CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 35636 Artery bypass graft All 35637 Artery bypass graft All 35638 Artery bypass graft All 35642 Artery bypass graft All 35645 Artery bypass graft All 35646 Artery bypass graft All 35647 Aorotofemoral bypass graft All 35650 Artery bypass graft All 35654 Artery bypass graft All 35656 Artery bypass graft All 35661 Artery bypass graft All 35663 Artery bypass graft All 35665 Artery bypass graft All 35666 Artery bypass graft All 35671 Artery bypass graft All 35681 Artery bypass graft All 35682 Composite bypass graft All 35683 Composite bypass graft All 35685 Bypass graft patency/ vein patch All 35686 Bypass graft patency/AV fistula patch All 35691 Arterial transposition All 35693 Arterial transposition All 35694 Arterial transposition All 35695 Arterial transposition All 35697 Reimplant Artery Each All 35700 Reoperation, bypass graft All 35701 Exploration, carotid artery All 35721 Exploration, femoral artery All 35741 Exploration popliteal artery All 35761 Exploration of artery/vein All 35800 Explore neck vessels All 35820 Explore chest vessels All 35840 Explore abdominal vessels All 35860 Explore limb vessels All 35870 Repair vessel graft defect All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 35875 Removal of clot in graft All 35876 Removal of clot in graft All 35879 Revision, lower extremity arterial bypass All 35881 Revision, lower extremity arterial bypass All 35883 Revise graft w/nonauto graft All 35884 Revise graft w/vein All 35901 Excision, graft, neck All 35903 Excision, graft, extremity All 35905 Excision, graft, thorax All 35907 Excision, graft, abdomen All 36251 Ins cath ren art 1st unilat All 36252 Ins cath ren art 1st bilat All 36253 Ins cath ren art 2nd+ unilat All 36254 Ins cath ren art 2nd+ bilat All 36299 Vessel injection procedure All 36460 Transfusion service, fetal All 36470 Injection therapy of vein All 36471 Injection therapy of veins All 36475 Endovenous rf, 1st vein All 36476 Endovenous rf, vein add-on All 36478 Endovenous laser, 1st vein All 36479 Endovenous laser vein addon All 36481 Insertion of catheter, vein All 36575 Insert Tunneled Cv Cath All 36583 Replace Tunneled Cv Cath All 36585 Replace Tunneled Cv Cath All 36589 Removal Tunneled Cv Cath All 36590 Removal Tunneled Cv Cath All 36598 Inj w/fluor, eval cv device All 36800 Insertion of cannula All 36810 Insertion of cannula All 36818 Av fuse, uppr arm, cephalic All 36819 Arteriovenous anastomosis, open All 36820 Anastomosis forearm vein transpos All 36821 Artery-vein fusion All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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