UNITED HEALTHCARE


Breast Reconstruction Prior Authorization DX Code List

UHC Breast Reconstruction Codes: CPT Codes - 11920, 11921, 11922, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19370, 19371, 19380, 19396, L8600 do NOT require prior authorization for the below Dx codes
Effective date: Feb 1, 2023

Code Not filtered
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C50.019
C50.112
C50.219
C50.411
C50.512
C50.619
C50.911
C50.021
C50.129
C50.321
C50.422
C50.529
C50.821
C50.922
D05.00
D05.11
D05.82
Z90.10
Z42.1
C50.011
C50.119
C50.311
C50.412
C50.519
C50.811
C50.912
C50.022
C50.221
C50.322
C50.429
C50.621
C50.822
C50.929
D05.01
D05.12
D05.91
Z90.11
 
C50.012
C50.211
C50.312
C50.419
C50.611
C50.812
C50.919
C50.121
C50.222
C50.329
C50.521
C50.622
C50.829
C79.81
D05.02
D05.80
D05.92
Z90.12
 
C50.111
C50.212
C50.319
C50.511
C50.612
C50.819
C50.029
C50.122
C50.229
C50.421
C50.522
C50.629
C50.921
D05.90
D05.10
D05.81
Z85.3
Z90.13
 

Last updated: Mar 7, 2022