CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 15576 Form skin pedicle flap All 15600 Skin graft procedure All 15610 Skin graft procedure All 15620 Skin graft procedure All 15630 Skin graft procedure All 15650 Transfer skin pedicle flap All 15731 Forehead flap w/vasc pedicle All 15732 Muscle-skin graft, head/neck All 15734 Muscle-skin graft, trunk All 15736 Muscle-skin graft, arm All 15738 Muscle-skin graft, leg All 15740 Island pedicle flap graft All 15750 Neurovascular pedicle graft All 15756 Free muscle flap All 15757 Free skin flap All 15758 Free fascial flap All 15760 Composite skin graft All 15770 Derma-fat-fascia graft All 15777 Acellular derm matrix implt All 15786 Abrasion treatment of lesion All 15787 Abrasion, added skin lesions All 15840 Graft for face nerve palsy All 15841 Graft for face nerve palsy All 15842 Graft for face nerve palsy All 15845 Skin and muscle repair, face All 15851 Removal of sutures Hospital setting only or if performed by a podiatrist 15920 Removal of tail bone ulcer All 15922 Removal of tail bone ulcer All 15931 Remove sacrum pressure sore All 15933 Remove sacrum pressure sore All 15934 Remove sacrum pressure sore All 15935 Remove sacrum pressure sore All 15936 Remove sacrum pressure sore All 15937 Remove sacrum pressure sore All 15940 Removal of pressure sore All 15941 Removal of pressure sore All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 15944 Removal of pressure sore All 15945 Removal of pressure sore All 15946 Removal of pressure sore All 15950 Remove thigh pressure sore All 15951 Remove thigh pressure sore All 15952 Remove thigh pressure sore All 15953 Remove thigh pressure sore All 15956 Remove thigh pressure sore All 15958 Remove thigh pressure sore All 15999 Removal of pressure sore All 16020 Treatment of burn(s) Hospital setting only or if performed by a podiatrist 16025 Treatment of burn(s) All 16030 Treatment of burn(s) All 17004 Destruction of benign lesions; 15 or more Hospital setting only or if performed by a podiatrist 17106 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17107 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17108 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17110 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17111 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17250 Chemical cautery, tissue Hospital setting only or if performed by a podiatrist 17270 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17271 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17272 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17273 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17274 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17276 Destruction of skin lesions Hospital setting only or if performed by a podiatrist 17340 Cryotherapy of skin All 17360 Skin peel therapy All 17999 Skin tissue procedure All 19105 Cryosurg ablate fa, each All 19260 Removal of chest wall lesion All 19271 Revision of chest wall All 19272 Extensive chest wall surgery All 19296 Place po breast cath for rad All 19300 Removal of breast tissue All 26994OH0812
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