Preauthorization List Reductions Starting April 1, 2023

76948

Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

10120

Incision and removal of foreign body, subcutaneous tissues; simple

10140

Incision and drainage of hematoma, seroma, or fluid collection

11400

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.5 cm or less

11401

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.6 to 1.0 cm

11402

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 1.1 to 2.0 cm

11403

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 2.1 to 3.0 cm

11404

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 3.1 to 4.0 cm

11406

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter over 4.0 cm

11420

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 0.5 cm or less

11421

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 0.6 to 1.0 cm

11422

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 1.1 to 2.0 cm

11423

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 2.1 to 3.0 cm

11424

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 3.1 to 4.0 cm

11426

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter over 4.0 cm

11442

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

13101

Repair, complex, trunk; 2.6 cm to 7.5 cm

13132

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

14040

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

14060

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

14301

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

19000

Puncture aspiration of cyst of breast

20680

Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod, or plate)

21320

Closed treatment of nasal bone fracture with manipulation; with stabilization

21552

Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3.0 cm or greater

21931

Excision, tumor, soft tissue of back or flank, subcutaneous; 3.0 cm or greater

23470

Arthroplasty, glenohumeral joint; hemiarthroplasty

23472

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder))

23473

Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

23474

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

24360

Arthroplasty, elbow; with membrane (e.g., fascial)

24361

Arthroplasty, elbow; with distal humeral prosthetic replacement

24362

Arthroplasty, elbow; with implant and fascia lata ligament reconstruction

24363

Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow)

24370

Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component

24371

Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component

27096

Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

27120

Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type)

27122

Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure)

27125

Hemiarthroplasty, hip partial

27130

Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip replacement), with or without autograft or allograft

27132

Conversation of previous hip surgery to total hip arthroplasty, both components with or without allograft or autograft

27134

Revision of total hip arthroplasty; both components, with or without autograft or allograft

27137

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

27138

Revision of total hip arthroplasty; femoral component only, with or without allograft

27437

Arthroplasty, patella; without prosthesis

27438

Arthroplasty, patella; with prosthesis

27440

Arthroplasty, knee, tibial plateau

27441

Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

27442

Arthroplasty, femoral condyles, or tibial plateau(s), knee

27443

Arthroplasty, femoral condyles, or tibial plateau(s), knee; with debridement and partial synovectomy

27445

Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)

27446

Arthroplasty, knee, condyle, and plateau; medial OR lateral compartment

27447

Arthroplasty, knee, condyle, and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

27486

Revision of total knee arthroplasty, with or without allograft; one component

27487

Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

29830

Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure)

29835

Arthroscopy, elbow, surgical; synovectomy, partial

29837

Arthroscopy, elbow, surgical; debridement, limited

29840

Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure)

29843

Arthroscopy, wrist, surgical; for infection, lavage, and drainage

29847

Arthroscopy, wrist, surgical; internal fixation for fracture or instability

29860

Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

29861

Arthroscopy, hip, surgical; with removal of loose body or foreign body

29862

Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum

29863

Arthroscopy, hip, surgical; with synovectomy

29885

Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)

29886

Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

29899

Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis

29914

Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)

29915

Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)

29916

Arthroscopy, hip, surgical; with labral repair

30140

Submucous resection inferior turbinate, partial or complete, any method

30520

Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

31579

Laryngoscopy, flexible or rigid telescopic, with stroboscopy

42821

Tonsillectomy and adenoidectomy; age 12 or over

42825

Tonsillectomy, primary or secondary; younger than age 12

42826

Tonsillectomy, primary or secondary; age 12 or over

42830

Adenoidectomy, primary; younger than age 12

43235

Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

43239

Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

43249

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

45300

Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

45330

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

45378

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

45380

Colonoscopy, flexible; with biopsy, single or multiple

45384

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

45385

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

46922

Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision

47000

Biopsy of liver, needle; percutaneous

49505

Repair initial inguinal hernia, age five years or older; reducible

49650

Laparoscopy, surgical; repair initial inguinal hernia

49651

Laparoscopy, surgical; repair recurrent inguinal hernia

50590

Lithotripsy, extracorporeal shock wave

52000

Cystourethroscopy (separate procedure)

52005

Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;

52204

Cystourethroscopy, with biopsy(s)

52224

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy

52234

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)

52235

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

52260

Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia

52281

Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female

52310

Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

52332

Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

52351

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic

52352

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

52353

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)

52356

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

54161

Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age

55040

Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure)

55250

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

55700

Biopsy, prostate; needle or punch, single or multiple, any approach

57288

Sling operation for stress incontinence (e.g., fascia or synthetic)

57460

Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix

57522

Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision

58152

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)

58267

Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

58270

Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58275

Vaginal hysterectomy, with total or partial vaginectomy

58280

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

58294

Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

58353

Endometrial ablation, thermal, without hysteroscopic guidance

58563

Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation)

58565

Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants

64520

Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)

64633

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

64635

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

64721

Neuroplasty and/or transposition; median nerve at carpal tunnel

65426

Excision or transposition of pterygium; with graft

65730

Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) Revised

65855

Trabeculoplasty by laser surgery

66170

Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae

66761

Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (per session)

66821

Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages)

66982

Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage

66984

Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)

67028

Intravitreal injection of a pharmacologic agent (separate procedure)

67036

Vitrectomy, mechanical, pars plana approach

67040

Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation

67228

Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation

67311

Strabismus surgery, recession or resection procedure; one horizontal muscle

67312

Strabismus surgery, recession or resection procedure; two horizontal muscles

69436

Tympanostomy (requiring insertion of ventilating tube), general anesthesia

69631

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction

93593

Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; normal native connections

93594

Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; abnormal native connections

93596

Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); normal native connections

93597

Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); abnormal native connections

94625

Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session)

94626

Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session)

49585

Repair umbilical hernia, age 5 years or older; reducible

49587

Repair umbilical hernia, age 5 years or older; incarcerated or strangulated

49652

Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible

49653

Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated

49654

Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible

49655

Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated

99343

Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.

K0553

Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service

K0554

Supply allowance for therapeutic continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service