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 />
54162 Lysis of penile circumcision adhesions All<br />
54163 Repair of incomplete circumcision All<br />
54205 Treatment of penis lesion All<br />
54250 Penis study All<br />
54300 Revision of penis All<br />
54304 Revision of penis All<br />
54308 Reconstruction of urethra All<br />
54312 Reconstruction of urethra All<br />
54316 Reconstruction of urethra All<br />
54318 Reconstruction of urethra All<br />
54322 Reconstruction of urethra All<br />
54324 Reconstruction of urethra All<br />
54326 Reconstruction of urethra All<br />
54328 Revise penis, urethra All<br />
54332 Revise penis, urethra All<br />
54336 Revise penis, urethra All<br />
54340 Secondary urethral surgery All<br />
54344 Secondary urethral surgery All<br />
54348 Secondary urethral surgery All<br />
54352 Reconstruct urethra, penis All<br />
54360 Penis plastic surgery All<br />
54380 Repair penis All<br />
54385 Repair penis All<br />
54390 Repair penis and bladder All<br />
54400 Insert semi-rigid prosthesis All<br />
54401 Insert self-contd prosthesis All<br />
54405 Insert multi-comp prosthesis All<br />
54406 Removal of penile prosthesis All<br />
54408 Repair of penile prosthesis All<br />
54410 Remove/replace, penile prosth, sa oper All<br />
54411 Remove/rep, penile prosth, irrig/debr All<br />
54415 Remove penile prosthesis, w/o replace All<br />
54416 Remove/replace penile prosth, sa op. All<br />
54417 Remove/rep, penile prosth, irrig/debr All<br />
54420 Revision of penis All<br />
26994OH0812
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