medical products and services requiring …...medical products and services requiring notification...
TRANSCRIPT
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
1
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA Ambulance or other transportation services for non-emergent reasons
PA Chiropractic Services (after 20 visits)
PA Occupational Therapy (after 30 visits)
PA Orthotics & Prosthetics with billed amount exceeding $15,000
PA Outpatient: Out-of-network services
PA Physical Therapy (after 30 visits)
PA Speech Therapy (after 30 visits)
PA Transition or Continuity of Care
PA Transplantation Services
PA 21 Place of Service
Inpatient Hospital
0-5 days length of stay, in-network: notification only
6 days or more length of stay, in-network: preauthorization
**Out of network requires preauthorization for any length of stay
PA 31 Place of Service Skil led Nursing Facility
Notification 34 Place of Service Hospice
PA 51 Place of Service
Inpatient Psychiatric Facility
0-5 days length of stay, in-network: notification only
6 days or more length of stay, in-network: preauthorization
**Out of network requires preauthorization for any length of stay
PA 55 Place of Service Residential Substance Abuse Treatment Facility
PA 56 Place of Service Psychiatric Residential Treatment Center
PA 61 Place of Service Comprehensive Inpatient Rehabilitation Facility
PA 15769 CPT Grafting of autologous soft tissue, other, harvested by direct excision
(eg, fat, dermis, fascia)
PA 15771 CPT Grafting of autologous fat harvested by liposuction technique to trunk,
breasts, scalp, arms, and/or legs; 50 cc or less injectate
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
2
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 15772 CPT
Grafting of autologous fat harvested by liposuction technique to trunk,
breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or
part thereof (List separately in addition to code for primary procedure)
PA 15773 CPT
Grafting of autologous fat harvested by liposuction technique to face,
eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc
or less injectate
PA 15774 CPT
Grafting of autologous fat harvested by liposuction technique to face,
eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each
additional 25 cc injectate, or part thereof (List separately in addition to
code for primary procedure)
PA 15830 CPT Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy
PA 15877 CPT Suction assisted lipectomy; trunk
PA 19318 CPT Reduction mammaplasty
PA 20932 CPT
Allograft, includes templating, cutting, placement and internal fixation,
when performed; osteoarticular, including articular surface and
contiguous bone (List separately in addition to code for primary
procedure)
PA 20933 CPT
Allograft, includes templating, cutting, placement and internal fixation,
when performed; hemicortical intercalary, partial (ie, hemicylindrical)
(List separately in addition to code for primary procedure)
PA 20934 CPT
Allograft, includes templating, cutting, placement and internal fixation,
when performed; intercalary, complete (ie, cylindrical) (List separately
in addition to code for primary procedure)
PA 20974 CPT Electrical stimulation to aid bone healing; noninvasive (nonoperative)
PA 20975 CPT Electrical stimulation to aid bone healing; invasive (operative)
PA 20979 CPT Low intensity ultrasound stimulation to aid bone healing, noninvasive
(nonoperative)
PA 22548 CPT Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2
(atlas-axis), with or without excision of odontoid process
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
3
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 22551 CPT
Arthrodesis, anterior interbody, including disc space preparation,
discectomy, osteophytectomy and decompression of spinal cord
and/or nerve roots; cervical below C2
PA 22552 CPT
Arthrodesis, anterior interbody, including disc space preparation,
discectomy, osteophytectomy and decompression of spinal cord
and/or nerve roots; cervical below C2, each additional interspace (List
separately in addition to code for separate procedure)
PA 22554 CPT
Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
cervical below C2
PA 22556 CPT
Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
thoracic
PA 22558 CPT
Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
lumbar
PA 22585 CPT
Arthrodesis, anterior interbody technique, including minimal
discectomy to prepare interspace (other than for decompression);
each additional interspace (List separately in addition to code for
primary procedure)
PA 22590 CPT Arthrodesis, posterior technique, craniocervical (occiput-C2)
PA 22595 CPT Arthrodesis, posterior technique, atlas-axis (C1-C2)
PA 22600 CPT Arthrodesis, posterior or posterolateral technique, single level; cervical
below C2 segment
PA 22610 CPT Arthrodesis, posterior or posterolateral technique, single level;
thoracic (with lateral transverse technique, when performed)
PA 22612 CPT Arthrodesis, posterior or posterolateral technique, single level; lumbar
(with lateral transverse technique, when performed)
PA 22614 CPT
Arthrodesis, posterior or posterolateral technique, single level; each
additional vertebral segment (List separately in addition to code for
primary procedure)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
4
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 22630 CPT
Arthrodesis, posterior interbody technique, including laminectomy
and/or discectomy to prepare interspace (other than for
decompression), single interspace; lumbar
PA 22632 CPT
Arthrodesis, posterior interbody technique, including laminectomy
and/or discectomy to prepare interspace (other than for
decompression), single interspace; each additional interspace (List
separately in addition to code for primary procedure)
PA 22633 CPT
Arthrodesis, combined posterior or posterolateral technique with
posterior interbody technique including laminectomy and/or
discectomy sufficient to prepare interspace (other than for
decompression), single interspace and segment; lumbar
PA 22634 CPT
Arthrodesis, combined posterior or posterolateral technique with
posterior interbody technique including laminectomy and/or
discectomy sufficient to prepare interspace (other than for
decompression), single interspace and segment; each additional
interspace and segment (List separately in addition to code for primary
procedure)
PA 22800 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; up to
6 vertebral segments
PA 22802 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to
12 vertebral segments
PA 22804 CPT Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or
more vertebral segments
PA 22808 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3
vertebral segments
PA 22810 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7
vertebral segments
PA 22812 CPT Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or
more vertebral segments
PA 22856 CPT
Total disc arthroplasty (artificial disc), anterior approach, including
discectomy with end plate preparation (includes osteophytectomy for
nerve root or spinal cord decompression and microdissection); single
interspace, cervical
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
5
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 22857 CPT
Total disc arthroplasty (artificial disc), anterior approach, including
discectomy to prepare interspace (other than for decompression),
single interspace, lumbar
PA 22858 CPT
Total disc arthroplasty (artificial disc), anterior approach, including
