Date Posted: April 1, 2023
The following tables shows the code added to, and the codes removed from, the EmblemHealth Preauthorization List.
The following code has been added to the EmblemHealth Preauthorization List starting July 14, 2023.
Code Added to the Preauthorization List Starting July 14, 2023
CPT/HCPCS Code |
CPT Code Description |
|---|---|
76948 |
Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation |
The following codes are removed from the EmblemHealth Preauthorization List starting April 1, 2023.
Codes Removed from the Preauthorization List Starting April 1, 2023
CPT/HCPCS Code |
CPT Code Description |
|---|---|
10120
|
Incision and removal of foreign body, subcutaneous tissues; simple |
10140 |
Incision and drainage of hematoma, seroma, or fluid collection |
11400 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.5 cm or less |
11401 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.6 to 1.0 cm |
11402 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 1.1 to 2.0 cm |
11403 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 2.1 to 3.0 cm |
11404 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 3.1 to 4.0 cm |
11406 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter over 4.0 cm |
11420 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 0.5 cm or less |
11421 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 0.6 to 1.0 cm |
11422 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 1.1 to 2.0 cm |
11423 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 2.1 to 3.0 cm |
11424 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter 3.1 to 4.0 cm |
11426 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, or genitalia; excised diameter over 4.0 cm |
11442 |
Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, or mucous membrane; excised diameter 1.1 to 2.0 cm |
13101 |
Repair, complex, trunk; 2.6 cm to 7.5 cm |
13132 |
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm |
14040 |
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less |
14060 |
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less |
14301 |
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm |
19000 |
Puncture aspiration of cyst of breast |
20680 |
Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod, or plate) |
21320 |
Closed treatment of nasal bone fracture with manipulation; with stabilization |
21552 |
Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3.0 cm or greater |
21931 |
Excision, tumor, soft tissue of back or flank, subcutaneous; 3.0 cm or greater |
23470 |
Arthroplasty, glenohumeral joint; hemiarthroplasty |
23472 |
Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder)) |
23473 |
Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component |
23474 |
Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component |
24360 |
Arthroplasty, elbow; with membrane (e.g., fascial) |
24361 |
Arthroplasty, elbow; with distal humeral prosthetic replacement |
24362 |
Arthroplasty, elbow; with implant and fascia lata ligament reconstruction |
24363 |
Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow) |
24370 |
Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component |
24371 |
Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component |
27096 |
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed |
27120 |
Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type) |
27122 |
Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure) |
27125 |
Hemiarthroplasty, hip partial |
27130 |
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip replacement), with or without autograft or allograft |
27132 |
Conversation of previous hip surgery to total hip arthroplasty, both components with or without allograft or autograft |
27134 |
Revision of total hip arthroplasty; both components, with or without autograft or allograft |
27137 |
Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft |
27138 |
Revision of total hip arthroplasty; femoral component only, with or without allograft |
27437 |
Arthroplasty, patella; without prosthesis |
27438 |
Arthroplasty, patella; with prosthesis |
27440 |
Arthroplasty, knee, tibial plateau |
27441 |
Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy |
27442 |
Arthroplasty, femoral condyles, or tibial plateau(s), knee |
27443 |
Arthroplasty, femoral condyles, or tibial plateau(s), knee; with debridement and partial synovectomy |
27445 |
Arthroplasty, knee, hinge prosthesis (e.g., Walldius type) |
27446 |
Arthroplasty, knee, condyle, and plateau; medial OR lateral compartment |
27447 |
Arthroplasty, knee, condyle, and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) |
27486 |
Revision of total knee arthroplasty, with or without allograft; one component |
27487 |
Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component |
29830 |
Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) |
29835 |
Arthroscopy, elbow, surgical; synovectomy, partial |
29837 |
Arthroscopy, elbow, surgical; debridement, limited |
29840 |
Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) |
29843 |
Arthroscopy, wrist, surgical; for infection, lavage, and drainage |
29847 |
Arthroscopy, wrist, surgical; internal fixation for fracture or instability |
29860 |
Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) |
29861 |
Arthroscopy, hip, surgical; with removal of loose body or foreign body |
29862 |
Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum |
29863 |
Arthroscopy, hip, surgical; with synovectomy |
29885 |
Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) |
29886 |
Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion |
29899 |
Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis |
29914 |
Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion) |
29915 |
Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion) |
29916 |
Arthroscopy, hip, surgical; with labral repair |
30140 |
Submucous resection inferior turbinate, partial or complete, any method |
30520 |
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft |
31579 |
Laryngoscopy, flexible or rigid telescopic, with stroboscopy |
42821 |
Tonsillectomy and adenoidectomy; age 12 or over |
42825 |
Tonsillectomy, primary or secondary; younger than age 12 |
42826 |
Tonsillectomy, primary or secondary; age 12 or over |
42830 |
Adenoidectomy, primary; younger than age 12 |
43235 |
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
43239 |
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple |
43249 |
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) |
45300 |
Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) |
45330 |
Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
45378 |
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
45380 |
Colonoscopy, flexible; with biopsy, single or multiple |
45384 |
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps |
45385 |
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique |
46922 |
Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision |
47000 |
Biopsy of liver, needle; percutaneous |
49505 |
Repair initial inguinal hernia, age five years or older; reducible |
49650 |
Laparoscopy, surgical; repair initial inguinal hernia |
49651 |
Laparoscopy, surgical; repair recurrent inguinal hernia |
50590 |
Lithotripsy, extracorporeal shock wave |
52000 |
Cystourethroscopy (separate procedure) |
52005 |
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; |
52204 |
Cystourethroscopy, with biopsy(s) |
52224 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy |
52234 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) |
52235 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) |
52260 |
Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia |
52281 |
Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female |
52310 |
Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple |
52332 |
Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type) |
52351 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic |
52352 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) |
52353 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) |
52356 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type) |
54161 |
Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age |
55040 |
Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) |
55250 |
Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) |
55700 |
Biopsy, prostate; needle or punch, single or multiple, any approach |
57288 |
Sling operation for stress incontinence (e.g., fascia or synthetic) |
57460 |
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix |
57522 |
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision |
58152 |
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch) |
58267 |
Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control |
58270 |
Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele |
58275 |
Vaginal hysterectomy, with total or partial vaginectomy |
58280 |
Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele |
58294 |
Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele |
58353 |
Endometrial ablation, thermal, without hysteroscopic guidance |
58563 |
Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation) |
58565 |
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants |
64520 |
Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) |
64633 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint |
64635 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint |
64721 |
Neuroplasty and/or transposition; median nerve at carpal tunnel |
65426 |
Excision or transposition of pterygium; with graft |
65730 |
Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) Revised |
65855 |
Trabeculoplasty by laser surgery |
66170 |
Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae |
66761 |
Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (per session) |
66821 |
Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages) |
66982 |
Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage |
66984 |
Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification) |
67028 |
Intravitreal injection of a pharmacologic agent (separate procedure) |
67036 |
Vitrectomy, mechanical, pars plana approach |
67040 |
Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation |
67228 |
Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation |
67311 |
Strabismus surgery, recession or resection procedure; one horizontal muscle |
67312 |
Strabismus surgery, recession or resection procedure; two horizontal muscles |
69436 |
Tympanostomy (requiring insertion of ventilating tube), general anesthesia |
69631 |
Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction |
93593 |
Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; normal native connections |
93594 |
Right heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone; abnormal native connections |
93596 |
Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); normal native connections |
93597 |
Right and left heart catheterization for congenital heart defect(s) including imaging guidance by the proceduralist to advance the catheter to the target zone(s); abnormal native connections |
94625 |
Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session) |
94626 |
Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session) |