CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 26554 Microvascular toe-to-hand transfer All 26555 Positional change of finger All 26556 Microvascular free toe joint transfer All 26560 Repair of web finger All 26561 Repair of web finger All 26562 Repair of web finger All 26565 Correct metacarpal flaw All 26567 Correct finger deformity All 26568 Lengthen metacarpal/finger All 26580 Repair hand deformity All 26587 Reconstruct extra finger All 26590 Repair finger deformity All 26591 Repair muscles of hand All 26593 Release muscles of hand All 26596 Excision constricting tissue All 26820 Thumb fusion with graft All 26841 Fusion of thumb All 26842 Thumb fusion with graft All 26843 Fusion of hand joint All 26844 Fusion/graft of hand joint All 26850 Fusion of knuckle All 26852 Fusion of knuckle with graft All 26860 Fusion of finger joint All 26861 Fusion of finger joint,added All 26862 Fusion/graft of finger joint All 26863 Fuse/graft added joint All 26910 Amputate metacarpal bone All 26951 Amputation of finger/thumb All 26952 Amputation of finger/thumb All 26989 Hand/finger surgery All 26990 Drainage of pelvis lesion All 26991 Drainage of pelvis bursa All 26992 Drainage of bone lesion All 27000 Incision of hip tendon All 27001 Incision of hip tendon All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 27003 Incision of hip tendon All 27005 Incision of hip tendon All 27006 Incision of hip tendons All 27025 Incision of hip/thigh fascia All 27027 Buttock fasciotomy All 27030 Drainage of hip joint All 27033 Exploration of hip joint All 27035 Denervation of hip joint All 27036 Capsulectomy or capsulotomy of hip All 27043 Exc hip pelvis les sc > 3 cm All 27045 Exc hip/pelv tum deep > 5cm All 27047 Exc hip/pelvis les sc < 3 cm All 27048 Exc hip/pelvis les sc < 5 cm All 27049 Resect hip/pelvis tum < 5 cm All 27050 Biopsy of sacroiliac joint All 27052 Biopsy of hip joint All 27054 Removal of hip joint lining All 27057 Buttock fasciotomy w/dbrdmt All 27059 Resect hip/pelv tum > 5 cm All 27060 Removal of ischial bursa All 27062 Remove femur lesion/bursa All 27065 Removal of hip bone lesion All 27066 Removal of hip bone lesion All 27067 Remove/graft hip bone lesion All 27070 Partial removal of hip bone All 27071 Partial removal of hip bone All 27075 Resect hip tumor All 27076 Resect hip tum incl acetabul All 27077 Resect hip tum w/innom bone All 27078 Rsect hip tum incl femur All 27080 Removal of tail bone All 27090 Removal of hip prosthesis All 27091 Removal of hip prosthesis All 27093 Injection for hip x-ray All 27095 Injection for hip x-ray All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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