discectomy with end plate preparation (includes osteophytectomy for
nerve root or spinal cord decompression and microdissection); second
level, cervical (List separately in addition to code for primary
procedure)
PA 22861 CPT Revision including replacement of total disc arthroplasty (artificial
disc), anterior approach, single interspace; cervical
PA 22862 CPT Revision including replacement of total disc arthroplasty (artificial
disc), anterior approach, single interspace; lumbar
PA 22864 CPT Removal of total disc arthroplasty (artificial disc), anterior approach,
single interspace; cervical
PA 22865 CPT Removal of total disc arthroplasty (artificial disc), anterior approach,
single interspace; lumbar
PA 27412 CPT Autologous chondrocyte implantation, knee
PA 33285 CPT Insertion, subcutaneous cardiac rhythm monitor, including
programming
PA 33286 CPT Removal, subcutaneous cardiac rhythm monitor
PA 42160 CPT Destruction of lesion, palate or uvula (thermal, cryo or chemical)
PA 43284 CPT
Laparoscopy, surgical, esophageal sphincter augmentation procedure,
placement of sphincter augmentation device (ie, magnetic band),
including cruroplasty when performed
PA 43285 CPT Removal of esophageal sphincter augmentation device
PA 43644 CPT Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass
and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
PA 43645 CPT Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass
and small intestine reconstruction to l imit absorption
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
6
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 43770 CPT
Laparoscopy, surgical, gastric restrictive procedure; placement of
adjustable gastric restrictive device (eg, gastric band and subcutaneous
port components)
PA 43771 CPT Laparoscopy, surgical, gastric restrictive procedure; revision of
adjustable gastric restrictive device component only
PA 43772 CPT Laparoscopy, surgical, gastric restrictive procedure; removal of
adjustable gastric restrictive device component only
PA 43773 CPT Laparoscopy, surgical, gastric restrictive procedure; removal and
replacement of adjustable gastric restrictive device component only
PA 43774 CPT
Laparoscopy, surgical, gastric restrictive procedure; removal of
adjustable gastric restrictive device and subcutaneous port
components
PA 43775 CPT Laparoscopy, surgical, gastric restrictive procedure; longitudinal
gastrectomy (ie, sleeve gastrectomy)
PA 43842 CPT Gastric restrictive procedure, without gastric bypass, for morbid
obesity; vertical-banded gastroplasty
PA 43843 CPT Gastric restrictive procedure, without gastric bypass, for morbid
obesity; other than vertical-banded gastroplasty
PA 43845 CPT
Gastric restrictive procedure with partial gastrectomy, pylorus-
preserving duodenoileostomy and ileoileostomy (50 to 100 cm
common channel) to l imit absorption (biliopancreatic diversion with
duodenal switch)
PA 43846 CPT Gastric restrictive procedure, with gastric bypass for morbid obesity;
with short l imb (150 cm or less) Roux-en-Y gastroenterostomy
PA 43847 CPT Gastric restrictive procedure, with gastric bypass for morbid obesity;
with small intestine reconstruction to l imit absorption
PA 43848 CPT Revision, open, of gastric restrictive procedure for morbid obesity,
other than adjustable gastric restrictive device (separate procedure)
PA 43886 CPT Gastric restrictive procedure, open; revision of subcutaneous port
component only
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
7
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 43887 CPT Gastric restrictive procedure, open; removal of subcutaneous port
component only
PA 43888 CPT Gastric restrictive procedure, open; removal and replacement of
subcutaneous port component only
PA 64912 CPT Nerve repair; with nerve allograft, each nerve, first strand (cable)
PA 64913 CPT Nerve repair; with nerve allograft, each additional strand (List
separately in addition to code for primary procedure)
PA 65785 CPT Implantation of intrastromal corneal ring segments
PA 66174 CPT Transluminal dilation of aqueous outflow canal; without retention of
device or stent
PA 66175 CPT Transluminal dilation of aqueous outflow canal; with retention of
device or stent
Notification 70450 CPT Computed tomography, head or brain; without contrast material
Notification 70470 CPT Computed tomography, head or brain; without contrast material,
followed by contrast material(s) and further sections
Notification 70486 CPT Computed tomography, maxillofacial area; without contrast material
Notification 70488 CPT Computed tomography, maxillofacial area; without contrast material,
followed by contrast material(s) and further sections
Notification 70490 CPT Computed tomography, soft tissue neck; without contrast material
Notification 70491 CPT Computed tomography, soft tissue neck; with contrast material(s)
Notification 70492 CPT Computed tomography, soft tissue neck; without contrast material
followed by contrast material(s) and further sections
Notification 70544 CPT Magnetic resonance angiography, head; without contrast material(s)
Notification 70545 CPT Magnetic resonance angiography, head; with contrast material(s)
Notification 70546 CPT Magnetic resonance angiography, head; without contrast material(s),
followed by contrast material(s) and further sequences
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
8
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
Notification 70547 CPT Magnetic resonance angiography, neck; without contrast material(s)
Notification 70549 CPT Magnetic resonance angiography, neck; without contrast material(s),
followed by contrast material(s) and further sequences
Notification 70551 CPT Magnetic resonance (eg, proton) imaging, brain (including brain stem);
without contrast material
Notification 70552 CPT Magnetic resonance (eg, proton) imaging, brain (including brain stem);
with contrast material(s)
Notification 70553 CPT
Magnetic resonance (eg, proton) imaging, brain (including brain stem);
without contrast material, followed by contrast material(s) and further
sequences
Notification 71250 CPT Computed tomography, thorax; without contrast material
Notification 71260 CPT Computed tomography, thorax; with contrast material(s)
Notification 71270 CPT Computed tomography, thorax; without contrast material, followed by
contrast material(s) and further sections
Notification 71275 CPT
Computed tomographic angiography, chest (noncoronary), with
contrast material(s), including noncontrast images, if performed, and
image postprocessing
Notification 72131 CPT Computed tomography, lumbar spine; without contrast material
Notification 72141 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
cervical; without contrast material
Notification 72142 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
cervical; with contrast material(s)
Notification 72146 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
thoracic; without contrast material
Notification 72147 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
thoracic; with contrast material(s)
Notification 72148 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
lumbar; without contrast material
Notification 72149 CPT Magnetic resonance (eg, proton) imaging, spinal canal and contents,
lumbar; with contrast material(s)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
9
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
Notification 72156 CPT
Magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further
sequences; cervical
Notification 72157 CPT
Magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further
