HCPCS Codes that Require Prior Authorization in Some or All Situations
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HCPCS Codes that Require Prior Authorization in Some or All Situations
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Procedure Codes under WPS Jurisdiction that require Prior Authorization
RSNAT for dates of service on or after April 1, 2022, for J5; on or after June 1, 2022, for J8:
- A0426 - Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1
- A0428 - Ambulance service, Basic Life Support (BLS), non-emergency transport
For additional information when the Prior Authorization is required, please review Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT).
Hospital Outpatient Department (HOPD):
Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair for dates of service on or after July 1, 2020
- 15820 - Removal of excessive skin of lower eyelid
- 15821 - Removal of excessive skin of lower eyelid and fat around eye
- 15822 - Removal of excessive skin of upper eyelid
- 15823 - Removal of excessive skin and fat of upper eyelid
- 67900 - Repair of brow paralysis
- 67901 - Repair of upper eyelid muscle to correct drooping or paralysis
- 67902 - Repair of upper eyelid muscle to correct drooping or paralysis
- 67903 - Shortening or advancement of upper eyelid muscle to correct drooping or paralysis
- 67904 - Repair of tendon of upper eyelid
- 67906 - Suspension of upper eyelid muscle to correct drooping or paralysis
- 67908 - Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis
Botulinum Toxin Injection for dates of service on or after July 1, 2020
- 64612 - Injection of chemical for destruction of nerve muscles on one side of face
- 64615 - Injection of chemical for destruction of facial and neck nerve muscles on both sides of face
- J0585 - Injection, onabotulinumtoxina, 1 unit
- J0586 - Injection, abobotulinumtoxina
- J0587 - Injection, rimabotulinumtoxinb, 100 units
- J0588 - Injection, incobotulinumtoxin a
Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services for dates of service on or after July 1, 2020
- 15830 - Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
- 15847 - Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)
- 15877 - Suction assisted removal of fat from trunk
Rhinoplasty, and Related Services for dates of service on or after July 1, 2020
- 20912 - Nasal cartilage graft
- 21210 - Repair of nasal or cheek bone with bone graft
- 30400 - Reshaping of tip of nose
- 30410 - Reshaping of bone, cartilage, or tip of nose
- 30420 - Reshaping of bony cartilage dividing nasal passages
- 30430 - Revision to reshape nose or tip of nose after previous repair
- 30435 - Revision to reshape nasal bones after previous repair
- 30450 - Revision to reshape nasal bones and tip of nose after previous repair
- 30460 - Repair of congenital nasal defect to lengthen tip of nose
- 30462 - Repair of congenital nasal defect with lengthening of tip of nose
- 30465 - Widening of nasal passage
- 30520 - Reshaping of nasal cartilage
Vein Ablation, and Related Services for dates of service on or after July 1, 2020
- 36473 - Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
- 36474 - Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
- 36475 - Destruction of insufficient vein of arm or leg, accessed through the skin
- 36476 - Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
- 36478 - Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin
- 36479 - Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance
- 36482 - Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
- 36483 - Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance
Cervical Fusion with Disc Removal for dates of service on or after July 1, 2021
- 22551 - Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial
- 22552 - Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck, anterior approach, each additional interspace
Implanted Spinal Neurostimulators (Spinal Cord Stimulators) for dates of service on or after July 1, 2021
- 63650 - Implantation of spinal neurostimulator electrodes, accessed through the skin
Facet Joint Interventions for dates of service on or after July 1, 2023
- 64490 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
- 64491 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level
- 64492 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s)
- 64493 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
- 64494 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
- 64495 - Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s)
- 64633 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
- 64634 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint
- 64635 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
- 64636 - Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint
For additional information, please review Prior Authorization for Hospital Outpatient Department Services (HOPD) Overview.
