ALASKA MEDICAID Pre-Auth List - Homepage | …

1 ALASKA MEDICAID Pre-Auth List INDEX: Select Imaging - ..2. Procedures ..5. ICD-10 .11. ICD-10 Procedures ..13. ICD-10 Transplants ..4 . OUTPATIENT IMAGING - CPT. Effective - February 2018. All outpatient imaging services on this list require pre-certification CPT Code Description 76390 MR spectroscopy 70551 Magnetic resonance imaging, brain (including brain stem) without contrast material 70552 Magnetic resonance imaging, brain (including brain stem) with contrast material 70553 MRI Brain without contrast material, followed by contrast material and further sequences 70554 MRI, Brain, functional MRI including rest selection and administration of repetitive body part movement and /or visual stimulation, requiring physician or psychologist administration 70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing 71550 MRI chest w/o dye 71551 MRI chest w/dye 71552 MRI chest w/o dye & w/dye 71555 MRI angio chest w/ or w/o dye 75557 Cardiac MRI w/ morph 75559 Cardiac MRI w/ stress image 75561 Cardiac MRI for morph w/dye 75563 Card MRI w/ stress image & dye 75565 Card MRI veloc flow mapping 72141 Magnetic resonance imaging, spinal canal and contents, cervical; without contrast material 72142 with contrast material 72146 Magnetic resonance imaging, spinal canal and contents, thoracic; without contrast material 72147 with contrast material(s).

2 72148 Magnetic resonance imaging, spinal canal and contents, lumbar, without contrast material 72149 with contrast material 72156 Magnetic resonance imaging, spinal canal and contents, without contrast material, followed by contrast material and further sequences; cervical 72157 Magnetic resonance imaging, spinal canal and contents, without contrast material, followed by contrast material and further sequences; Thoracic 72158 Magnetic resonance imaging, spinal canal and contents, without contrast material, followed by contrast material and further sequences; Lumbar 72159 MRI angiography, spinal canal and contents, with or without contrast material 73218 MRI, upper extremity, other than joint, without contrast material 73219 with contrast material 73220 MRI upper extremity w/o & w/dye 73221 Magnetic resonance imaging, any joint of upper extremity; without contrast materials 73222 with contrast material 73223 without contrast material, followed by contrast material and further sections 73225 MR angio ur extr w/o & w/dye 73718 MRI, lower extremity other than joint; without contrast material 73719 with contrast material 73720 without contrast material, followed by contrast material and further sequences 73721 Magnetic resonance imaging; any joint of lower extremity; without contrast material 73722 with contrast material 73723 without contrast material, followed by contrast material and further sections 73725 MRI, lower extremity, with or without contrast material 77084 Magnetic image bone marrow 74712 MRI of Fetus (single gestation) - only if fetus is imaged 74713 add for each additional gestation - only if fetus is imaged Current Procedural Terminology (CPT ) is a copyright of American Medical Association 2011.

3 All rights reserved. CPT is a registered trademark of the American Medical Association. 2. OUTPATIENT IMAGING - CPT. Effective - February 2018. All outpatient imaging services on this list require pre-certification 72195 MRI, pelvis, without contrast material 72196 with contrast material 72197 without contrast material, followed by contrast material and further sections 72198 MRI angiography, pelvis, with or without contrast material 70557 Magnetic Resonance Imaging (including brain stem and skull base), during open intracranial procedure; without contrast material 70558 Magnetic Resonance Imaging (including brain stem and skull base), during open intracranial procedure; with contrast material 70559 Magnetic Resonance Imaging (including brain stem and skull base), during open intracranial procedure; without contrast material, followed by contrast material & further sequences 70336 Magnetic Image jaw joint 70540 MRI orbit/face/neck w/o dye 70542 MRI orbit/face/neck w/dye 70543 MRI orbit/face/neck w/o & w/dye 70544 MR angiography head w/o dye 70545 MR angiography head w/dye 70546 MR angiography head w/o dye & w/dye 70547 MR angiography neck w/o dye 70548 MR angiography neck w/dye 70549 MR angiography neck w/o & w/ dye 74181 MRI abdomen w/o dye 74182 MRI abdomen w/ dye 74183 MRI abdomen w/o & w/dye 74185 MRI angio abdomen w/ or w/o dye 76498 MRI procedure 77021 MR guidance for needle place 77058 MRI, breast without and/or with contrast material, unilateral 77059 MRI, breast without and/or with contrast material, bilateral 77022 Magnetic Resonance guidance for, and monitoring of, parenchymal tissue ablation 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound.

4 Or other tomographic modality with image post processing under concurrent supervision; not requiring image post processing on an independent workstation 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; requiring image post processing on an independent workstation 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton ( , hips, pelvis, spine). Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton ( , hips, pelvis, spine). 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton ( , hips, pelvis, spine), including vertebral fracture assessment 77085. 78205 Liver imaging (SPECT). 78206 Liver imaging (SPECT); with vascular flow 78710 Kidney imaging morphology; tomographic (SPECT).

5 Current Procedural Terminology (CPT ) is a copyright of American Medical Association 2011. All rights reserved. CPT is a registered trademark of the American Medical Association. 3. OUTPATIENT IMAGING - CPT. Effective - February 2018. All outpatient imaging services on this list require pre-certification 78451 HT muscle image spect sing 78452 HT muscle image spect mult 78459 Heart muscle imaging (PET). 78466 Heart infarct image 78468 Heart infarct image (EF). 78469 Heart infarct image (3D). 78491 Heart image (PET) image single 78492 Heart image (PET) image multiple 78494 Heart image spect 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, add'l quantification, when performed); single study, at rest or stress (exercise or pharmacologic). Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or 78454 gated technique, add'l quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic).