sequences; thoracic
Notification 72158 CPT
Magnetic resonance (eg, proton) imaging, spinal canal and contents,
without contrast material, followed by contrast material(s) and further
sequences; lumbar
Notification 72195 CPT Magnetic resonance (eg, proton) imaging, pelvis; without contrast
material(s)
Notification 72197 CPT Magnetic resonance (eg, proton) imaging, pelvis; without contrast
material(s), followed by contrast material(s) and further sequences
Notification 73221 CPT Magnetic resonance (eg, proton) imaging, any joint of upper extremity;
without contrast material(s)
Notification 73222 CPT Magnetic resonance (eg, proton) imaging, any joint of upper extremity;
with contrast material(s)
Notification 73223 CPT
Magnetic resonance (eg, proton) imaging, any joint of upper extremity;
without contrast material(s), followed by contrast material(s) and
further sequences
Notification 73225 CPT Magnetic resonance angiography, upper extremity, with or without
contrast material(s)
Notification 73718 CPT Magnetic resonance (eg, proton) imaging, lower extremity other than
joint; without contrast material(s)
Notification 73719 CPT Magnetic resonance (eg, proton) imaging, lower extremity other than
joint; with contrast material(s)
Notification 73721 CPT Magnetic resonance (eg, proton) imaging, any joint of lower extremity;
without contrast material
Notification 73722 CPT Magnetic resonance (eg, proton) imaging, any joint of lower extremity;
with contrast material(s)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
10
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
Notification 73723 CPT
Magnetic resonance (eg, proton) imaging, any joint of lower extremity;
without contrast material(s), followed by contrast material(s) and
further sequences
Notification 73725 CPT Magnetic resonance angiography, lower extremity, with or without
contrast material(s)
Notification 74150 CPT Computed tomography, abdomen; without contrast material
Notification 74160 CPT Computed tomography, abdomen; with contrast material(s)
Notification 74170 CPT Computed tomography, abdomen; without contrast material, followed
by contrast material(s) and further sections
Notification 74176 CPT Computed tomography, abdomen and pelvis; without contrast
material
Notification 74177 CPT Computed tomography, abdomen and pelvis; with contrast material(s)
Notification 74178 CPT
Computed tomography, abdomen and pelvis; without contrast
material in one or both body regions, followed by contrast material(s)
and further sections in one or both body regions
Notification 74181 CPT Magnetic resonance (eg, proton) imaging, abdomen; without contrast
material(s)
Notification 74183 CPT
Magnetic resonance (eg, proton) imaging, abdomen; without contrast
material(s), followed by with contrast material(s) and further
sequences
PA 77520 CPT Proton treatment delivery; simple, without compensation
PA 77522 CPT Proton treatment delivery; simple, with compensation
PA 77523 CPT Proton treatment delivery; intermediate
PA 77525 CPT Proton treatment delivery; complex
PA 78429 CPT
Myocardial imaging, positron emission tomography (PET), metabolic
evaluation study (including ventricular wall motion[s] and/or ejection
fraction[s], when performed), single study; with concurrently acquired
computed tomography transmission scan
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
11
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 78430 CPT
Myocardial imaging, positron emission tomography (PET), perfusion
study (including ventricular wall motion[s] and/or ejection fraction[s],
when performed); single study, at rest or stress (exercise or
pharmacologic), with concurrently acquired computed tomography
transmission scan
PA 78431 CPT
Myocardial imaging, positron emission tomography (PET), perfusion
study (including ventricular wall motion[s] and/or ejection fraction[s],
when performed); multiple studies at rest and stress (exercise or
pharmacologic), with concurrently acquired computed tomography
transmission scan
PA 78432 CPT
Myocardial imaging, positron emission tomography (PET), combined
perfusion with metabolic evaluation study (including ventricular wall
motion[s] and/or ejection fraction[s], when performed), dual
radiotracer (eg, myocardial viability);
PA 78433 CPT
Myocardial imaging, positron emission tomography (PET), combined
perfusion with metabolic evaluation study (including ventricular wall
motion[s] and/or ejection fraction[s], when performed), dual
radiotracer (eg, myocardial viability); with concurrently acquired
computed tomography transmission scan
Notification 78815 CPT
Positron emission tomography (PET) with concurrently acquired
computed tomography (CT) for attenuation correction and anatomical
localization imaging; skull base to mid-thigh
PA 78830 CPT
Radiopharmaceutical localization of tumor, inflammatory process or
distribution of radiopharmaceutical agent(s) (includes vascular flow
and blood pool imaging, when performed); tomographic (SPECT) with
concurrently acquired computed tomography (CT) transmission scan
for anatomical review, localization and determination/detection of
pathology, single area (eg, head, neck, chest, pelvis), single day
imaging
PA 78831 CPT
Radiopharmaceutical localization of tumor, inflammatory process or
distribution of radiopharmaceutical agent(s) (includes vascular flow
and blood pool imaging, when performed); tomographic (SPECT),
minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single
day imaging, or single area imaging over 2 or more days
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
12
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 78832 CPT
Radiopharmaceutical localization of tumor, inflammatory process or
distribution of radiopharmaceutical agent(s) (includes vascular flow
and blood pool imaging, when performed); tomographic (SPECT) with
concurrently acquired computed tomography (CT) transmission scan
for anatomical review, localization and determination/detection of
pathology, minimum 2 areas (eg, pelvis and knees, abdomen and
pelvis), single day imaging, or single area imaging over 2 or more days
PA 81105 CPT
Human Platelet Antigen 1 genotyping (HPA-1), ITGB3 (integrin, beta 3
[platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-1a/b (L33P)
PA 81106 CPT
Human Platelet Antigen 2 genotyping (HPA-2), GP1BA (glycoprotein Ib
[platelet], alpha polypeptide [GPIba]) (eg, neonatal alloimmune
thrombocytopenia [NAIT], post-transfusion purpura), gene analysis,
common variant, HPA-2a/b (T145M)
PA 81107 CPT
Human Platelet Antigen 3 genotyping (HPA-3), ITGA2B (integrin, alpha
2b [platelet glycoprotein IIb of IIb/IIIa complex], antigen CD41 [GPIIb])
(eg, neonatal alloimmune thrombocytopenia [NAIT], post-transfusion
purpura), gene analysis, common variant, HPA-3a/b (I843S)
PA 81108 CPT
Human Platelet Antigen 4 genotyping (HPA-4), ITGB3 (integrin, beta 3
[platelet glycoprotein IIIa], antigen CD61 [GPIIIa]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-4a/b (R143Q)
PA 81109 CPT
Human Platelet Antigen 5 genotyping (HPA-5), ITGA2 (integrin, alpha 2
[CD49B, alpha 2 subunit of VLA-2 receptor] [GPIa]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant (eg, HPA-5a/b (K505E))
PA 81110 CPT
Human Platelet Antigen 6 genotyping (HPA-6w), ITGB3 (integrin, beta 3
[platelet glycoprotein IIIa, antigen CD61] [GPIIIa]) (eg, neonatal
alloimmune thrombocytopenia [NAIT], post-transfusion purpura), gene
analysis, common variant, HPA-6a/b (R489Q)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
13
