![]() Coverage is determined by the member specific benefit plan document and any applicable laws regarding coverage of specific services. Inclusion of a procedure or device code(s) does not constitute or imply coverage nor does it imply or guarantee provider reimbursement. These lists are modified periodically with appropriate notice of these changes consistent with state and federal requirements. In addition, inclusion on this list indicates, if covered the code would require prior authorization for coverage. It does not indicate/list codes which may be excluded from coverage or not covered for other reasons. This document is intended only to provide information related to which CPT/HCPCs codes require prior authorization. ![]() ![]() CPT® is a registered trademark of the American Medical Association. ![]() CPT Copyright 2017 American Medical Association. ![]()
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