CPT Codes Requiring Prior Authorization - Molina Healthcare

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Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 64400 Injection for nerve block All 64402 Injection for nerve block All 64405 Injection for nerve block All 64408 Injection for nerve block All 64410 Injection for nerve block All 64412 Injection for nerve block All 64413 Injection for nerve block All 64415 Injection for nerve block All 64416 N block cont infuse, b plex All 64417 Injection for nerve block All 64418 Injection for nerve block All 64420 Injection for nerve block All 64421 Injection for nerve block All 64425 Injection for nerve block All 64430 Injection for nerve block All 64435 Injection for nerve block All 64445 Injection for nerve block All 64446 N blk inj, sciatic, cont inf All 64447 N block inj fem, single All 64448 N block inj fem, cont inf All 64449 N Block Inj, Lumbar Plexus All 64450 Injection for nerve block Hospital setting only or if performed by a podiatrist 64455 N block inj, plantar digit Hospital setting only or if performed by a podiatrist 64479 Injection,anesthetic agent and/or steriod, epidural All 64480 Injection, cervical or thoracic, each added level All 64483 Injection, lumbar orsacral, single level All 64484 Injection,lumbar or sacral, each added level All 64490 Inj paravert f jnt c/t 1 lev All 64491 Inj paravert f jnt c/t 2 lev All 64492 Inj paravert f jnt c/t 3 lev All 64493 Inj paravert f jnt l/s 1 lev All 64494 Inj paravert f jnt l/s 2 lev All 64495 Inj paravert f jnt l/s 3 lev All 26994OH0812
Procedure Code CPT Codes Requiring Prior Authorization Service Description PA Required by POS 64505 Injection for nerve block All 64508 Injection for nerve block All 64510 Injection for nerve block All 64517 N Block Inj, Hypogas Plxs All 64520 Injection for nerve block All 64530 Injection for nerve block All 64550 Apply neurostimulator All 64553 Implant neuroelectrodes All 64555 Implant neuroelectrodes All 64561 Perc implant neurostimular electrode All 64565 Implant neuroelectrodes All 64566 Post tib neurostimulation prq needle electrode All 64568 Inc impltj crnl nrv nstim eltrds & pulse gener All 64569 Revision/replmt nstim crnl eltrds All 64570 Removal crnl nrv nstim eltrds & pulse generator All 64575 Implant neuroelectrodes All 64580 Implant neuroelectrodes All 64581 Incision neurostimulator electrode imp All 64585 Revise/remove neuroelectrode All 64590 Implant neuroreceiver All 64595 Revise/remove neuroreceiver All 64600 Injection treatment of nerve All 64605 Injection treatment of nerve All 64610 Injection treatment of nerve All 64611 Chemodenerv parotid&submandibl salivary glnds bi All 64612 Destroy nerve, face muscle All 64613 Destroy nerve, spine muscle All 64614 Destroy nerve, extrem musc All 64620 Injection treatment of nerve All 64630 Injection treatment of nerve All 64632 N block inj, common digit Hospital setting only or if performed by a podiatrist 64633 Destroy cerv/thor facet jnt All 26994OH0812
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CPT Codes Requiring Prior Authorization - Molina Healthcare

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