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81111 CPT
Human Platelet Antigen 9 genotyping (HPA-9w), ITGA2B (integrin,
alpha 2b [platelet glycoprotein IIb of IIb/IIIa complex, antigen CD41]
[GPIIb]) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-
transfusion purpura), gene analysis, common variant, HPA-9a/b
(V837M)
PA 81112 CPT
Human Platelet Antigen 15 genotyping (HPA-15), CD109 (CD109
molecule) (eg, neonatal alloimmune thrombocytopenia [NAIT], post-
transfusion purpura), gene analysis, common variant, HPA-15a/b
(S682Y)
PA 81120 CPT IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma),
common variants (eg, R132H, R132C)
PA 81121 CPT IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg,
glioma), common variants (eg, R140W, R172M)
PA 81161 CPT DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion
analysis, and duplication analysis, if performed
PA 81162 CPT
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and
ovarian cancer) gene analysis; full sequence analysis and full
duplication/deletion analysis
PA 81163 CPT
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair
associated) (eg, hereditary breast and ovarian cancer) gene analysis;
full sequence analysis
PA 81164 CPT
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair
associated) (eg, hereditary breast and ovarian cancer) gene analysis;
full duplication/deletion analysis (ie, detection of large gene
rearrangements)
PA 81165 CPT BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and
ovarian cancer) gene analysis; full sequence analysis
PA 81166 CPT
BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and
ovarian cancer) gene analysis; full duplication/deletion analysis (ie,
detection of large gene rearrangements)
PA 81167 CPT
BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and
ovarian cancer) gene analysis; full duplication/deletion analysis (ie,
detection of large gene rearrangements)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
14
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81171 CPT
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental
retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal
(eg, expanded) alleles
PA 81172 CPT
AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental
retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg,
expanded size and methylation status)
PA 81173 CPT
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy,
Kennedy disease, X chromosome inactivation) gene analysis; full gene
sequence
PA 81174 CPT
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy,
Kennedy disease, X chromosome inactivation) gene analysis; known
familial variant
PA 81175 CPT
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
myelodysplastic syndrome, myeloproliferative neoplasms, chronic
myelomonocytic leukemia), gene analysis; full gene sequence
PA 81176 CPT
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
myelodysplastic syndrome, myeloproliferative neoplasms, chronic
myelomonocytic leukemia), gene analysis; targeted sequence analysis
(eg, exon 12)
PA 81177 CPT ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene
analysis, evaluation to detect abnormal (eg, expanded) alleles
PA 81178 CPT ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation
to detect abnormal (eg, expanded) alleles
PA 81179 CPT ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation
to detect abnormal (eg, expanded) alleles
PA 81180 CPT ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease)
gene analysis, evaluation to detect abnormal (eg, expanded) alleles
PA 81181 CPT ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation
to detect abnormal (eg, expanded) alleles
PA 81182 CPT
ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg,
spinocerebellar ataxia) gene analysis, evaluation to detect abnormal
(eg, expanded) alleles
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
15
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81183 CPT ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis,
evaluation to detect abnormal (eg, expanded) alleles
PA 81184 CPT
CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,
spinocerebellar ataxia) gene analysis; evaluation to detect abnormal
(eg, expanded) alleles
PA 81185 CPT CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,
spinocerebellar ataxia) gene analysis; full gene sequence
PA 81186 CPT CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg,
spinocerebellar ataxia) gene analysis; known familial variant
PA 81187 CPT
CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg,
myotonic dystrophy type 2) gene analysis, evaluation to detect
abnormal (eg, expanded) alleles
PA 81188 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis;
evaluation to detect abnormal (eg, expanded) alleles
PA 81189 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full
gene sequence
PA 81190 CPT CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis;
known familial variant(s)
PA 81200 CPT ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common
variants (eg, E285A, Y231X)
PA 81201 CPT APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis
[FAP], attenuated FAP) gene analysis; full gene sequence
PA 81202 CPT APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis
[FAP], attenuated FAP) gene analysis; known familial variants
PA 81203 CPT APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis
[FAP], attenuated FAP) gene analysis; duplication/deletion variants
PA 81204 CPT
AR (androgen receptor) (eg, spinal and bulbar muscular atrophy,
Kennedy disease, X chromosome inactivation) gene analysis;
characterization of alleles (eg, expanded size or methylation status)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
16
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81205 CPT
BCKDHB (branched-chain keto acid dehydrogenase E1, beta
polypeptide) (eg, maple syrup urine disease) gene analysis, common
variants (eg, R183P, G278S, E422X)
PA 81206 CPT BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation
analysis; major breakpoint, qualitative or quantitative
PA 81207 CPT BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation
analysis; minor breakpoint, qualitative or quantitative
PA 81208 CPT BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation
analysis; other breakpoint, qualitative or quantitative
PA 81209 CPT BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene
analysis, 2281del6ins7 variant
PA 81210 CPT BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon
cancer, melanoma), gene analysis, V600 variant(s)
PA 81212 CPT BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and
ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants
PA 81215 CPT BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer)
gene analysis; known familial variant
PA 81216 CPT BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer)
gene analysis; full sequence analysis
PA 81217 CPT BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer)
gene analysis; known familial variant
PA 81218 CPT CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute
myeloid leukemia), gene analysis, full gene sequence
PA 81219 CPT CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis,
common variants in exon 9
PA 81220 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic
fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines)
PA 81221 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic
fibrosis) gene analysis; known familial variants
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
17
