Humana

Prior Authorization Required Code List

***If service or procedure is being performed inpatient, prior authorization is required***
***Prior authorization is NOT required when drug administered as an Inpatient or in the ED or Urgent Care Clinic***
***All chemotherapy drugs require prior authorization***

Service Category Not filtered
Code Not filtered
Rules/Description Not filtered
Notes Not filtered
Open filter row popup menu
Open filter row popup menu
Open filter row popup menu
Open filter row popup menu
Breast procedures19301Breast Lumpectomy 
Viscosupplementation (Musculokeletal)20610  
Viscosupplementation (Musculokeletal)20611  
Orthopedic surgeries: hip, knee and shoulder arthroscopy27299  
Foot surgeries: bunionectomy and hammertoe28110  
Lung biopsy and resection32607  
Cardiac Devices33244Cardiac implantable devices [e.g., pacemakers, leadless pacemaker. Left atrial appendage closure (LAAC), defibrillators (implantable and subcutaneous) and cardiac resynchronization therapy] 
Cardiac Devices33286Loop recorders 
Esophagogastroduodenoscopy (EGD)43235  
Esophagogastroduodenoscopy (EGD)43237  
Esophagogastroduodenoscopy (EGD)43238  
Esophagogastroduodenoscopy (EGD)43239  
Esophagogastroduodenoscopy (EGD)43242  
Esophagogastroduodenoscopy (EGD)43252  
Esophagogastroduodenoscopy (EGD)43253  
Esophagogastroduodenoscopy (EGD)43259  
Colonoscopy45378 Repeat only, not initial
Ablation47382 Includes cardic ablation for bone, liver, kidney and prostate cancer
Ablation50541 Includes cardic ablation for bone, liver, kidney and prostate cancer
Ablation50542 Includes cardic ablation for bone, liver, kidney and prostate cancer
Infertility testing and treatment58555  
Thyroid surgeries (thyroidectomy and lobectomy)60210  
Thyroid surgeries (thyroidectomy and lobectomy)60220  
Neurostimulators64566  
Diagnostic/cardiac imaging70554Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imaging71551Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imaging71555Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imaging72159Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imaging73206Computed tomography (CT) scan 
Diagnostic/cardiac imaging73219Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imaging74176Computed tomography (CT) scan 
Diagnostic/cardiac imaging74262Computed tomography (CT) scan 
Diagnostic/cardiac imaging75559Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imaging75563Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imaging75573Computed tomography (CT) scan 
Infertility testing and treatment76856  
Diagnostic/cardiac imaging77084Magnetic resonance imaging (MRI) 
Radiation therapy77771  
Diagnostic/cardiac imaging78454Nuclear stress test 
Diagnostic/cardiac imaging78466Nuclear stress test 
Diagnostic/cardiac imaging78468Nuclear stress test 
Diagnostic/cardiac imaging78469Nuclear stress test 
Diagnostic/cardiac imaging78473Nuclear stress test 
Diagnostic/cardiac imaging78481Nuclear stress test 
Diagnostic/cardiac imaging78483Nuclear stress test 
Diagnostic/cardiac imaging78494Single photon emission computerized tomgraphy (SPECT) scan 
Molecular diagnostic/genetic testing81240  
Molecular diagnostic/genetic testing81241  
Molecular diagnostic/genetic testing81301  
Molecular diagnostic/genetic testing81518  
Cardiac Procedures/Surgeries92928Outpantient coronary angioplasty/stent 
Cardiac Devices93228Wearable cardiac devices (e.g., LifeVest) 
Cardiac Devices93229Wearable cardiac devices (e.g., LifeVest) 
Diagnostic/cardiac imaging93318Transesophageal echocardiogram (TEE) 
Diagnostic/cardiac imaging93618Electrophysicology (EPS) or EPS with 3D mapping 
Diagnostic/cardiac imaging93620Electrophysicology (EPS) or EPS with 3D mapping 
Diagnostic/cardiac imaging93642Electrophysicology (EPS) or EPS with 3D mapping 
Ablation93653Includes cardic ablation for bone, liver, kidney and prostate cancer 
Facility-based sleep studies(PSG)95807  
Facility-based sleep studies(PSG)95808  
Facility-based sleep studies(PSG)95810  
Facility-based sleep studies(PSG)95811  
Therapy (physical speech and occupational)97010  
Therapy (physical speech and occupational)97542  
Negative pressure wound therapy (NPWT)97605  
Micro Invasive Glaucoma Surgery (MIGs)0191T  
Micro Invasive Glaucoma Surgery (MIGs)0449T  
Negative pressure wound therapy (NPWT)A6550  
ProstheticsA9282  
Diagnostic/cardiac imagingC8900Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8901Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8902Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8903Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imagingC8905Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imagingC8906Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imagingC8908Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imagingC8909Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8910Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8911Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8912Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8913Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8918Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8919Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8920Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8921Outpatient transthoracic echocardiogram 
Diagnostic/cardiac imagingC8922Outpatient transthoracic echocardiogram 
Diagnostic/cardiac imagingC8923Outpatient transthoracic echocardiogram 
Diagnostic/cardiac imagingC8924Outpatient transthoracic echocardiogram 
Diagnostic/cardiac imagingC8925Transesophageal echocardiogram (TEE) 
Diagnostic/cardiac imagingC8926Transesophageal echocardiogram (TEE) 
Diagnostic/cardiac imagingC8927Transesophageal echocardiogram (TEE) 
