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Inpatient Only Code00176Anesth pharyngeal surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00192Anesth facial bone surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00211Anesth cran surg hemotomaHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00214Anesth skull drainageHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00215Anesth skull repair/fractHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00474Anesth surgery of ribHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00524Anesth chest drainageHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00540Anesth chest surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00542Anesthesia removal pleuraHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00546Anesth lung chest wall surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00560Anesth heart surg w/o pumpHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00561Anesth heart surg <1 yrHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00562Anesth hrt surg w/pmp age 1+HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00567Anesth cabg w/pumpHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00580Anesth heart/lung transplntHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00604Anesth sitting procedureHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00632Anesth removal of nervesHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00792Anesth hemorr/excise liverHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00794Anesth pancreas removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00796Anesth for liver transplantHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00844Anesth pelvis surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00846Anesth hysterectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00848Anesth pelvic organ surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00864Anesth removal of bladderHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00866Anesth removal of adrenalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00868Anesth kidney transplantHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00882Anesth major vein ligationHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00904Anesth perineal surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00908Anesth removal of prostateHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00932Anesth amputation of penisHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00934Anesth penis nodes removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code00936Anesth penis nodes removalHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01140Anesth amputation at pelvisHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01150Anesth pelvic tumor surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01212Anesth hip disarticulationHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01232Anesth amputation of femurHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01234Anesth radical femur surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01272Anesth femoral artery surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01274Anesth femoral embolectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01404Anesth amputation at kneeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01442Anesth knee artery surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01444Anesth knee artery repairHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01502Anesth lwr leg embolectomyHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01634Anesth shoulder joint amputHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01636Anesth forequarter amputHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01652Anesth shoulder vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01654Anesth shoulder vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01656Anesth arm-leg vessel surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01756Anesth radical humerus surgHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code01990Support for organ donorHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code11004Debride genitalia & perineumHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code11005Debride abdom wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code11006Debride genit/per/abdom wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code11008Remove mesh from abd wallHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
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
Cosmetic & Reconstructive15821REVISION OF LOWER EYELIDPreauth required for such services whether scheduled as inpatient or outpatient.
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 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 Services15100SKIN SPLT GRFT TRNK/ARM/LEG 
Other Services15120SKN SPLT A-GRFT FAC/NCK/HF/G 
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 2022
Inpatient Only Code15757Free skin flap microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code15758Free fascial flap microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
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 & 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.
Cosmetic & Reconstructive15877Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15878Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive15879Cosmetic 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 functionPreauth required for such services whether scheduled as inpatient or outpatient.
Inpatient Only Code16036Escharotomy addl incisionHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
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.
Cosmetic & Reconstructive17999SKIN TISSUE PROCEDUREPreauth required for such services whether scheduled as inpatient or outpatient.
