CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 29819 Shoulder arthroscopy/surgery All 29820 Shoulder arthroscopy/surgery All 29821 Shoulder arthroscopy/surgery All 29822 Shoulder arthroscopy/surgery All 29823 Shoulder arthroscopy/surgery All 29824 Shoulder arthroscopy, dist claviculect All 29825 Shoulder arthroscopy/surgery All 29826 Shoulder arthroscopy/surgery All 29827 Arthroscop rotator cuff repr All 29828 Arthroscopy biceps tenodesis All 29830 Elbow arthroscopy All 29834 Elbow arthroscopy/surgery All 29835 Elbow arthroscopy/surgery All 29836 Elbow arthroscopy/surgery All 29837 Elbow arthroscopy/surgery All 29838 Elbow arthroscopy/surgery All 29840 Wrist arthroscopy All 29843 Wrist arthroscopy/surgery All 29844 Wrist arthroscopy/surgery All 29845 Wrist arthroscopy/surgery All 29846 Wrist arthroscopy/surgery All 29847 Wrist arthroscopy/surgery All 29848 Wrist arthroscopy/surgery All 29850 Knee arthroscopy/surgery All 29851 Knee arthroscopy/surgery All 29855 Tibial arthroscopy/surgery All 29856 Tibial arthroscopy/surgery All 29860 Hip arthroscopy, diagnostic All 29861 Hip arthroscopy/surgery All 29862 Hip arthroscopy/surgery All 29863 Hip arthroscopy/surgery All 29866 Autgrft implnt, knee w/scope All 29867 Allgrft implnt, knee w/scope All 29868 Meniscal trnspl, knee w/scpe All 29870 Knee arthroscopy, diagnostic All 29871 Knee arthroscopy/drainage All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 29873 Knee arthroscopy/surgery All 29874 Knee arthroscopy/surgery All 29875 Knee arthroscopy/surgery All 29876 Knee arthroscopy/surgery All 29877 Knee arthroscopy/surgery All 29879 Knee arthroscopy/surgery All 29880 Knee arthroscopy/surgery All 29881 Knee arthroscopy/surgery All 29882 Knee arthroscopy/surgery All 29883 Knee arthroscopy/surgery All 29884 Knee arthroscopy/surgery All 29885 Knee arthroscopy/surgery All 29886 Knee arthroscopy/surgery All 29887 Knee arthroscopy/surgery All 29888 Knee arthroscopy/surgery All 29889 Knee arthroscopy/surgery All 29891 Ankle arthroscopy/surgery All 29892 Ankle arthroscopy/surgery All 29893 Endoscopic plantar fasciotomy All 29894 Ankle arthroscopy/surgery All 29895 Ankle arthroscopy/surgery All 29897 Ankle arthroscopy/surgery All 29898 Ankle arthroscopy/surgery All 29899 Ankle arthroscopy/surgery All 29900 Metacarp jt arthroscopy,w synov biop All 29901 Metacarp joint arthroscopy w debride All 29902 Metacarp jt arthroscopy, w reduc ligam All 29904 Subtalar arthro w/fb rmvl All 29905 Subtalar arthro w/exc All 29906 Subtalar arthro w/deb All 29907 Subtalar arthro w/fusion All 29914 Arthroscopy hip w/femoroplasty All 29915 Arthroscopy hip w/acetabuloplasty All 29916 Arthroscopy hip w/labral repair All 29999 Unlisted arthroscopy procedure All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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