CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 63173 Drainage of spinal cyst All 63180 Revise spinal cord ligaments All 63182 Revise spinal cord ligaments All 63185 Incise spinal column/nerves All 63190 Incise spinal column/nerves All 63191 Incise spinal column/nerves All 63194 Incise spinal column & cord All 63195 Incise spinal column & cord All 63196 Incise spinal column & cord All 63197 Incise spinal column & cord All 63198 Incise spinal column & cord All 63199 Incise spinal column & cord All 63200 Release of spinal cord All 63250 Revise spinal cord vessels All 63251 Revise spinal cord vessels All 63252 Revise spinal cord vessels All 63265 Excise intraspinal lesion All 63266 Excise intraspinal lesion All 63267 Excise intraspinal lesion All 63268 Excise intraspinal lesion All 63270 Excise intraspinal lesion All 63271 Excise intraspinal lesion All 63272 Excise intraspinal lesion All 63273 Excise intraspinal lesion All 63275 Biopsy/excise spinal tumor All 63276 Biopsy/excise spinal tumor All 63277 Biopsy/excise spinal tumor All 63278 Biopsy/excise spinal tumor All 63280 Biopsy/excise spinal tumor All 63281 Biopsy/excise spinal tumor All 63282 Biopsy/excise spinal tumor All 63283 Biopsy/excise spinal tumor All 63285 Biopsy/excise spinal tumor All 63286 Biopsy/excise spinal tumor All 63287 Biopsy/excise spinal tumor All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 63290 Biopsy/excise spinal tumor All 63295 Repair of laminectomy defect All 63300 Removal of vertebral body All 63301 Removal of vertebral body All 63302 Removal of vertebral body All 63303 Removal of vertebral body All 63304 Removal of vertebral body All 63305 Removal of vertebral body All 63306 Removal of vertebral body All 63307 Removal of vertebral body All 63308 Removal of vertebral body All 63600 Remove spinal cord lesion All 63610 Stimulation of spinal cord All 63615 Remove lesion of spinal cord All 63620 Srs, spinal lesion All 63621 Srs, spinal lesion, addl All 63650 Implant neuroelectrodes All 63655 Implant neuroelectrodes All 63661 Remove spine eltrd perq aray All 63662 Remove spine eltrd plate All 63663 Revise spine eltrd perq aray All 63664 Revise spine eltrd plate All 63685 Implant neuroreceiver All 63688 Revise/remove neuroreceiver All 63700 Repair of spinal herniation All 63702 Repair of spinal herniation All 63704 Repair of spinal herniation All 63706 Repair of spinal herniation All 63707 Repair spinal fluid leakage All 63709 Repair spinal fluid leakage All 63710 Graft repair of spine defect All 63740 Install spinal shunt All 63741 Install spinal shunt All 63744 Revision of spinal shunt All 63746 Removal of spinal shunt All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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