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Inpatient Only Code00176ANESTH PROCEDURE ON MOUTHHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00192ANESTH PHARYNGEAL SURGERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00211ANESTH FACE/SKULL BONE SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00214ANESTH CRANIAL SURG NOSHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00215ANESTH CRAN SURG HEMOTOMAHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00300ANESTH SPECIAL HEAD SURGERY 
Inpatient Only Code00474ANESTH SURGERY OF SHOULDERHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00524ANESTH SURGERY OF RIBHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00540ANESTH PACEMAKER INSERTIONHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00542ANESTH CARDIOVERTER/DEFIBHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00546ANESTH CARDIAC ELECTROPHYSHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00560ANESTH ONE LUNG VENTILATIONHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00561ANESTHESIA REMOVAL PLEURAHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00562ANESTH LUNG CHEST WALL SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00567ANESTH STERNAL DEBRIDEMENTHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00580BONE SRGRY CMPTR CT/MRI IMAGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00604ANESTH HEART SURG <1 YRHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00630ANESTH CABG W/PUMP 
Inpatient Only Code00632ANESTH HEART/LUNG TRANSPLNTHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00731ANESTH SPINE CORD SURGERY 
Inpatient Only Code00792US LEIOMYOMATA ABLATE >200HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00794ANESTH ABDOMINAL WALL SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00796ANES UPR GI NDSC PX NOSHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00802ANESTH REPAIR OF HERNIA 
Inpatient Only Code00844ANESTH ABDOMINAL WALL SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00846ANESTH FAT LAYER REMOVALHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00848ANES LWR INTST NDSC NOSHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00864ANESTH REPAIR OF HERNIAHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00865ANESTH REPAIR OF HERNIA 
Inpatient Only Code00866ANESTH HERNIA REPAIR < 1 YRHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00868ANESTH HERNIA REPAIR PREEMIEHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00882ANESTH PELVIC ORGAN SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00904BREATH TEST HEART REJECTHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00908ANESTH KIDNEY/URETER SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00932ANESTH REMOVAL OF PROSTATEHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00934ANESTH BLADDER SURGERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code00936ANESTH BLADDER TUMOR SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services00944ANESTH GENITALIA SURGERY 
Inpatient Only Code01140ANESTH BODY CAST PROCEDUREHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01150ANESTH AMPUTATION AT PELVISHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01212ANESTH HIP JOINT SURGERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services01214ANESTH HIP DISARTICULATION 
Inpatient Only Code01232ANESTH SURGERY OF FEMURHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01234ANESTH AMPUTATION OF FEMURHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01272CHD RISK IMT STUDYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01274ANESTH THIGH ARTERIES SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01404ANESTH KNEE JOINT SURGERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01442ANESTH KNEE VESSEL SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01444ANESTH KNEE ARTERIES SURGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01486ANESTH RADICAL LEG SURGERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01502ANESTH LOWER LEG CASTINGHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01634ANES DX SHOULDER ARTHROSCOPYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01636ANESTH SURGERY OF SHOULDERHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01638ANESTH SHOULDER JOINT AMPUTHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01652ANESTH SHOULDER REPLACEMENTHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01654LUMB ARTIF DISKECTOMY ADDLHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01656REMOVE LUMB ARTIF DISC ADDLHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code01756ANESTH UPPR ARM PROCEDUREHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services01916ANESTH WRIST REPLACEMENT 
Other Services01922ANESTH LWR ARM EMBOLECTOMY 
Other Services01924ANESTH VASCULAR SHUNT SURG 
Other Services01930ANESTH LWR ARM VEIN REPAIR 
Other Services01936ANESTH CAT OR MRI SCAN 
Inpatient Only Code01990ANESTH VAGINAL DELIVERYHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services01992ANESTH EMER HYSTERECTOMY 
Other Services10021FNA BX W/O IMG GDN 1ST LES 
Other Services10030GUIDE CATHET FLUID DRAINAGE 
Other Services10140DRAINAGE OF HEMATOMA/FLUID 
Other Services10180COMPLEX DRAINAGE WOUND 
Inpatient Only Code11004DEBRIDE GENITALIA & PERINEUMHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11005DEBRIDE ABDOM WALLHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11006DEBRIDE GENIT/PER/ABDOM WALLHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code11008REMOVE MESH FROM ABD WALLHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services11012DEB SKIN BONE AT FX SITE 
Other Services11042DEB SUBQ TISSUE 20 SQ CM/< 
Other Services11043DEB MUSC/FASCIA 20 SQ CM/< 
Other Services11044DEB BONE 20 SQ CM/< 
Other Services11045DEB SUBQ TISSUE ADD-ON 
Other Services11055TRIM SKIN LESION 
Other Services11102TANGNTL BX SKIN SINGLE LES 
Other Services11106INCAL BX SKN SINGLE LES 
Other Services11306SHAVE SKIN LESION 0.6-1.0 CM 
Other Services11400EXC TR-EXT B9+MARG 0.5 CM< 
Other Services11401EXC TR-EXT B9+MARG 0.6-1 CM 
Other Services11402EXC TR-EXT B9+MARG 1.1-2 CM 
Other Services11403EXC TR-EXT B9+MARG 2.1-3CM 
Other Services11420EXC H-F-NK-SP B9+MARG 0.5/< 
Other Services11421EXC H-F-NK-SP B9+MARG 0.6-1 
Other Services11422EXC H-F-NK-SP B9+MARG 1.1-2 
Other Services11423EXC H-F-NK-SP B9+MARG 2.1-3 
Other Services11426EXC H-F-NK-SP B9+MARG >4 CM 
Other Services11620EXC H-F-NK-SP MAL+MARG 0.5/< 
Other Services11721DEBRIDE NAIL 6 OR MORE 
Other Services11770REMOVE PILONIDAL CYST SIMPLE 
Breast Reconstruction11920CORRECT SKIN COLOR 6.0 CM/<Notification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Breast Reconstruction11921CORRECT SKN COLOR 6.1-20.0CMNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Breast Reconstruction11922CORRECT SKIN COLOR EA 20.0CMNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Cosmetic & Reconstructive11960INSERT TISSUE EXPANDER(S)Preauth required for such services whether scheduled as inpatient or outpatient.
Other Services11970REPLACE TISSUE EXPANDER 
Cosmetic & Reconstructive11971REMOVE TISSUE EXPANDER(S)Preauth required for such services whether scheduled as inpatient or outpatient.
Other Services11980IMPLANT HORMONE PELLET(S) 
Other Services11981INSERT DRUG IMPLANT DEVICE 
Other Services12005RPR S/N/A/GEN/TRK12.6-20.0CM 
Other Services12020CLOSURE OF SPLIT WOUND 
Other Services12051INTMD RPR FACE/MM 2.5 CM/< 
Other Services13100CMPLX RPR TRUNK 1.1-2.5 CM 
Other Services13160LATE CLOSURE OF WOUND 
Other Services14000TIS TRNFR TRUNK 10 SQ CM/< 
Other Services14001TIS TRNFR TRUNK 10.1-30SQCM 
Other Services14020TIS TRNFR S/A/L 10 SQ CM/< 
Other Services14021TIS TRNFR S/A/L 10.1-30 SQCM 
Other Services14040TIS TRNFR F/C/C/M/N/A/G/H/F 
Other Services14041TIS TRNFR F/C/C/M/N/A/G/H/F 
Other Services14060TIS TRNFR E/N/E/L 10 SQ CM/< 
Other Services14061TIS TRNFR E/N/E/L10.1-30SQCM 
Other Services14301TIS TRNFR ANY 30.1-60 SQ CM 
Other Services14302TIS TRNFR ADDL 30 SQ CM 
Other Services15002WOUND PREP TRK/ARM/LEG 
Other Services15004WOUND PREP F/N/HF/G 
Other Services15100SKIN SPLT GRFT TRNK/ARM/LEG 
Other Services15120SKN SPLT A-GRFT FAC/NCK/HF/G 
Other Services15220SKIN FULL GRAFT SCLP/ARM/LEG 
Other Services15240SKIN FULL GRFT FACE/GENIT/HF 
Other Services15260SKIN FULL GRAFT EEN & LIPS 
Other Services15271SKIN SUB GRAFT TRNK/ARM/LEG 
Other Services15272SKIN SUB GRAFT T/A/L ADD-ON 
Other Services15275SKIN SUB GRAFT FACE/NK/HF/G 
Other Services15572SKIN PEDICLE FLAP ARMS/LEGS 
Other Services15574PEDCLE FH/CH/CH/M/N/AX/G/H/F 
Other Services15576PEDICLE E/N/E/L/NTRORAL 
Other Services15620DELAY FLAP F/C/C/N/AX/G/H/F 
Other Services15630DELAY FLAP EYE/NOS/EAR/LIP 
Other Services15650TRANSFER SKIN PEDICLE FLAP 
Other Services15730MDFC FLAP W/PRSRV VASC PEDCL 
Other Services15731FOREHEAD FLAP W/VASC PEDICLE 
Other Services15733MUSC MYOQ/FSCQ FLP H&N PEDCL 
Other Services15734MUSCLE-SKIN GRAFT TRUNK 
Other Services15736MUSCLE-SKIN GRAFT ARM 
Other Services15738MUSCLE-SKIN GRAFT LEG 
Other Services15750NEUROVASCULAR PEDICLE FLAP 
Inpatient Only Code15756FREE MYO/SKIN FLAP MICROVASCHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code15757FREE SKIN FLAP MICROVASCHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code15758FREE FASCIAL FLAP MICROVASCHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services15770DERMA-FAT-FASCIA GRAFT 
Other Services15775HAIR TRNSPL 1-15 PUNCH GRFTS 
Other Services15776HAIR TRNSPL >15 PUNCH GRAFTS 
Other Services15780DERMABRASION TOTAL FACE 
Other Services15781DERMABRASION SEGMENTAL FACE 
Other Services15782DERMABRASION OTHER THAN FACE 
Other Services15783DERMABRASION SUPRFL ANY SITE 
Other Services15788CHEMICAL PEEL FACE EPIDERM 
Other Services15789CHEMICAL PEEL FACE DERMAL 
Other Services15792CHEMICAL PEEL NONFACIAL 
Other Services15793CHEMICAL PEEL NONFACIAL 
Cosmetic & Reconstructive15820REVISION OF LOWER EYELIDPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15821REVISION OF LOWER EYELIDPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15822REVISION OF UPPER EYELIDPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15823REVISION OF UPPER EYELIDPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15830EXC SKIN ABDPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15847EXC SKIN ABD ADD-ONPreauth required for such services whether scheduled as inpatient or outpatient.
Other Services15946REMOVE HIP PRESSURE SORE 
Inpatient Only Code16036ESCHAROTOMY ADDL INCISIONHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services17000DESTRUCT PREMALG LESION 
Other Services17003DESTRUCT PREMALG LES 2-14 
Other Services17004DESTROY PREMAL LESIONS 15/> 
Cosmetic & Reconstructive17106DESTRUCTION OF SKIN LESIONSPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive17107DESTRUCTION OF SKIN LESIONSPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive17108DESTRUCTION OF SKIN LESIONSPreauth required for such services whether scheduled as inpatient or outpatient.
Other Services17110DESTRUCT B9 LESION 1-14 
Other Services17111DESTRUCT LESION 15 OR MORE 
Other Services17262DESTRUCTION OF SKIN LESIONS 
Other Services17263DESTRUCTION OF SKIN LESIONS 
Other Services17273DESTRUCTION OF SKIN LESIONS 
Other Services17281DESTRUCTION OF SKIN LESIONS 
Other Services17282DESTRUCTION OF SKIN LESIONS 
Other Services17311MOHS 1 STAGE H/N/HF/G 
Other Services17312MOHS ADDL STAGE 
Other Services17313MOHS 1 STAGE T/A/L 
Other Services17314MOHS ADDL STAGE T/A/L 
Other Services17315MOHS SURG ADDL BLOCK 
Cosmetic & Reconstructive17999SKIN TISSUE PROCEDUREPreauth required for such services whether scheduled as inpatient or outpatient.
Other Services19020INCISION OF BREAST LESION 
Other Services19281PERQ DEVICE BREAST 1ST IMAG 
Other Services19303MAST SIMPLE COMPLETE 
Inpatient Only Code19305MAST RADICALHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Inpatient Only Code19306MAST RAD URBAN TYPEHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2021
Other Services19307MAST MOD RAD 
Breast Reconstruction19316SUSPENSION OF BREASTNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Breast Reconstruction19318REDUCTION OF LARGE BREASTNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Other Services21146LEFORT I-2 PIECE W/ GRAFT 
Other Services21147LEFORT I-3/> PIECE W/ GRAFT 
Other Services21150LEFORT II ANTERIOR INTRUSION 
Other Services21151LEFORT II W/BONE GRAFTS 
Other Services21154LEFORT III W/O LEFORT I 
Other Services21155LEFORT III W/ LEFORT I 
Other Services21159LEFORT III W/FHDW/O LEFORT I 
Other Services21160LEFORT III W/FHD W/ LEFORT I 
Cosmetic & Reconstructive21172RECONSTRUCT ORBIT/FOREHEADPreauth required for such services whether scheduled as inpatient or outpatient.
Breast Reconstruction19325ENLARGE BREAST WITH IMPLANTNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Breast Reconstruction19328REMOVAL OF BREAST IMPLANTNotification or Prior Authorization is not required for the following diagnosis codes: C50.019, C50.011, C50.012, C50.111, C50.112, C50.119, C50.211, C50.212, C50.219, C50.311, C50.312, C50.319, C50.411, C50.412, C50.419, C50.511, C50.512, C50.519, C50.611, C50.612, C50.619, C50.811, C50.812, C50.819, C50.911, C50.912, C50.919, C50.029, C50.021, C50.022, C50.121, C50.122, C50.129, C50.221, C50.222, C50.229, C50.321, C50.322, C50.329, C50.421, C50.422, C50.429, C50.521, C50.522, C50.529, C50.621, C50.622, C50.629, C50.821, C50.822, C50.829, C50.921, C50.922, C50.929, C79.81, D05.90, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.91, D05.92, Z85.3, Z90.10, Z90.11, Z90.12, Z90.13, Z42.1
Last updated: February 10, 2021