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81222 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic
fibrosis) gene analysis; duplication/deletion variants
PA 81223 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic
fibrosis) gene analysis; full gene sequence
PA 81224 CPT CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic
fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility)
PA 81225 CPT
CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg,
drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8,
*17)
PA 81226 CPT
CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg,
drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5,
*6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)
PA 81227 CPT CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg,
drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6)
PA 81228 CPT
Cytogenomic constitutional (genome-wide) microarray analysis;
interrogation of genomic regions for copy number variants (eg,
bacterial artificial chromosome [BAC] or oligo-based comparative
genomic hybridization [CGH] microarray analysis)
PA 81229 CPT
Cytogenomic constitutional (genome-wide) microarray analysis;
interrogation of genomic regions for copy number and single
nucleotide polymorphism (SNP) variants for chromosomal
abnormalities
PA 81230 CPT CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug
metabolism), gene analysis, common variant(s) (eg, *2, *22)
PA 81231 CPT
CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug
metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6,
*7)
PA 81232 CPT
DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and
capecitabine drug metabolism), gene analysis, common variant(s) (eg,
*2A, *4, *5, *6)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
18
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81233 CPT BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene
analysis, common variants (eg, C481S, C481R, C481F)
PA 81234 CPT DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene
analysis; evaluation to detect abnormal (expanded) alleles
PA 81235 CPT
EGFR (epidermal growth factor receptor) (eg, non-small cell lung
cancer) gene analysis, common variants (eg, exon 19 LREA deletion,
L858R, T790M, G719A, G719S, L861Q)
PA 81236 CPT
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit)
(eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene
analysis, full gene sequence
PA 81237 CPT
EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit)
(eg, diffuse large B-cell lymphoma) gene analysis, common variant(s)
(eg, codon 646)
PA 81238 CPT F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence
PA 81239 CPT DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene
analysis; characterization of alleles (eg, expanded size)
PA 81242 CPT FANCC (Fanconi anemia, complementation group C) (eg, Fanconi
anemia, type C) gene analysis, common variant (eg, IVS4+4A>T)
PA 81243 CPT FMR1 (fragile X mental retardation 1) (eg, fragile X mental retardation)
gene analysis; evaluation to detect abnormal (eg, expanded) alleles
PA 81244 CPT
FMR1 (fragile X mental retardation 1) (eg, fragile X mental retardation)
gene analysis; characterization of alleles (eg, expanded size and
methylation status)
PA 81245 CPT FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene
analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15)
PA 81246 CPT FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene
analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836)
PA 81247 CPT G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice), gene analysis; common variant(s) (eg, A, A-)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
19
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81248 CPT G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice), gene analysis; known familial variant(s)
PA 81249 CPT G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice), gene analysis; full gene sequence
PA 81250 CPT
G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage
disease, type 1a, von Gierke disease) gene analysis, common variants
(eg, R83C, Q347X)
PA 81251 CPT GBA (GLUCOSIDASE, BETA, ACID) (EG, GAUCHER DISEASE) GENE
ANALYSIS, COMMON VARIANTS (EG, L444P IVS2+1G>A)
PA 81252 CPT GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg,
nonsyndromic hearing loss) gene analysis; full gene sequence
PA 81253 CPT GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg,
nonsyndromic hearing loss) gene analysis; known familial variants
PA 81254 CPT
GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg,
nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb
[del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)])
PA 81255 CPT HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-Sachs disease)
gene analysis, common variants (eg, 1278insTATC, 1421+1G>C, G269S)
PA 81256 CPT HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene
analysis, common variants (eg, C282Y, H63D)
PA 81257 CPT
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia,
Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for
common deletions or variant (eg, Southeast Asian, Thai, Fi lipino,
Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring)
PA 81258 CPT
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia,
Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known
familial variant
PA 81259 CPT
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia,
Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full
gene sequence
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
20
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81260 CPT
IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells,
kinase complex-associated protein) (eg, familial dysautonomia) gene
analysis, common variants (eg, 2507+6T>C, R696P)
PA 81261 CPT
IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and
lymphomas, B-cell), gene rearrangement analysis to detect abnormal
clonal population(s); amplified methodology (eg, polymerase chain
reaction)
PA 81262 CPT
IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and
lymphomas, B-cell), gene rearrangement analysis to detect abnormal
clonal population(s); direct probe methodology (eg, Southern blot)
PA 81263 CPT IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and
lymphoma, B-cell), variable region somatic mutation analysis
PA 81264 CPT
IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and
lymphoma, B-cell), gene rearrangement analysis, evaluation to detect
abnormal clonal population(s)
PA 81265 CPT
Comparative analysis using Short Tandem Repeat (STR) markers;
patient and comparative specimen (eg, pre-transplant recipient and
donor germline testing, post-transplant non-hematopoietic recipient
germline [eg, buccal swab or other germline tissue sample] and donor
testing, twin zygosity testing, or maternal cell contamination of fetal
cells)
PA 81266 CPT
Comparative analysis using Short Tandem Repeat (STR) markers; each
additional specimen (eg, additional cord blood donor, additional fetal
samples from different cultures, or additional zygosity in multiple birth
pregnancies) (List separately in addition to code for primary
procedure)
PA 81267 CPT
Chimerism (engraftment) analysis, post transplantation specimen (eg,
hematopoietic stem cell), includes comparison to previously
performed baseline analyses; without cell selection
PA 81268 CPT
Chimerism (engraftment) analysis, post transplantation specimen (eg,
hematopoietic stem cell), includes comparison to previously
performed baseline analyses; with cell selection (eg, CD3, CD33), each
cell type
