < 1.5 cm All 26116 Exc hand tum deep < 1.5 cm All 26117 Exc hand tum ra < 3 cm All 26118 Exc hand tum ra > 3cm All 26121 Release palm contracture All 26123 Release palm contracture All 26125 Release palm contracture All 26130 Remove wrist joint lining All 26135 Revise finger joint, each All 26140 Revise finger joint, each All 26145 Tendon excision, palm/finger All 26160 Remove tendon sheath lesion All 26170 Removal of palm tendon, each All 26180 Removal of finger tendon All 26185 Sesamoidectomy, thumb or finger All 26200 Remove hand bone lesion All 26205 Remove/graft bone lesion All 26210 Removal of finger lesion All 26215 Remove/graft finger lesion All 26230 Partial removal of hand bone All 26235 Partial removal, finger bone All 26236 Partial removal, finger bone All 26250 Extensive hand surgery All 26260 Resect prox finger tumor All 26262 Resect distal finger tumor All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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