6 And/or redistribution and/or rest reinjection 78607 Brain imaging; tomographic (SPECT). 78608 PET, brain, metabolic evaluation 78609 PET, brain, perfusion evaluation 78630 Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT). 78071 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT). 78072 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization 78320 Bone and/or joint imaging; tomographic (SPECT). 78816 PET image w/ CT full body 78803 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent; tomographic (SPECT). 78807 Radiopharmaceutical localization of inflammatory process; tomographic (SPECT). 78811 PET, limited area ( Chest, head, neck). 78812 PET, Skull base to mid-thigh 78813 PET, whole body 78814 PET image w/CT limited 78815 PET image w/CT skull-thigh Current Procedural Terminology (CPT ) is a copyright of American Medical Association 2011.

7 All rights reserved. CPT is a registered trademark of the American Medical Association. 4. PROCEDURES - CPT. All procedures on this list require pre-certification All inpatient continued stays exceeding 3 days require certification All long term acute care (LTAC) admissions require pre-certification Effective - February 2018. CPT/HCPCS Code Description Inpatient Outpatient 21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts). 21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies). 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation 27132, 27134 Revision of hip replacement, both acetabular and femoral components Total hip revision x x 27137 Revision of hip replacement, acetabular component.

8 Partial, acetabular component only. That with: exchange of acetabular cup and liner x x exchange of femoral head 27138 Revision of hip replacement, femoral component. Partial, femoral component only. That with: exchange of acetabular x x liner exchange of femoral stem and head 27132, 27134, 27137, Revision of hip replacement, acetabular liner and/or femoral head only x x 27138. 27125, 27130,27132, Hip bearing surface, metal-on-polyethylene 27134, 27137, 27138, x x 27236. 27125, 27130,27132, Hip bearing surface, metal-on-metal 27134, 27137, 27138, x x 27236. 27125, 27130,27132, Hip bearing surface, ceramic-on-ceramic 27134, 27137, 27138, x x 27236. 27125, 27130,27132, Hip bearing surface, ceramic-on-polyethylene 27134, 27137, 27138, x x 27236. 27299 Resurfacing hip, total, acetabulum and femoral head Hip resurfacing arthroplasty, total x x 27299 Resurfacing hip, partial, femoral head Hip resurfacing arthroplasty, NOS. x x Hip resurfacing arthroplasty, partial, femoral head 27299 Resurfacing hip, partial, acetabulum Hip resurfacing arthroplasty, partial, acetabulum x x 61885, 61886, 61888 Cranial implantation or replacement of neurostimulator pulse generator x x 22830, 63040, 63042, Reopening of laminectomy site x x 63043, 63044.

9 22100, Other exploration and decompression of spinal canal 22101,22102,22103, Decompression: 61343, 61575, 61576, laminectomy 62272, 63001, 63003, laminotomy 63005, 63011, 63012, Expansile laminoplasty 63015, 63016, 63017, Exploration of spinal nerve root x x 63020,63030, 63035, Foraminotomy 63045, 63046, 63047, 63048, 63050, 63055, 63056, 63057, 63064, 63066,63172, 63173. 63185, 63190 Division of intraspinal nerve root Rhizotomy x x 43647, 43648, 43881, Implantation or replacement of peripheral neurostimulator lead(s). 43882, 64553, 64555, 64561, 64568, 64569, x x 64575, 64580, 64581, 64585. 69710 Implantation electromagnetic hearing device x x 69930 Implantation or replacement of cochlear prosthetic device, not otherwise specified x x 69930 Implantation or replacement of cochlear prosthetic device, single channel x x 69714, 69715, 69717, Implantation or replacement of cochlear prosthetic device, multiple channel x x 69718, 69930. 69711, 69799, 69949, Other operations on middle and inner ear 69979 Attachment of percutaneous abutment (screw) for prosthetic device x x Repair or removal of cochlear prosthetic device (receiver) (electrode).

10 30520 Repair of nasal septum x x 30620 Total nasal reconstruction x x 30430, 30435, 30450, Revision rhinoplasty x x 30462. 21235 Augmentation rhinoplasty x x 15276, 30400, 30460 Limited rhinoplasty x x Current Procedural Terminology (CPT ) is a copyright of American Medical Association 2011. All rights reserved. CPT is a registered trademark of the American Medical Association. PROCEDURES - CPT. All procedures on this list require pre-certification All inpatient continued stays exceeding 3 days require certification All long term acute care (LTAC) admissions require pre-certification Effective - February 2018. CPT/HCPCS Code Description Inpatient Outpatient 30400,30410, 30420, Other rhinoplasty x x 30460, 33999 Removal of internal biventricular heart replacement system. Explanation of artificial heart. x x 33976 Implantation or insertion of biventricular external heart assist system x x 33967, 33970, 33973 Implant of pulsation balloon x x 92970 Insertion of temporary non-implantable extracorporeal circulatory assist device Insertion of heart assist system, NOS x x Insertion of heart pump 33981, 33982, 33983, Repair of heart assist system x x 33999 Replacement of parts of an existing ventricular assist device (VAD).