Preauthorization Requirements
Starting Nov. 15, 2022, and Dec. 1, 2022

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

G0299

Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes

G0300

Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes

G2168

Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G2168

Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

M0244

Intravenous infusion or subcutaneous injection, casirivimab and imdevimab, includes infusion or injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the COVID-19 public health emergency

M0246

Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the COVID-19 public health emergency

S5108

Home care training to home care client, per 15 minutes

S5109

Home care training to home care client, per session

S5110

Home care training, family; per 15 minutes

S5111

Home care training, family; per session

S5115

Home care training, nonfamily; per 15 minutes

S5116

Home care training, nonfamily; per session

S5180

Home health respiratory therapy, initial evaluation

S5181

Home health respiratory therapy, NOS, per diem

S9097

Home visit for wound care

S9122

Home health aide or certified nurse assistant, providing care in the home; per hour

T1000

Private duty/independent nursing service(s), licensed, up to 15 minutes

T1002

RN services, up to 15 minutes

T1021

Home health aide or certified nurse assistant, per visit

T1022

Contracted home health agency services, all services provided under contract, per day

T1030

Nursing care, in the home, by registered nurse, per diem

T1031

Nursing care, in the home, by licensed practical nurse, per diem

77299

Unlisted procedure, therapeutic radiology clinical treatment planning

A4648

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon, with interpretation and report

A4650

Tissue marker, implantable, any type, each

C1715

Implantable radiation dosimeter, each

C1716

Brachytherapy needle

C1717

Brachytherapy source, nonstranded, gold-198, per source

C1719

Brachytherapy source, nonstranded, high dose rate iridium-192, per source

C2634

Brachytherapy source, nonstranded, nonhigh dose rate iridium-192, per source

C2635

Brachytherapy source, nonstranded, high activity, iodine-125, greater than 1.01 mCi (NIST), per source

C2636

Brachytherapy source, nonstranded, high activity, palladium-103, greater than 2.2 mCi (NIST), per source

C2637

Brachytherapy linear source, nonstranded, palladium-103, per 1 mm

C2638

Brachytherapy source, nonstranded, ytterbium-169, per source

C2639

Brachytherapy source, stranded, iodine-125, per source

C2640

Brachytherapy source, nonstranded, iodine-125, per source

C2641

Brachytherapy source, stranded, palladium-103, per source

C2642

Brachytherapy source, nonstranded, palladium-103, per source

C2643

Brachytherapy source, stranded, cesium-131, per source

C2644

Brachytherapy source, nonstranded, cesium-131, per source

C2698

Brachytherapy source, cesium-131 chloride solution, per millicurie

C2699

Brachytherapy source, stranded, not otherwise specified, per source

C9725

Brachytherapy source, nonstranded, not otherwise specified, per source

C9728

Placement of endorectal intracavitary applicator for high intensity brachytherapy

Q3001

Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter), for other than the following sites (any approach): abdomen, pelvis, prostate, retroperitoneum, thorax, single or multiple