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 2022
Inpatient Only Code19306Mast rad urban typeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
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
Inpatient Only Code20956Iliac bone graft microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20957Mt bone graft microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20962Other bone graft microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
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 Services19324ENLARGE BREAST 
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
Breast Reconstruction19330REMOVAL OF IMPLANT MATERIALNotification 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 Reconstruction19340IMMEDIATE BREAST PROSTHESISNotification 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 Reconstruction19342DELAYED BREAST PROSTHESISNotification 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 Reconstruction19350BREAST RECONSTRUCTIONNotification 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 Reconstruction19357BREAST RECONSTRUCTIONNotification 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 Code19361Brst rcnstj latsms drsi flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code19364Brst rcnstj free flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code19367Brst rcnstj 1 pdcl tram flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code19368Brst rcnstj 1pdcl tram anastHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code19369Brst rcnstj 2 pdcl tram flapHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Breast Reconstruction19370SURGERY OF BREAST CAPSULENotification 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 Code20969Bone/skin graft microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20970Bone/skin graft iliac crestHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Breast Reconstruction19371REMOVAL OF BREAST CAPSULENotification 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 Reconstruction19380REVISE BREAST RECONSTRUCTIONNotification 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 Reconstruction19396DESIGN CUSTOM 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
Other Services20205DEEP MUSCLE BIOPSY 
Other Services20206NEEDLE BIOPSY MUSCLE 
Other Services20220BONE BIOPSY TROCAR/NEEDLE 
Other Services20240BONE BIOPSY OPEN SUPERFICIAL 
Other Services20245BONE BIOPSY OPEN DEEP 
Inpatient Only Code20661Application of head braceHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20664Application of haloHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20802Replantation arm completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20805Replant forearm completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20808Replantation hand completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20816Replantation digit completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20824Replantation thumb completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20827Replantation thumb completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code20838Replantation foot completeHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services20930SP BONE ALGRFT MORSEL ADD-ON 
Other Services20931SP BONE ALGRFT STRUCT ADD-ON 
Spine Surgery20939  
Inpatient Only Code20955Fibula bone graft microvascHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services20974ELECTRICAL BONE STIMULATION 
Other Services20975ELECTRICAL BONE STIMULATION 
Other Services20979US BONE STIMULATION 
Other Services21040EXCISE MANDIBLE LESION 
Inpatient Only Code21045Extensive jaw surgeryHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services21120RECONSTRUCTION OF CHIN 
Other Services21121RECONSTRUCTION OF CHIN 
Other Services21122RECONSTRUCTION OF CHIN 
Other Services21123RECONSTRUCTION OF CHIN 
Other Services21125AUGMENTATION LOWER JAW BONE 
Other Services21127AUGMENTATION LOWER JAW BONE 
Inpatient Only Code21141Lefort i-1 piece w/o graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21142Lefort i-2 piece w/o graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21143Lefort i-3/> piece w/o graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21145Lefort i-1 piece w/ graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21146Lefort i-2 piece w/ graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21147Lefort i-3/> piece w/ graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services21150LEFORT II ANTERIOR INTRUSION 
Inpatient Only Code21151Lefort ii w/bone graftsHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21154Lefort iii w/o lefort iHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21155Lefort iii w/ lefort iHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21159Lefort iii w/fhdw/o lefort iHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21160Lefort iii w/fhd w/ lefort iHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Cosmetic & Reconstructive21172RECONSTRUCT ORBIT/FOREHEADPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21175RECONSTRUCT ORBIT/FOREHEADPreauth required for such services whether scheduled as inpatient or outpatient.
Inpatient Only Code21179Reconstruct entire foreheadHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21180Reconstruct entire foreheadHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Cosmetic & Reconstructive21181CONTOUR CRANIAL BONE LESIONPreauth required for such services whether scheduled as inpatient or outpatient.
Inpatient Only Code21182Reconstruct cranial boneHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21183Reconstruct cranial boneHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21184Reconstruct cranial boneHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Inpatient Only Code21188Reconstruction of midfaceHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services21193RECONST LWR JAW W/O GRAFT 
Inpatient Only Code21194Reconst lwr jaw w/graftHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services21195RECONST LWR JAW W/O FIXATION 
Inpatient Only Code21196Reconst lwr jaw w/fixationHCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2022
Other Services21198RECONSTR LWR JAW SEGMENT 
Other Services21199RECONSTR LWR JAW W/ADVANCE 
Other Services21206RECONSTRUCT UPPER JAW BONE 
Other Services21210FACE BONE GRAFT 
Other Services21215LOWER JAW BONE GRAFT 
Cosmetic & Reconstructive21230RIB CARTILAGE GRAFTPreauth required for such services whether scheduled as inpatient or outpatient.
Cosmetic & Reconstructive21235EAR CARTILAGE GRAFTPreauth required for such services whether scheduled as inpatient or outpatient.
Other Services21240RECONSTRUCTION OF JAW JOINT 
Other Services21242RECONSTRUCTION OF JAW JOINT 
Other Services21244RECONSTRUCTION OF LOWER JAW