CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 11300 Shave skin lesion Hospital setting only or if performed by a podiatrist 11301 Shave skin lesion Hospital setting only or if performed by a podiatrist 11302 Shave skin lesion Hospital setting only or if performed by a podiatrist 11303 Shave skin lesion Hospital setting only or if performed by a podiatrist 11305 Shave skin lesion Hospital setting only or if performed by a podiatrist 11306 Shave skin lesion Hospital setting only or if performed by a podiatrist 11307 Shave skin lesion Hospital setting only or if performed by a podiatrist 11310 Shave skin lesion Hospital setting only or if performed by a podiatrist 11311 Shave skin lesion Hospital setting only or if performed by a podiatrist 11312 Shave skin lesion Hospital setting only or if performed by a podiatrist 11600 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11601 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11602 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11603 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11620 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11621 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11622 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11623 Removal of skin lesion Hospital setting only or if performed by a podiatrist 11626 Removal of skin lesion All 11900 Injection into skin lesions Hospital setting only or if performed by a podiatrist 11901 Added skin lesion injections Hospital setting only or if performed by a podiatrist 11950 Subcutaneous inj. of filling material, 1cc or less All 11951 Subcutaneous inj. of filling material, 1.1 to 5.0 cc All 11952 Subcutaneous inj. of filling material, 5.1 to 10.0 cc All 11954 Subcutaneous inj. of filling material, over 10.0 cc All 11960 Insert tissue expander(s) All 11971 Remove tissue expander(s) All 11981 Insert drug delivery implant device All 11983 Remove rein drug deliv implant device All 14000 Skin tissue rearrangement All 14001 Skin tissue rearrangement All 14020 Skin tissue rearrangement All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 14021 Skin tissue rearrangement All 14040 Skin tissue rearrangement All 14041 Skin tissue rearrangement All 14060 Skin tissue rearrangement All 14061 Skin tissue rearrangement All 14301 Skin tissue rearrangement All 14302 Skin tissue rearrange add-on All 14350 Skin tissue rearrangement All 15002 Wnd prep, ch/inf, trk/arm/lg All 15003 Wnd prep, ch/inf addl 100 cm All 15004 Wnd prep ch/inf, f/n/hf/g All 15005 Wnd prep, f/n/hf/g, addl cm All 15050 Skin pinch graft procedure All 15100 Skin split graft procedure All 15101 Skin split graft procedure All 15120 Skin split graft procedure All 15121 Skin split graft procedure All 15200 Skin full graft procedure All 15201 Skin full graft procedure All 15220 Skin full graft procedure All 15221 Skin full graft procedure All 15240 Skin full graft procedure All 15241 Skin full graft procedure All 15260 Skin full graft procedure All 15261 Skin full graft procedure All 15271 Skin sub graft trnk/arm/leg All 15272 Skin sub graft t/a/l add-on All 15273 Skin sub grft t/arm/lg child All 15274 Skn sub grft t/a/l child add All 15275 Skin sub graft face/nk/hf/g All 15276 Skin sub graft f/n/hf/g addl All 15277 Skn sub grft f/n/hf/g child All 15278 Skn sub grft f/n/hf/g ch add All 15570 Form skin pedicle flap All 15572 Form skin pedicle flap All 15574 Form skin pedicle flap All 26994OH0812
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