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
21
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81269 CPT
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia,
Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis;
duplication/deletion variants
PA 81270 CPT JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis,
p.Val617Phe (V617F) variant
PA 81271 CPT HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to
detect abnormal (eg, expanded) alleles
PA 81272 CPT
KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog)
(eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia,
melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11,
13, 17, 18)
PA 81273 CPT KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog)
(eg, mastocytosis), gene analysis, D816 variant(s)
PA 81274 CPT HTT (huntingtin) (eg, Huntington disease) gene analysis;
characterization of alleles (eg, expanded size)
PA 81275 CPT KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma)
gene analysis; variants in exon 2 (eg, codons 12 and 13)
PA 81276 CPT KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma)
gene analysis; additional variant(s) (eg, codon 61, codon 146)
PA 81277 CPT
Cytogenomic neoplasia (genome-wide) microarray analysis,
interrogation of genomic regions for copy number and loss-of-
heterozygosity variants for chromosomal abnormalities
PA 81283 CPT IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis,
rs12979860 variant
PA 81284 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to
detect abnormal (expanded) alleles
PA 81285 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of
alleles (eg, expanded size)
PA 81286 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence
PA 81287 CPT MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma
multiforme), methylation analysis
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
22
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81288 CPT
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; promoter methylation analysis
PA 81289 CPT FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial
variant(s)
PA 81290 CPT MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis,
common variants (eg, IVS3-2A>G, del6.4kb)
PA 81292 CPT
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; full sequence analysis
PA 81293 CPT
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; known familial variants
PA 81294 CPT
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; duplication/deletion variants
PA 81295 CPT
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; full sequence analysis
PA 81296 CPT
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; known familial variants
PA 81297 CPT
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; duplication/deletion variants
PA 81298 CPT
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene analysis; full sequence
analysis
PA 81299 CPT
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene analysis; known familial
variants
PA 81300 CPT
MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion
variants
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
23
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81301 CPT
Microsatellite instability analysis (eg, hereditary non-polyposis
colorectal cancer, Lynch syndrome) of markers for mismatch repair
deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and
normal tissue, if performed
PA 81302 CPT MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene
analysis; full sequence analysis
PA 81303 CPT MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene
analysis; known familial variant
PA 81304 CPT MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene
analysis; duplication/deletion variants
PA 81305 CPT
MYD88 (myeloid differentiation primary response 88) (eg,
Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia)
gene analysis, p.Leu265Pro (L265P) variant
PA 81306 CPT NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis,
common variant(s) (eg, *2, *3, *4, *5, *6)
PA 81307 CPT PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic
cancer) gene analysis; full gene sequence
PA 81308 CPT PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic
cancer) gene analysis; known familial variant
PA 81309 CPT
PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic
subunit alpha) (eg, colorectal and breast cancer) gene analysis,
targeted sequence analysis (eg, exons 7, 9, 20)
PA 81310 CPT NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis,
exon 12 variants
PA 81311 CPT
NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg,
colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12
and 13) and exon 3 (eg, codon 61)
PA 81312 CPT
PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal
muscular dystrophy) gene analysis, evaluation to detect abnormal (eg,
expanded) alleles
PA 81313 CPT
PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-
related peptidase 3 [prostate specific antigen]) ratio (eg, prostate
cancer)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
24
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81314 CPT
PDGFRA (platelet-derived growth factor receptor, alpha polypeptide)
(eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted
sequence analysis (eg, exons 12, 18)
PA 81315 CPT
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid
receptor alpha) (eg, promyelocytic leukemia) translocation analysis;
common breakpoints (eg, intron 3 and intron 6), qualitative or
quantitative
PA 81316 CPT
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid
receptor alpha) (eg, promyelocytic leukemia) translocation analysis;
single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or
quantitative
PA 81317 CPT
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; full sequence analysis
PA 81318 CPT
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; known familial variants
PA 81319 CPT
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) gene
analysis; duplication/deletion variants
PA 81320 CPT PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia)
gene analysis, common variants (eg, R665W, S707F, L845F)
PA 81321 CPT PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN
hamartoma tumor syndrome) gene analysis; full sequence analysis
PA 81322 CPT PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN
hamartoma tumor syndrome) gene analysis; known familial variant
PA 81323 CPT
PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN
hamartoma tumor syndrome) gene analysis; duplication/deletion
variant
PA 81324 CPT
PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth,
hereditary neuropathy with l iability to pressure palsies) gene analysis;
duplication/deletion analysis
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
25
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81325 CPT
PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth,
hereditary neuropathy with l iability to pressure palsies) gene analysis;
full sequence analysis
PA 81326 CPT
PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth,
hereditary neuropathy with l iability to pressure palsies) gene analysis;
known familial variant
PA 81328 CPT
SLCO1B1 (solute carrier organic anion transporter family, member
1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg,
*5)
PA 81329 CPT
SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular
atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing),
includes SMN2 (survival of motor neuron 2, centromeric) analysis, if
performed
PA 81330 CPT
SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg,