Diagnostic/cardiac imagingC8928Nuclear stress test 
Diagnostic/cardiac imagingC8929Outpatient transthoracic echocardiogram 
Diagnostic/cardiac imagingC8930Nuclear stress test 
Diagnostic/cardiac imagingC8931Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8932Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8933Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8934Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8935Magnetic resonance angiogram (MRA) 
Diagnostic/cardiac imagingC8936Magnetic resonance angiogram (MRA) 
Specialty DrugsC9257  
Specialty DrugsC9399  
Other durable medical equipment (DME)E0371  
Other durable medical equipment (DME)E0912  
Wheelchairs/scootersE2359  
DME Negative Pressure Wound TherapyE2402  
Specialty DrugsJ9035  
Specialty DrugsJ9400  
Other durable medical equipment (DME)K0553  
Other durable medical equipment (DME)K0554  
Other durable medical equipment (DME)L1843  
Other durable medical equipment (DME)L1845  
Other durable medical equipment (DME)L1846  
Other durable medical equipment (DME)L1851  
ProstheticsL5000  
Ventricular assist devices (VADs)Q0477Ventricular assist devides (VADs) 
Ventricular assist devices (VADs)Q0508Ventricular assist devides (VADs) 
Skin and tissue substitutesQ4101  
Skin and tissue substitutesQ4106  
Skin and tissue substitutesQ4110  
Skin and tissue substitutesQ4121  
Skin and tissue substitutesQ4132  
Skin and tissue substitutesQ4133  
Skin and tissue substitutesQ4160  
Diagnostic/cardiac imagingS8037Magnetic resonance imaging (MRI) 
Diagnostic/cardiac imagingS8042Magnetic resonance imaging (MRI) 
Breast procedures11971Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Blepharoplasty15820  
Blepharoplasty15821  
Blepharoplasty15822  
Blepharoplasty15823  
Abdominoplasty15830  
Abdominoplasty15847  
Cautaneous Vascular Lesion Removal17106  
Cautaneous Vascular Lesion Removal17107  
Cautaneous Vascular Lesion Removal17108  
Breast procedures19120Brest Cancer Biopsy (excisional) 
Breast procedures19125  
Breast procedures19300Simple mastectomy and gynecomastia surgery (excludes radical and modified) 
Breast procedures19302Breast Lumpectomy 
Breast procedures19303Simple mastectomy and gynecomastia surgery (excludes radical and modified) 
Breast procedures19316Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19318Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19324Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19325Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19328Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19330Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19340Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19342Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19350Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19357Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19366Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19370Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19371Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Breast procedures19380Other breast procedures (excludes breast reconstruction following medically necessary mastectomies for breast cancer) 
Oral, orthognathic, temporomandibular joint (TMJ) surgeries20910  
Bone growth stimulators20974  
Bone growth stimulators20975  
Bone growth stimulators20979  
Ablation20982Includes cardic ablation for bone, liver, kidney and prostate cancer 
Ablation20983Includes cardic ablation for bone, liver, kidney and prostate cancer 
Spinal fusion, decompression, kyphoplasty and vertebroplasty20999  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21010  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21050  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21060  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21070  
Prosthetics21081  
Prosthetics21082  
Prosthetics21084  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21085  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21100  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21110  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21116  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21125  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21127  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21141  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21142  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21143  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21145  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21146  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21147  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21150  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21151  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21154  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21155  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21159  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21160  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21188  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21193  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21194  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21195  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21196  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21198  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21199  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21206  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21208  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21210  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21215  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21240  
Oral, orthognathic, temporomandibular joint (TMJ) surgeries21242  
Last updated: February 10, 2021