Loading...Loading...This pre-authorization list includes services and supplies that require pre-authorization or notification for Medicare Advantage products.
Please use the online form or pre-authorization request form below to ensure the most current version is utilized as forms are subject to change. If your Medicare patient requests a service or item that you know or expect is non-covered, please follow our Medicare pre-authorization process to request a pre-service organization determination.
Expedited requests
Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.
- Availity Essentials: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request
Via fax using the appropriate pre-authorization request form below
Non-covered services
If your Medicare Advantage patient requests a service or item you expect to be non-covered, you can request a pre-service determination by submitting our pre-authorization request form by phone or fax. Note: Do not submit them via the Availity electronic authorization tool. You must follow our Medicare pre-authorization process for a pre-service organization determination in order for services to be considered for approval and for you to be able to bill the member for services that are not covered. This process replaces the former Advanced Beneficiary Notification (ABN) process for Medicare Advantage.
Within 14 calendar days, we will approve or deny the request, and provide notification to you and the member. A denial notice will include the reason and explain the appeal process. If you wish to appeal a denial on behalf of the member, you must also have a completed Appointment of Representative form (Form CMS-1696).
Online | Phone | Fax (only if unable to submit online) | |
Continued stay | Submit an authorization request through Availity Essentials | 1 (855) 848-8220 | |
Admissions and/or discharge notification | 1 (800) 423-6884 | 1 (800) 453-4341 |
Online | Phone | Fax | |
Admissions and/or discharge notification Clinical records for stays | |||
Acute inpatient medical and behavioral health hospital stays require concurrent review. | |||
Medical management program | Authorization |
|---|---|
Cardiology/Radiology/Sleep programs Codes requiring authorization are listed in the Radiology section below. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials. View Carelon's clinical guidelines. | Request pre-authorization from Carelon:
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Codes requiring authorization are listed in the Physical Medicine section below. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials. View eviCore's clinical guidelines. | Obtain or verify an authorization with eviCore healthcare
|
- Failure to pre-authorize services subject to pre-authorization requirements or follow concurrent review requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
- Before requesting pre-authorization and providing services, please verify member eligibility and benefits via the Availity Provider Portal as the member contract determines the covered benefits.
- Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
- If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
- Emergency services do not require pre-authorization, but notification should be provided for all hospital admissions or discharges within 24 hours of admission or discharge. Hospital admissions are subject to concurrent review.
- Our Medicare Medical Policy, MCG and CMS criteria may be used as the basis for medical necessity determinations, including length of stay and level of care.
- Experimental and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially experimental services and are subject to review. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Please refer to the Always Not Medically Necessary Denials list for additional information.
- Please note that a notification or pre-authorization does not guarantee payment for requested services. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
- All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete information.
Type of review | Timeframe | Additional time allowed for review if additional information is needed: |
|---|---|---|
Urgent | 72 hours | None |
Standard initial | 14 calendar days | Regence provider: None |
Concurrent | 24 hours - includes newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission.
Exception: | 72 hours |
Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first. We will respond to your notification with the date clinical records are due. If you have granted our clinical team access to your electronic medical records (EMR) system, please ensure these records are available in your EMR system. | ||
Failure to secure approval for services subject to pre-authorization or concurrent review authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.
Notification of inpatient admission should be provided to the health plan. Urgent/emergent services are subject to review post-service for medical necessity; please submit proper clinical documentation with claim.
Please note the following:
- Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient. Additionally, the pre-authorization should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
- A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be medically necessary.
- If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility/provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.
Pre-authorization is required for the services listed below. Emergency inpatient services do not require pre-authorization but are subject to admission notification requirements.
- Applied behavior analysis (ABA) therapy:
- Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
- Procedure codes 97151, 97152, and 0362T: Pre-authorization Is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments
- Pre-authorization for medical necessity is not required for Medicare members under the age of 18, but Medicare-approved provider requirements still apply
- Inpatient: Psychiatric or ASAM 4.0 detoxification - Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Concurrent review will be required. Failure to follow concurrent review requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
- Partial hospitalization: Psychiatric or ASAM level 2.5 for substance use disorders - Request for authorization is required no later than the day of admission.
Intensive outpatient: Psychiatric or ASAM level 2.1 for substance use disorders - Request for authorization is required no later than the day of admission.
