CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
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Procedure<br />
Code<br />
<strong>CPT</strong> <strong>Codes</strong> <strong>Requiring</strong><br />
<strong>Prior</strong> <strong>Authorization</strong><br />
Service Description PA Required by POS<br />
36822 Insertion of cannula(s) All<br />
36823 Insertion of cannula(s) All<br />
36825 Artery-vein graft All<br />
36830 Artery-vein graft All<br />
36835 Artery to vein shunt All<br />
36838 Dist Revas Ligation, Hemo All<br />
36860 Cannula declotting All<br />
36861 Cannula declotting All<br />
37140 Revision of circulation All<br />
37145 Revision of circulation All<br />
37160 Revision of circulation All<br />
37180 Revision of circulation All<br />
37181 Splice spleen/kidney veins All<br />
37182 Insert hepatic shunt (tips) All<br />
37183 Remove hepatic shunt (tips) All<br />
37191 Ins endovas vena cava filtr All<br />
37192 Redo endovas vena cava filtr All<br />
37193 Rem endovas vena cava filter All<br />
37210 Embolization uterine fibroid All<br />
37220 Revascularization iliac artery angiop 1st<br />
vsl<br />
All<br />
37221 Revsc opn/prq iliac art w/stnt plmt &<br />
angiop uni<br />
All<br />
37222 Revascularization iliac art angiop ea ipsi<br />
vsl<br />
All<br />
37223 Revsc opn/prq iliac art w/stnt & angiop<br />
ipsi vsl<br />
All<br />
37224 Revsc opn/prg fem/pop w/angioplasty uni All<br />
37225 Revsc opn/prq fem/pop w/athrc/angiop<br />
sm vsl<br />
All<br />
37226 Revsc opn/prq fem/pop w/stnt/angiop sm<br />
vsl<br />
All<br />
37227 Revsc opn/prq fem/pop w/stnt/athrc/angiop<br />
sm vsl<br />
All<br />
37228 Revsc opn/prq tib/pero w/angioplasty uni All<br />
37229 Revsc opn/prq tib/pero w/athrc/angiop sm<br />
vsl<br />
All<br />
26994OH0812
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