CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
CPT Codes Requiring Prior Authorization - Molina Healthcare
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
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 />
57120 Closure of vagina All<br />
57155 Insertion uterine tandems/vag brachyth All<br />
57156 Insj vaginal radiation device All<br />
57230 Repair of urethral lesion All<br />
57240 Repair bladder & vagina All<br />
57250 Repair rectum & vagina All<br />
57260 Repair of vagina All<br />
57265 Extensive repair of vagina All<br />
57268 Repair of bowel bulge All<br />
57270 Repair of bowel pouch All<br />
57280 Suspension of vagina All<br />
57282 Repair of vaginal prolapse All<br />
57283 Colpopexy, intraperitoneal All<br />
57284 Repair paravaginal defect All<br />
57285 Repair paravag defect, vag All<br />
57287 Revise/remove sling repair All<br />
57288 Repair bladder defect All<br />
57289 Repair bladder & vagina All<br />
57291 Construction of vagina All<br />
57292 Construct vagina with graft All<br />
57295 Change vaginal graft All<br />
57296 Revise vag graft, open abd All<br />
57300 Repair rectum-vagina fistula All<br />
57305 Repair rectum-vagina fistula All<br />
57307 Fistula repair & colostomy All<br />
57308 Closure of rectovaginal fistula All<br />
57330 Repair bladder-vagina lesion All<br />
57335 Repair vagina All<br />
57425 Laparoscopy, Surg, Colpopexy All<br />
57426 Revise prosth vag graft lap All<br />
57530 Removal of cervix All<br />
57531 Radical trachelectomy All<br />
57540 Removal of residual cervix All<br />
57545 Remove cervix, repair pelvis All<br />
57550 Removal of residual cervix All<br />
26994OH0812
Change language