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 />
58542 Lsh w/t/o ut 250 g or less All<br />
58543 Lsh uterus above 250 g All<br />
58544 Lsh w/t/o uterus above 250 g All<br />
58545 Laparoscopic myomectomy All<br />
58546 Laparo-myomectomy, complex All<br />
58548 Lap radical hyst All<br />
58550 Laparoscopy; hysterectomy All<br />
58552 Laparo-vag hyst incl t/o All<br />
58553 Laparo-vag hyst, complex All<br />
58554 Laparo-vag hyst w/t/o, compl All<br />
58560 Hysteroscopy; resect septum All<br />
58561 Hysteroscopy; remove myoma All<br />
58563 Hysteroscopy; ablation All<br />
58565 Hysteroscopy, sterilization All<br />
58570 Tlh, uterus 250 g or less All<br />
58571 Tlh w/t/o 250 g or less All<br />
58572 Tlh, uterus over 250 g All<br />
58573 Tlh w/t/o uterus over 250 g All<br />
58578 Unlisted laparoscopy procedure, uterus All<br />
58579 Unlisted hysterectomy procedure, uterus All<br />
58600 Division of fallopian tube All<br />
58605 Division of fallopian tube All<br />
58611 Ligate oviduct(s) All<br />
58615 Occlude fallopian tube(s) All<br />
58660 Laparoscopy; lysis All<br />
58661 Laparoscopy; remove adnexa All<br />
58662 Laparoscopy; excise lesions All<br />
58671 Laparoscopy; tubal block All<br />
58672 Laparoscopy with fimbrioplasty All<br />
58673 Laparoscopy with salpingostomy All<br />
58679 Unlisted laparoscopy procedure, oviduct,<br />
ovary<br />
All<br />
58700 Removal of fallopian tube All<br />
58720 Removal of ovary/tube(s) All<br />
58740 Lysis of adhesions All<br />
58800 Drainage of ovarian cyst(s) All<br />
26994OH0812
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