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 />
53415 Reconstruction of urethra All<br />
53420 Reconstruct urethra, stage 1 All<br />
53425 Reconstruct urethra, stage 2 All<br />
53430 Reconstruction of urethra All<br />
53431 Urethroplasty All<br />
53440 Correct bladder function All<br />
53442 Remove perineal prosthesis All<br />
53444 Insertion of tandem cuff All<br />
53445 Correct urine flow control All<br />
53447 Remove artificial sphincter All<br />
53448 Remove/repl ureth/bladder n sphincter All<br />
53449 Correct artificial sphincter All<br />
53450 Revision of urethra All<br />
53460 Revision of urethra All<br />
53500 Urethrlys, Transvag W/ Scope All<br />
53502 Repair of urethra injury All<br />
53505 Repair of urethra injury All<br />
53510 Repair of urethra injury All<br />
53515 Repair of urethra injury All<br />
53520 Repair of urethra defect All<br />
53665 Dilation of urethra All<br />
53850 Prostatic microwave thermotherapy All<br />
53852 Prostatic radiofrequency thermotherapy All<br />
53855 Insert prost urethral stent All<br />
53860 Trurl rf female bladder neck strs urin<br />
incont<br />
All<br />
53899 Urology surgery procedure All<br />
54110 Treatment of penis lesion All<br />
54111 Treat penis lesion, graft All<br />
54112 Treat penis lesion, graft All<br />
54115 Treatment of penis lesion All<br />
54120 Partial removal of penis All<br />
54125 Removal of penis All<br />
54130 Remove penis & nodes All<br />
54135 Remove penis & nodes All<br />
26994OH0812
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