Procedure Codes Outside WPS Jurisdiction that Require a Prior Authorization. For additional information, contact the appropriate MAC in your jurisdiction:
Home Health RCD:
- G0151 - Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
- G0152 - Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
- G0153 - Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
- G0155 - Services of clinical social worker in home health or hospice settings, each 15 minutes
- G0156 - Services of home health/hospice aide in home health or hospice settings, each 15 minutes
- G0157 - Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
- G0158 - Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes
- G0159 - Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes
- G0160 - Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
- G0161 - Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes
- G0162 - Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; 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
- G0493 - Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes
- G0494 - Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes
- G0495 - Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes
- G0496 - Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, 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
- G2169 - 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
WPS does not process Home Health or Hospice claims. Submit your prior authorization request to the MAC for your jurisdiction.
DMEPOS:
- K0856 - Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0861 - Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0813 - Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
- K0814 - Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
- K0815 - Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
- K0816 - Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
- K0820 - Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300pounds
- K0821 - Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
- K0822 - Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0823 - Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
- K0824 - Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
- K0825 - Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
- K0826 - Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
- K0827 - Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
- K0828 - Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
- K0829 - Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601pounds or more
- K0835 - Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0836 - Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
- K0837 - Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
- K0838 - Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
- K0839 - Power wheelchair, group 2 very heavy duty, single power option sling/solid seat/back, patient weight capacity 451 to 600pounds
- K0840 - Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more
- K0841 - Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0842 - Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
- K0843 - Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
- K0848 - Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
- K0849 - Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
- K0850 - Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
- K0851 - Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity301 to 450 pounds
- K0852 - Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
- K0853 - Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
- K0854 - Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
- K0855 - Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
- K0857 - Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
- K0858 - Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds
- K0859 - Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
- K0860 - Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
- K0862 - Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
- K0863 - Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
- K0864 - Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
- E0193 - Powered air flotation bed (low air loss therapy)
- E0277 - Powered pressure-reducing air mattress
- E0371 - Non-powered advanced pressure reducing overlay for mattress, standard mattress length and
- E0372 - Powered air overlay for mattress, standard mattress length and width
- E0373 - Non-powered advanced pressure reducing mattress
- L5856 - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
- L5857 - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s),any type
- L5858 - Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s),any type
- L5973 - Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source
- L5980 - All lower extremity prostheses, flex foot system
- L5987 - All lower extremity prosthesis, shank foot system with vertical loading pylon
- K0800 - Power Operated Vehicle, Group 1 Standard, Patient Weight Capacity Up To And Including 300 Pounds
- K0801 - Power Operated Vehicle, Group 1 Heavy Duty, Patient Weight Capacity, 301 To 450 Pounds
- K0802 - Power Operated Vehicle, Group 1 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds
- K0806 - Power Operated Vehicle, Group 2 Standard, Patient Weight Capacity Up To And Including 300 Pounds
- K0807 - Power Operated Vehicle, Group 2 Heavy Duty, Patient Weight Capacity 301 To 450 Pounds
- K0808 - Power Operated Vehicle, Group 2 Very Heavy Duty, Patient Weight Capacity 451 To 600 Pounds
- L0648 - Lumbar-Sacral Orthosis, Sagittal Control, With Rigid Anterior And Posterior Panels, Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Produces Intracavitary Pressure To Reduce Load On The Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off The-Shelf
- L0650 - Lumbar-Sacral Orthosis, Sagittal-Coronal Control, With Rigid Anterior And Posterior Frame/Panel(S), Posterior Extends From Sacrococcygeal Junction To T-9 Vertebra, Lateral Strength Provided By Rigid Lateral Frame/Panel(S), Produces Intracavitary Pressure To Reduce Load On Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf
- L1832 - Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise
- L1833 - Knee Orthosis, Adjustable Knee Joints (Unicentric Or Polycentric), Positional Orthosis, Rigid Support, Prefabricated, Off-The Shelf
- L1851 - Knee Orthosis (Ko), Single Upright, Thigh And Calf, With Adjustable Flexion And Extension Joint (Unicentric Or Polycentric), Medial-Lateral And Rotation Control, With Or Without Varus/Valgus Adjustment, Prefabricated, Off The-Shelf
WPS does not process DMEPOS claims. Submit your prior authorization request to the DME MAC for your jurisdiction.
global-tags: J8A,J5A,J8B,J5B
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