View our resources and forms for behavioral health facilities and our behavioral health medical policies.
Clinical trial, registry or study | Contact and coverage summary |
|---|---|
IMPORTANT NOTE: Services in the following categories that are not listed as requiring pre-authorization elsewhere on this page do not require pre-authorization. In addition, the following guidelines may apply to these services, and should be fully reviewed. We recommend confirming coverage with Medicare and/or the health plan. Providers are expected to only submit claims for medically reasonable and necessary services per Title XVIII of the Social Security Act §1862(a)(1)(A). | |
Category A and Category B Investigational Device Exemption (IDE) studies | Coverage for CMS-approved Category A and B IDE studies includes routine care items and services. Category B IDE devices are also reimbursable, but reimbursement for Category A devices under investigation is statutorily excluded. View the Medicare Advantage medical policy for Category A and Category B Investigational Device Exemption (IDE) Studies (PDF) |
Coverage with Evidence Development (CED) studies and registries | Medicare determines coverage requirements and restrictions for services covered under the CED provision. These services generally have a national coverage determination (NCD) available, and approved studies and registries are added to the CMS clinical trials/registry web site. View the Medicare Advantage medical policy for Coverage with Evidence Development (CED) Studies and Registries (PDF) |
Clinical trials or registries (not otherwise specified) | Medicare determines coverage for clinical trials, including for Medicare Advantage beneficiaries. We recommend providers call Medicare directly at 1-800-MEDICARE to determine Medicare approval status of the requested clinical trial/registry. View the Medicare Advantage medical policy for Clinical Trials/Registries (PDF) |
21245, 21246, 21248, 21249
Bone Growth Stimulators (Osteogenic Stimulation) (PDF)
20979, E0747, E0760
Commode Chairs with Seat Lift Mechanism (PDF)
E0170, E0171
Electrical Stimulation and Electromagnetic Therapy Devices (PDF)
0278T, A4542, A4560, A4596, E0731, E0732, E0733, E0734, E0745, E0761, E0764, E0770, G0329
Multi-Positional Patient Transfer System (PDF)
E0636, E1035, E1036
Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)
L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L8701, L8702
Definitive Lower Limb Prostheses (PDF)
- L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987
Negative Pressure Wound Therapy in the Outpatient Setting (PDF)
- 97605, 97606, 97607, 97608, A6550, A7000, E2402, K0743
The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.
Noninvasive Ventilators in the Home Setting (PDF)
E0466
Pneumatic Compression Devices (PDF)
E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673
Power Wheelchairs - Group 2 and Group 3 (PDF)
E2300, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864
Powered Exoskeleton for Ambulation (PDF)
K1007
K1014, L2006, L5615, L5859, L5973 L5856, L5857, L5858
Sleep Medicine
- View the Sleep Medicine Program for notification or authorization requirements
Review the codes requiring authorization or notification in the sleep medicine section on this list.
Tumor Treatment Field Therapy (TTFT) (PDF)
- E0766
- 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81161, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81204, 81205, 81209, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81234, 81238, 81239, 81242, 81243, 81244, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81265, 81266, 81267, 81268, 81269, 81271, 81274, 81283, 81284, 81285, 81286, 81289, 81290, 81302, 81303, 81304, 81306, 81312, 81324, 81325, 81326, 81328, 81329, 81330, 81331, 81332, 81333, 81335, 81336, 81337, 81343, 81344, 81349, 81350, 81355, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81434, 81439, 81440, 81441, 81442, 81443, 81448, 81460, 81465, 81470, 81471, 81493, 81507, 81513, 81514, 81554, 87523, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0039U, 0068U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0086U, 0105U, 0109U, 0112U, 0115U, 0118U, 0140U, 0141U, 0142U, 0156U, 0169U, 0202U, 0218U, 0223U, 0225U, 0230U, 0231U, 0232U, 0233U, 0234U, 0236U, 0237U, 0311U, 0323U, 0327U, 0330U, 0345U, 0352U, 0355U, 0371U, 0372U, 0377U, 0378U, 0380U, 0389U, 0393U, 0399U, 0402U, 0407U, 0411U, 0419U, 0423U, 0441U, 0442U, 0446U, 0447U, G9143