Niemann-Pick disease, Type A) gene analysis, common variants (eg,
R496L, L302P, fsP330)
PA 81331 CPT
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and
ubiquitin protein ligase E3A) (eg, Prader-Willi syndrome and/or
Angelman syndrome), methylation analysis
PA 81332 CPT
SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase,
antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene
analysis, common variants (eg, *S and *Z)
PA 81333 CPT
TGFBI (transforming growth factor beta-induced) (eg, corneal
dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L,
R555W, R555Q)
PA 81334 CPT
RUNX1 (runt related transcription factor 1) (eg, acute myeloid
leukemia, familial platelet disorder with associated myeloid
malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8)
PA 81335 CPT TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene
analysis, common variants (eg, *2, *3)
PA 81336 CPT SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular
atrophy) gene analysis; full gene sequence
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
26
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81337 CPT SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular
atrophy) gene analysis; known familial sequence variant(s)
PA 81340 CPT
TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma),
gene rearrangement analysis to detect abnormal clonal population(s);
using amplification methodology (eg, polymerase chain reaction)
PA 81341 CPT
TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma),
gene rearrangement analysis to detect abnormal clonal population(s);
using direct probe methodology (eg, Southern blot)
PA 81342 CPT
TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma),
gene rearrangement analysis, evaluation to detect abnormal clonal
population(s)
PA 81343 CPT
PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg,
spinocerebellar ataxia) gene analysis, evaluation to detect abnormal
(eg, expanded) alleles
PA 81344 CPT TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene
analysis, evaluation to detect abnormal (eg, expanded) alleles
PA 81345 CPT
TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma,
glioblastoma multiforme) gene analysis, targeted sequence analysis
(eg, promoter region)
PA 81346 CPT
TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug
metabolism), gene analysis, common variant(s) (eg, tandem repeat
variant)
PA 81350 CPT
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg,
irinotecan metabolism), gene analysis, common variants (eg, *28, *36,
*37)
PA 81355 CPT
VKORC1 (vitamin K epoxide reductase complex, subunit 1) (eg,
warfarin metabolism), gene analysis, common variant(s) (eg, -
1639G>A, c.173+1000C>T)
PA 81361 CPT
HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta
thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC,
HbE)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
27
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81362 CPT HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta
thalassemia, hemoglobinopathy); known familial variant(s)
PA 81363 CPT HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta
thalassemia, hemoglobinopathy); duplication/deletion variant(s)
PA 81364 CPT HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta
thalassemia, hemoglobinopathy); full gene sequence
PA 81370 CPT HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-
A, -B, -C, -DRB1/3/4/5, and -DQB1
PA 81371 CPT HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-
A, -B, and -DRB1 (eg, verification typing)
PA 81372 CPT HLA Class I typing, low resolution (eg, antigen equivalents); complete
(ie, HLA-A, -B, and -C)
PA 81373 CPT HLA Class I typing, low resolution (eg, antigen equivalents); one locus
(eg, HLA-A, -B, or -C), each
PA 81374 CPT HLA Class I typing, low resolution (eg, antigen equivalents); one
antigen equivalent (eg, B*27), each
PA 81375 CPT HLA Class II typing, low resolution (eg, antigen equivalents); HLA-
DRB1/3/4/5 and -DQB1
PA 81376 CPT HLA Class II typing, low resolution (eg, antigen equivalents); one locus
(eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each
PA 81377 CPT HLA Class II typing, low resolution (eg, antigen equivalents); one
antigen equivalent, each
PA 81378 CPT HLA Class I and II typing, high resolution (ie, alleles or allele groups),
HLA-A, -B, -C, and -DRB1
PA 81379 CPT HLA Class I typing, high resolution (ie, alleles or allele groups);
complete (ie, HLA-A, -B, and -C)
PA 81380 CPT HLA Class I typing, high resolution (ie, alleles or allele groups); one
locus (eg, HLA-A, -B, or -C), each
PA 81381 CPT HLA Class I typing, high resolution (ie, alleles or allele groups); one
allele or allele group (eg, B*57:01P), each
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
28
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81382 CPT
HLA Class II typing, high resolution (ie, alleles or allele groups); one
locus (eg, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1),
each
PA 81383 CPT HLA Class II typing, high resolution (ie, alleles or allele groups); one
allele or allele group (eg, HLA-DQB1*06:02P), each
PA 81400 CPT
Molecular pathology procedure, Level 1(eg, identification of single
germline variant [eg, SNP] by techniques such as restriction enzyme
digestion or melt curve analysis)
PA 81401 CPT
Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated
variant, or 1 somatic variant [typically using nonsequencing target
variant analysis], or detection of a dynamic mutation disorder/triplet
repeat)
PA 81402 CPT
Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10
methylated variants, or 2-10 somatic variants [typically using non-
sequencing target variant analysis], immunoglobulin and T-cell
receptor gene rearrangements, duplication/deletion variants of 1
exon, loss of heterozygosity [LOH], uniparental disomy [UPD])
PA 81403 CPT
Molecular pathology procedure, Level 4 (eg, analysis of single exon by
DNA sequence analysis, analysis of >10 amplicons using multiplex PCR
in 2 or more independent reactions, mutation scanning or
duplication/deletion variants of 2-5 exons)
PA 81404 CPT
Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by
DNA sequence analysis, mutation scanning or duplication/deletion
variants of 6-10 exons, or characterization of a dynamic mutation
disorder/triplet repeat by Southern blot analysis)
PA 81405 CPT
Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by
DNA sequence analysis, mutation scanning or duplication/deletion
variants of 11-25 exons, regionally targeted cytogenomic array
analysis)
PA 81406 CPT
Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by
DNA sequence analysis, mutation scanning or duplication/deletion
variants of 26-50 exons, cytogenomic array analysis for neoplasia)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
29
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81407 CPT
Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by
DNA sequence analysis, mutation scanning or duplication/deletion
variants of >50 exons, sequence analysis of multiple genes on one
platform)
PA 81408 CPT Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a
single gene by DNA sequence analysis)
PA 81410 CPT
Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz
syndrome, Ehler Danlos syndrome type IV, arterial tortuosity
syndrome); genomic sequence analysis panel, must include sequencing
of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11,
ACTA2, SLC2A10, SMAD3, and MYLK
PA 81411 CPT
Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz
syndrome, Ehler Danlos syndrome type IV, arterial tortuosity
