CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 34510 Transposition of vein valve All 34520 Cross-over vein graft All 34530 Leg vein fusion All 34800 Endovasc abdo repair w/tube All 34802 Endovasc abdo repr w/device All 34803 Endovas aaa repr w/3-p part All 34804 Endovasc abdo repr w/device All 34805 Endovasc Abdo Repair W/Pros All 34806 Aneurysm press sensor add-on All 34808 Endovasc abdo occlud device All 34812 Xpose for endoprosth, aortic All 34813 Xpose for endoprosth, femorl All 34820 Xpose for endoprosth, iliac All 34825 Endovasc extend prosth, init All 34826 Endovasc exten prosth, addl All 34830 Open aortic tube prosth repr All 34831 Open aortoiliac prosth repr All 34832 Open aortofemor prosth repr All 34833 Xpose for endoprosth, iliac All 34834 Xpose, endoprosth, brachial All 34900 Endovasc iliac repr w/graft All 35001 Repair defect of artery All 35002 Repair artery rupture, neck All 35005 Repair defect of artery All 35011 Repair defect of artery All 35013 Repair artery rupture, arm All 35021 Repair defect of artery All 35022 Repair artery rupture, chest All 35045 Repair defect of arm artery All 35081 Repair defect of artery All 35082 Repair artery rupture, aorta All 35091 Repair defect of artery All 35092 Repair artery rupture, aorta All 35102 Repair defect of artery All 35103 Repair artery rupture, groin All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 35111 Repair defect of artery All 35112 Repair artery rupture,spleen All 35121 Repair defect of artery All 35122 Repair artery rupture, belly All 35131 Repair defect of artery All 35132 Repair artery rupture, groin All 35141 Repair defect of artery All 35142 Repair artery rupture, thigh All 35151 Repair defect of artery All 35152 Repair artery rupture, knee All 35182 Repair blood vessel lesion All 35189 Repair blood vessel lesion All 35201 Repair blood vessel lesion All 35206 Repair blood vessel lesion All 35207 Repair blood vessel lesion All 35211 Repair blood vessel lesion All 35216 Repair blood vessel lesion All 35221 Repair blood vessel lesion All 35226 Repair blood vessel lesion All 35231 Repair blood vessel lesion All 35236 Repair blood vessel lesion All 35241 Repair blood vessel lesion All 35246 Repair blood vessel lesion All 35251 Repair blood vessel lesion All 35256 Repair blood vessel lesion All 35261 Repair blood vessel lesion All 35266 Repair blood vessel lesion All 35271 Repair blood vessel lesion All 35276 Repair blood vessel lesion All 35281 Repair blood vessel lesion All 35286 Repair blood vessel lesion All 35301 Rechanneling of artery All 35302 Rechanneling of artery All 35303 Rechanneling of artery All 35304 Rechanneling of artery All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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