- 0011M, 0017M, 0005U, 0009U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0037U, 0045U, 0046U, 0047U, 0048U, 0049U, 0069U, 0080U, 0089U, 0090U, 0111U, 0154U, 0155U, 0171U, 0172U, 0177U, 0179U, 0229U, 0239U, 0242U, 0244U, 0245U, 0250U, 0288U, 0306U, 0307U, 0314U, 0326U, 0329U, 0331U, 0334U, 0338U, 0339U, 0340U, 0343U, 0356U, 0362U, 0364U, 0375U, 0376U, 0379U, 0387U, 0388U, 0391U, 0395U, 0398U, 0404U, 0405U, 0406U, 0409U, 0410U, 0413U, 0414U, 0418U, 0420U, 0422U, 0424U, 0428U, 0433U, 0436U, 0444U, 0448U, 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81175, 81176, 81191, 81192, 81193, 81194, 81206, 81207, 81208, 81210, 81212, 81216, 81218, 81219, 81233, 81235, 81236, 81237, 81245, 81246, 81261, 81262, 81263, 81264, 81270, 81272, 81273, 81275, 81276, 81277, 81278, 81279, 81287, 81301, 81305, 81309, 81310, 81311, 81313, 81314, 81315, 81316, 81320, 81327, 81334, 81338, 81339, 81340, 81341, 81342, 81345, 81347, 81348, 81351, 81352, 81357, 81360, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81462, 81463, 81464, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, G0327
Genetic and Molecular Diagnostics - Testing for Inherited Cancer Risk (PDF)
- 0101U, 0129U, 0130U, 0131U, 0133U, 0134U, 0162U, 0235U, 0238U, 81162, 81163, 81164, 81165, 81166, 81167, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81307, 81308, 81317, 81318, 81319, 81321, 81322, 81323, 81351, 81352, 81353, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81432, 81433, 81435, 81436, 81437, 81438
Allergy and Sensitivity Tests of Uncertain Efficacy (PDF)
86001, 86343, 95065
Biochemical and Cellular Markers of Alzheimer’s Disease (PDF)
0206U, 0207U, 0412U, 0445U
Chemoresistance and Chemosensitivity Assays (PDF)
81535, 81536, 0083U
0202U, 0223U, 0225U
Measurement of Serum Antibodies to Selected Biologic Agents (PDF)
80145, 80230, 80280
81232, 81346
81596, 0002M, 0003M, 0014M, 0166U, 81517
Multimarker and Proteomics-based Testing Related to Ovarian Cancer (PDF)
- 81500, 81503
- Review this entire page for similar services that require pre-authorization
- Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials
Obtain or verify an authorization with eviCore:
- Login to eviCore's portal
- Phone (855) 252-1115
- Fax (855) 774-1319
Physical therapy, speech therapy, occupational therapy (PT,ST,OT); complementary and alternative medicine
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials.
- Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF) for enrolled dependents aged 17 and younger.
We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 95851, 95852, 96105, 97012, 97016, 97018, 97022, 97024, 97028, 97032, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97129, 97130, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, S9152
Pain management
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials.
We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685, 63688, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72285, 72295, G0259, G0260
Joint management
- Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
- We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916
Spine
- Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
- We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749
Contact Regence for pre-authorization for the following codes:
- Cone Beam Computed Tomography of the Breast (PDF)
- 0633T, 0634T, 0635T, 0636T, 0637T, 0638T
- Opto-acoustic Imaging of the Breast
- 0857T
- 93895
We partner with Carelon to administer our radiology program. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.
Note: The Radiology Quality Initiative (RQI) component of this program was phased out in 2023.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
Contact Carelon to request pre-authorization for the following codes:
- 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78102, 78103, 78104, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78429, 78430, 78431, 78432, 78433, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0648T, 0649T
Ventricular Assist Devices and Total Artificial Hearts (PDF)
33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, L8698
33945
33935
Intestinal and Multi-Visceral Transplants (PDF)
44132, 44133, 44135, 44136, 44715, 44720, 44721, 47135, 48554
Islet Cell Transplantation (PDF)
0584T, 0585T, 0586T, G0343, G0341, G0342
47135
32851, 32852, 32853, 32854
48554
Stem Cell and Bone Marrow Transplantation (PDF)
38205, 38206, 38232, 38240, 38241, 38242, C9782
- A0430, A0435
- Pre-authorization is required prior to elective fixed wing air ambulance transport.
- Emergency air ambulance transports may be reviewed retrospectively for medical necessity.