Prior authorization requirement changes effective May 1, 2024

11442

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm

11446

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm

11971

Removal of tissue expander without insertion of implant

11980

Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

13132

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm

13151

Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm

13152

Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm

13153

Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)

13160

Secondary closure of surgical wound or dehiscence, extensive or complicated

14020

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less

14021

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm

14301

Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

14302

Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

15201

Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

15240

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less

15241

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)

15274

Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

15734

Muscle, myocutaneous, or fasciocutaneous flap; trunk

15738

Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

15750

Flap; neurovascular pedicle

15860

Intravenous injection of agent (for example, fluorescein) to test vascular flow in flap or graft

17110

Destruction (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

17111

Destruction (for example, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions

19355

Correction of inverted nipples

19370

Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy

19371

Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

19380

Revision of reconstructed breast (for example, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)

19499

Unlisted procedure, breast

21299

Unlisted craniofacial and maxillofacial procedure

21899

Unlisted procedure, neck or thorax

27656

Repair, fascial defect of leg

30460

Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only

31081

Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation)

31580

Laryngoplasty; for laryngeal web, with indwelling keel or stent insertion

31750

Tracheoplasty; cervical

40650

Repair lip, full thickness; vermilion only

40652

Repair lip, full thickness; up to half vertical height

40654

Repair lip, full thickness; over one-half vertical height, or complex

43496

Free jejunum transfer with microvascular anastomosis

44204

Laparoscopy, surgical; colectomy, partial, with anastomosis

44700

Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (for example, bladder or omentum)

45395

Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy

45400

Laparoscopy, surgical; proctopexy (for prolapse)

51925

Closure of vesicouterine fistula; with hysterectomy

53210

Urethrectomy, total, including cystostomy; female

54120

Amputation of penis; partial

54522

Orchiectomy, partial

54692

Laparoscopy, surgical; orchiopexy for intra-abdominal testis

55150

Resection of scrotum

55250

Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)

55559

Unlisted laparoscopy procedure, spermatic cord

55870

Electroejaculation

56620

Vulvectomy simple; partial

56630

Vulvectomy, radical, partial;

56633

Vulvectomy, radical, complete;

56640

Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy

56700

Partial hymenectomy or revision of hymenal ring

57109

Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)

57200

Colporrhaphy, suture of injury of vagina (nonobstetrical)

57282

Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)

57425

Laparoscopy, surgical, colpopexy (suspension of vaginal apex)

58210

Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

58280

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

58970

Follicle puncture for oocyte retrieval, any method

62362

Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

64912

Nerve repair; with nerve allograft, each nerve, first strand (cable)

67902

Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

69300

Otoplasty, protruding ear, with or without size reduction

76948

Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

89254

Oocyte identification from follicular fluid

89257

Sperm identification from aspiration (other than seminal fluid)

89259

Cryopreservation; sperm

89264

Sperm identification from testis tissue, fresh or cryopreserved

89337

Cryopreservation, mature oocyte(s)

89398

Unlisted reproductive medicine laboratory procedure

92508

Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals

C1789

Prosthesis, breast (implantable)

S0122

Injection, menotropins, 75 IU

S0126

Injection, follitropin alfa, 75 IU

S0128

Injection, follitropin beta, 75 IU

S0138

Finasteride, 5 mg

S0156

Exemestane, 25 mg

S0170

Anastrozole, oral, 1 mg

S0175

Flutamide, oral, 125 mg

S0179

Megestrol acetate, oral, 20 mg

S0187

Tamoxifen citrate, oral, 10 mg

S4028

Microsurgical epididymal sperm aspiration (MESA)

S4042

Management of ovulation induction (interpretation of diagnostic tests and studies, nonface-to-face medical management of the patient), per cycle

S9560

Home injectable therapy; hormonal therapy (for example, leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem