    
Inpatient Only Code  00176  Anesth pharyngeal surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00192  Anesth facial bone surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00211  Anesth cran surg hemotoma  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00214  Anesth skull drainage  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00215  Anesth skull repair/fract  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00474  Anesth surgery of rib  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00524  Anesth chest drainage  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00540  Anesth chest surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00542  Anesthesia removal pleura  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00546  Anesth lung chest wall surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00560  Anesth heart surg w/o pump  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00561  Anesth heart surg <1 yr  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00562  Anesth hrt surg w/pmp age 1+  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00567  Anesth cabg w/pump  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00580  Anesth heart/lung transplnt  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00604  Anesth sitting procedure  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00632  Anesth removal of nerves  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00792  Anesth hemorr/excise liver  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00794  Anesth pancreas removal  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00796  Anesth for liver transplant  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00844  Anesth pelvis surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00846  Anesth hysterectomy  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00848  Anesth pelvic organ surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00864  Anesth removal of bladder  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00866  Anesth removal of adrenal  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00868  Anesth kidney transplant  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00882  Anesth major vein ligation  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00904  Anesth perineal surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00908  Anesth removal of prostate  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00932  Anesth amputation of penis  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00934  Anesth penis nodes removal  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  00936  Anesth penis nodes removal  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01140  Anesth amputation at pelvis  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01150  Anesth pelvic tumor surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01212  Anesth hip disarticulation  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01232  Anesth amputation of femur  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01234  Anesth radical femur surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01272  Anesth femoral artery surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01274  Anesth femoral embolectomy  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01404  Anesth amputation at knee  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01442  Anesth knee artery surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01444  Anesth knee artery repair  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01502  Anesth lwr leg embolectomy  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01634  Anesth shoulder joint amput  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01636  Anesth forequarter amput  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01652  Anesth shoulder vessel surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01654  Anesth shoulder vessel surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01656  Anesth armleg vessel surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01756  Anesth radical humerus surg  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  01990  Support for organ donor  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  11004  Debride genitalia & perineum  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  11005  Debride abdom wall  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  11006  Debride genit/per/abdom wall  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  11008  Remove mesh from abd wall  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Breast Reconstruction  11920  CORRECT 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  
Cosmetic & Reconstructive  15820  REVISION OF LOWER EYELID  Preauth required for such services whether scheduled as inpatient or outpatient.  
Breast Reconstruction  11921  CORRECT SKN COLOR 6.120.0CM  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 Reconstruction  11922  CORRECT SKIN COLOR EA 20.0CM  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  
Cosmetic & Reconstructive  11960  INSERT TISSUE EXPANDER(S)  Preauth required for such services whether scheduled as inpatient or outpatient.  
Other Services  11970  REPLACE TISSUE EXPANDER   
Cosmetic & Reconstructive  11971  REMOVE TISSUE EXPANDER(S)  Preauth required for such services whether scheduled as inpatient or outpatient.  
Other Services  11980  IMPLANT HORMONE PELLET(S)   
Other Services  11981  INSERT DRUG IMPLANT DEVICE   
Other Services  14000  TIS TRNFR TRUNK 10 SQ CM/<   
Other Services  14001  TIS TRNFR TRUNK 10.130SQCM   
Other Services  14020  TIS TRNFR S/A/L 10 SQ CM/<   
Other Services  14021  TIS TRNFR S/A/L 10.130 SQCM   
Other Services  14040  TIS TRNFR F/C/C/M/N/A/G/H/F   
Other Services  14041  TIS TRNFR F/C/C/M/N/A/G/H/F   
Other Services  14060  TIS TRNFR E/N/E/L 10 SQ CM/<   
Other Services  14061  TIS TRNFR E/N/E/L10.130SQCM   
Other Services  14301  TIS TRNFR ANY 30.160 SQ CM   
Other Services  14302  TIS TRNFR ADDL 30 SQ CM   
Other Services  15100  SKIN SPLT GRFT TRNK/ARM/LEG   
Other Services  15120  SKN SPLT AGRFT FAC/NCK/HF/G   
Other Services  15734  MUSCLESKIN GRAFT TRUNK   
Other Services  15736  MUSCLESKIN GRAFT ARM   
Other Services  15738  MUSCLESKIN GRAFT LEG   
Other Services  15750  NEUROVASCULAR PEDICLE FLAP   
Inpatient Only Code  15756  Free myo/skin flap microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  15757  Free skin flap microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  15758  Free fascial flap microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  15770  DERMAFATFASCIA GRAFT   
Other Services  15775  HAIR TRNSPL 115 PUNCH GRFTS   
Other Services  15776  HAIR TRNSPL >15 PUNCH GRAFTS   
Inpatient Only Code  15778  Impl absrb msh/prsth dly cls  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  15780  DERMABRASION TOTAL FACE   
Other Services  15781  DERMABRASION SEGMENTAL FACE   
Other Services  15782  DERMABRASION OTHER THAN FACE   
Other Services  15783  DERMABRASION SUPRFL ANY SITE   
Other Services  15788  CHEMICAL PEEL FACE EPIDERM   
Other Services  15789  CHEMICAL PEEL FACE DERMAL   
Other Services  15792  CHEMICAL PEEL NONFACIAL   
Other Services  15793  CHEMICAL PEEL NONFACIAL   
Cosmetic & Reconstructive  15821  REVISION OF LOWER EYELID  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15822  REVISION OF UPPER EYELID  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15823  REVISION OF UPPER EYELID  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15830  EXC SKIN ABD  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15847  EXC SKIN ABD ADDON  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15877  Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15878  Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  15879  Cosmetic procedures that change or improve physical appearance, without significantly improving or restoring physiological function Reconstructive procedures that either treat a medical condition or improve or restore physiologic function  Preauth required for such services whether scheduled as inpatient or outpatient.  
Inpatient Only Code  16036  Escharotomy addl incision  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  17004  DESTROY PREMAL LESIONS 15/>   
Cosmetic & Reconstructive  17106  DESTRUCTION OF SKIN LESIONS  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  17107  DESTRUCTION OF SKIN LESIONS  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  17108  DESTRUCTION OF SKIN LESIONS  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  17999  SKIN TISSUE PROCEDURE  Preauth required for such services whether scheduled as inpatient or outpatient.  
Other Services  19281  PERQ DEVICE BREAST 1ST IMAG   
Other Services  19303  MAST SIMPLE COMPLETE   
Inpatient Only Code  19305  Mast radical  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  19306  Mast rad urban type  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  19307  MAST MOD RAD   
Breast Reconstruction  19316  SUSPENSION OF BREAST  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  
Inpatient Only Code  20956  Iliac bone graft microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20957  Mt bone graft microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Breast Reconstruction  19318  REDUCTION OF LARGE BREAST  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  
Other Services  19324  ENLARGE BREAST   
Breast Reconstruction  19325  ENLARGE BREAST WITH IMPLANT  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 Reconstruction  19328  REMOVAL OF BREAST IMPLANT  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 Reconstruction  19330  REMOVAL OF IMPLANT MATERIAL  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 Reconstruction  19340  IMMEDIATE BREAST PROSTHESIS  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 Reconstruction  19342  DELAYED BREAST PROSTHESIS  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 Reconstruction  19350  BREAST RECONSTRUCTION  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 Reconstruction  19357  BREAST RECONSTRUCTION  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  
Inpatient Only Code  19361  Brst rcnstj latsms drsi flap  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  19364  Brst rcnstj free flap  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  19367  Brst rcnstj 1 pdcl tram flap  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  19368  Brst rcnstj 1pdcl tram anast  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  19369  Brst rcnstj 2 pdcl tram flap  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Breast Reconstruction  19370  SURGERY OF BREAST CAPSULE  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  
Inpatient Only Code  20962  Other bone graft microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20969  Bone/skin graft microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Breast Reconstruction  19371  REMOVAL OF BREAST CAPSULE  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 Reconstruction  19380  REVISE BREAST RECONSTRUCTION  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 Reconstruction  19396  DESIGN CUSTOM BREAST IMPLANT  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  
Other Services  20205  DEEP MUSCLE BIOPSY   
Other Services  20206  NEEDLE BIOPSY MUSCLE   
Other Services  20220  BONE BIOPSY TROCAR/NEEDLE   
Other Services  20240  BONE BIOPSY OPEN SUPERFICIAL   
Other Services  20245  BONE BIOPSY OPEN DEEP   
Inpatient Only Code  20661  Application of head brace  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20664  Application of halo  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20802  Replantation arm complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20805  Replant forearm complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20808  Replantation hand complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20816  Replantation digit complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20824  Replantation thumb complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20827  Replantation thumb complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20838  Replantation foot complete  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  20930  SP BONE ALGRFT MORSEL ADDON   
Other Services  20931  SP BONE ALGRFT STRUCT ADDON   
Spine Surgery  20939    
Inpatient Only Code  20955  Fibula bone graft microvasc  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  20970  Bone/skin graft iliac crest  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  20974  ELECTRICAL BONE STIMULATION   
Other Services  21040  EXCISE MANDIBLE LESION   
Inpatient Only Code  21045  Extensive jaw surgery  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  21120  RECONSTRUCTION OF CHIN   
Other Services  21121  RECONSTRUCTION OF CHIN   
Other Services  21122  RECONSTRUCTION OF CHIN   
Other Services  21123  RECONSTRUCTION OF CHIN   
Other Services  21125  AUGMENTATION LOWER JAW BONE   
Other Services  21127  AUGMENTATION LOWER JAW BONE   
Inpatient Only Code  21145  Lefort i1 piece w/ graft  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21146  Lefort i2 piece w/ graft  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21147  Lefort i3/> piece w/ graft  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  21150  LEFORT II ANTERIOR INTRUSION   
Inpatient Only Code  21151  Lefort ii w/bone grafts  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21154  Lefort iii w/o lefort i  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21155  Lefort iii w/ lefort i  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21159  Lefort iii w/fhdw/o lefort i  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21160  Lefort iii w/fhd w/ lefort i  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Cosmetic & Reconstructive  21172  RECONSTRUCT ORBIT/FOREHEAD  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  21175  RECONSTRUCT ORBIT/FOREHEAD  Preauth required for such services whether scheduled as inpatient or outpatient.  
Inpatient Only Code  21179  Reconstruct entire forehead  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21180  Reconstruct entire forehead  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Cosmetic & Reconstructive  21181  CONTOUR CRANIAL BONE LESION  Preauth required for such services whether scheduled as inpatient or outpatient.  
Inpatient Only Code  21182  Reconstruct cranial bone  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21183  Reconstruct cranial bone  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21184  Reconstruct cranial bone  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Inpatient Only Code  21188  Reconstruction of midface  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Other Services  21193  RECONST LWR JAW W/O GRAFT   
Other Services  21195  RECONST LWR JAW W/O FIXATION   
Other Services  21198  RECONSTR LWR JAW SEGMENT   
Other Services  21199  RECONSTR LWR JAW W/ADVANCE   
Other Services  21206  RECONSTRUCT UPPER JAW BONE   
Other Services  21210  FACE BONE GRAFT   
Other Services  21215  LOWER JAW BONE GRAFT   
Cosmetic & Reconstructive  21230  RIB CARTILAGE GRAFT  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  21235  EAR CARTILAGE GRAFT  Preauth required for such services whether scheduled as inpatient or outpatient.  
Other Services  21240  RECONSTRUCTION OF JAW JOINT   
Other Services  21242  RECONSTRUCTION OF JAW JOINT   
Other Services  21244  RECONSTRUCTION OF LOWER JAW   
Other Services  21245  RECONSTRUCTION OF JAW   
Other Services  21246  RECONSTRUCTION OF JAW   
Inpatient Only Code  21247  Reconstruct lower jaw bone  HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2023  
Cosmetic & Reconstructive  21248  RECONSTRUCTION OF JAW  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  21249  RECONSTRUCTION OF JAW  Preauth required for such services whether scheduled as inpatient or outpatient.  
Cosmetic & Reconstructive  21256  RECONSTRUCTION OF ORBIT  Preauth required for such services whether scheduled as inpatient or outpatient.  
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