CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 61711 Fusion of skull arteries All 61720 Incise skull/brain surgery All 61735 Incise skull/brain surgery All 61750 Incise skull; brain biopsy All 61751 Brain biopsy with cat scan All 61760 Implant brain electrodes All 61770 Incise skull for treatment All 61781 Strtctc cptr asstd px idrl crnl All 61782 Strtctc cptr asstd px xdrl crnl All 61783 Strtctc cptr asstd px spinal All 61790 Treat trigeminal nerve All 61791 Treat trigeminal tract All 61796 Srs, cranial lesion simple All 61797 Srs, cran les simple, addl All 61798 Srs, cranial lesion complex All 61799 Srs, cran les complex, addl All 61800 Apply srs headframe add-on All 61850 Implant neuroelectrodes All 61860 Implant neuroelectrodes All 61862 Implant neuroelectrodes All 61863 Implant Neuroelectrode All 61864 Implant Neuroelectrde, Add’L All 61867 Implant Neuroelectrode All 61868 Implant Neuroelectrde, Addl All 61870 Implant neuroelectrodes All 61875 Implant neuroelectrodes All 61880 Revise/remove neuroelectrode All 61885 Implant neuroreceiver All 61886 Implant neuroelectrodes with connection to arrays All 61888 Revise/remove neuroreceiver All 62000 Repair of skull fracture All 62005 Repair of skull fracture All 62010 Treatment of head injury All 62100 Repair brain fluid leakage All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 62115 Reduction of skull defect All 62116 Reduction of skull defect All 62117 Reduction of skull defect All 62120 Repair skull cavity lesion All 62121 Incise skull repair All 62140 Repair of skull defect All 62141 Repair of skull defect All 62142 Remove skull plate/flap All 62143 Replace skull plate/flap All 62145 Repair of skull & brain All 62146 Repair of skull with graft All 62147 Repair of skull with graft All 62148 Retr bone flap to fix skull All 62160 Neuroendoscopy add-on All 62161 Dissect brain w/scope All 62162 Remove colloid cyst w/scope All 62163 Neuroendoscopy w/fb removal All 62164 Remove brain tumor w/scope All 62165 Remove pituit tumor w/scope All 62180 Establish brain cavity shunt All 62190 Establish brain cavity shunt All 62192 Establish brain cavity shunt All 62194 Replace/irrigate catheter All 62200 Establish brain cavity shunt All 62201 Establish brain cavity shunt All 62220 Establish brain cavity shunt All 62223 Establish brain cavity shunt All 62225 Replace/irrigate catheter All 62230 Replace/revise brain shunt All 62252 Csf shunt reprogram All 62256 Remove brain cavity shunt All 62258 Replace brain cavity shunt All 62263 Percutaneous lysis of epidual adhesions All 62264 Epidural lysis on single day All 62267 Interdiscal perq aspir, dx All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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