CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 28238 Revision of foot tendon All 28240 Release of big toe All 28250 Revision of foot fascia All 28260 Release of midfoot joint All 28261 Revision of foot tendon All 28262 Revision of foot and ankle All 28264 Release of midfoot joint All 28270 Release of foot contracture All 28272 Release of toe joint, each Hospital setting only or if performed by a podiatrist 28280 Fusion of toes All 28285 Repair of hammertoe All 28286 Repair of hammertoe All 28288 Partial removal of foot bone All 28289 Hallux rigidus correction All 28290 Correction of bunion All 28292 Correction of bunion All 28293 Correction of bunion All 28294 Correction of bunion All 28296 Correction of bunion All 28297 Correction of bunion All 28298 Correction of bunion All 28299 Correction of bunion All 28300 Incision of heel bone All 28302 Incision of ankle bone All 28304 Incision of midfoot bones All 28305 Incise/graft midfoot bones All 28306 Incision of metatarsal All 28307 Incision of metatarsal All 28308 Incision of metatarsal All 28309 Incision of metatarsals All 28310 Revision of big toe All 28312 Revision of toe All 28313 Repair deformity of toe All 28315 Removal of sesamoid bone All 28320 Repair of foot bones All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 28322 Repair of metatarsals All 28340 Resect enlarged toe tissue All 28341 Resect enlarged toe All 28344 Repair extra toe(s) All 28345 Repair webbed toe(s) All 28360 Reconstruct cleft foot All 28705 Fusion of foot bones All 28715 Fusion of foot bones All 28725 Fusion of foot bones All 28730 Fusion of foot bones All 28735 Fusion of foot bones All 28737 Revision of foot bones All 28740 Fusion of foot bones All 28750 Fusion of big toe joint All 28755 Fusion of big toe joint All 28760 Fusion of big toe joint All 28800 Amputation of midfoot All 28805 Amputation thru metatarsal All 28810 Amputation toe & metatarsal All 28820 Amputation of toe All 28825 Partial amputation of toe All 28890 High energy eswt, plantar f Hospital setting only or if performed by a podiatrist 28899 Foot/toes surgery procedure All 29582 Application of multi-layer compression system; thigh and leg, including ankle and foot, when performed All 29583 Application of multi-layer compression system; upper arm and forearm All 29584 Application of multi-layer compression system; upper arm, forearm, hand, and fingers All 29799 Casting/strapping procedure All 29800 Jaw arthroscopy/surgery All 29804 Jaw arthroscopy/surgery All 29805 Shouder arthroscopy, w/w/o synov biopsy All 29806 Shoulder arthroscopy, capsulorrhaphy All 29807 Repair of slap lesion All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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