syndrome); duplication/deletion analysis panel, must include analyses
for TGFBR1, TGFBR2, MYH11, and COL3A1
PA 81412 CPT
Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan
disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C,
Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel,
must include sequencing of at least 9 genes, including ASPA, BLM,
CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1
PA 81413 CPT
Cardiac ion channelopathies (eg, Brugada syndrome, long QT
syndrome, short QT syndrome, catecholaminergic polymorphic
ventricular tachycardia); genomic sequence analysis panel, must
include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3,
KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A
PA 81414 CPT
Cardiac ion channelopathies (eg, Brugada syndrome, long QT
syndrome, short QT syndrome, catecholaminergic polymorphic
ventricular tachycardia); duplication/deletion gene analysis panel,
must include analysis of at least 2 genes, including KCNH2 and KCNQ1
PA 81415 CPT Exome (eg, unexplained constitutional or heritable disorder or
syndrome); sequence analysis
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
30
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81416 CPT
Exome (eg, unexplained constitutional or heritable disorder or
syndrome); sequence analysis, each comparator exome (eg, parents,
siblings) (List separately in addition to code for primary procedure)
PA 81417 CPT
Exome (eg, unexplained constitutional or heritable disorder or
syndrome); re-evaluation of previously obtained exome sequence (eg,
updated knowledge or unrelated condition/syndrome)
PA 81420 CPT
Fetal chromosomal aneuploidy (eg, trisomy 21, monosomy X) genomic
sequence analysis panel, circulating cell-free fetal DNA in maternal
blood, must include analysis of chromosomes 13, 18, and 21
PA 81422 CPT
Fetal chromosomal microdeletion(s) genomic sequence analysis (eg,
DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal
DNA in maternal blood
PA 81425 CPT Genome (eg, unexplained constitutional or heritable disorder or
syndrome); sequence analysis
PA 81426 CPT
Genome (eg, unexplained constitutional or heritable disorder or
syndrome); sequence analysis, each comparator genome (eg, parents,
siblings) (List separately in addition to code for primary procedure)
PA 81427 CPT
Genome (eg, unexplained constitutional or heritable disorder or
syndrome); re-evaluation of previously obtained genome sequence
(eg, updated knowledge or unrelated condition/syndrome)
PA 81430 CPT
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
syndrome); genomic sequence analysis panel, must include sequencing
of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1,
MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C,
USH1G, USH2A, and WFS1
PA 81431 CPT
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
syndrome); duplication/deletion analysis panel, must include copy
number analyses for STRC and DFNB1 deletions in GJB2 and GJB6
genes
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
31
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81432 CPT
Hereditary breast cancer-related disorders (eg, hereditary breast
cancer, hereditary ovarian cancer, hereditary endometrial cancer);
genomic sequence analysis panel, must include sequencing of at least
14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2,
MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53
PA 81433 CPT
Hereditary breast cancer-related disorders (eg, hereditary breast
cancer, hereditary ovarian cancer, hereditary endometrial cancer);
duplication/deletion analysis panel, must include analyses for BRCA1,
BRCA2, MLH1, MSH2, and STK11
PA 81434 CPT
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital
amaurosis, cone-rod dystrophy), genomic sequence analysis panel,
must include sequencing of at least 15 genes, including ABCA4,
CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1,
RP2, RPE65, RPGR, and USH2A
PA 81435 CPT
Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN
hamartoma syndrome, Cowden syndrome, familial adenomatosis
polyposis); genomic sequence analysis panel, must include sequencing
of at least 10 genes, including APC, BMPR1A, CDH1, MLH1, MSH2,
MSH6, MUTYH, PTEN, SMAD4, and STK11
PA 81436 CPT
Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN
hamartoma syndrome, Cowden syndrome, familial adenomatosis
polyposis); duplication/deletion analysis panel, must include analysis
of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11
PA 81437 CPT
Hereditary neuroendocrine tumor disorders (eg, medullary thyroid
carcinoma, parathyroid carcinoma, malignant pheochromocytoma or
paraganglioma); genomic sequence analysis panel, must include
sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD,
TMEM127, and VHL
PA 81438 CPT
Hereditary neuroendocrine tumor disorders (eg, medullary thyroid
carcinoma, parathyroid carcinoma, malignant pheochromocytoma or
paraganglioma); duplication/deletion analysis panel, must include
analyses for SDHB, SDHC, SDHD, and VHL
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
32
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81439 CPT
Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated
cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy)
genomic sequence analysis panel, must include sequencing of at least
5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN
PA 81440 CPT
Nuclear encoded mitochondrial genes (eg, neurologic or myopathic
phenotypes), genomic sequence panel, must include analysis of at
least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK,
MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4,
SUCLA2, SUCLG1, TAZ, TK2, and TYMP
PA 81442 CPT
Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-
cutaneous syndrome, Costello syndrome, LEOPARD syndrome,
Noonan-like syndrome), genomic sequence analysis panel, must
include sequencing of at least 12 genes, including BRAF, CBL, HRAS,
KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1
PA 81443 CPT
Genetic testing for severe inherited conditions (eg, cystic fibrosis,
Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan
disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher
disease, Tay-Sachs disease], beta hemoglobinopathies,
phenylketonuria, galactosemia), genomic sequence analysis panel,
must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA,
ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA,
GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
PA 81445 CPT
Targeted genomic sequence analysis panel, solid organ neoplasm, DNA
analysis, and RNA analysis when performed, 5-50 genes (eg, ALK,
BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB,
PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy
number variants or rearrangements, if performed
PA 81448 CPT
Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic
paraplegia), genomic sequence analysis panel, must include
sequencing of at least 5 peripheral neuropathy-related genes (eg,
BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
33
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81450 CPT
Targeted genomic sequence analysis panel, hematolymphoid
neoplasm or disorder, DNA analysis, and RNA analysis when
performed, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1,
IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for
sequence variants, and copy number variants or rearrangements, or
isoform expression or mRNA expression levels, if performed
PA 81455 CPT
Targeted genomic sequence analysis panel, solid organ or
hematolymphoid neoplasm, DNA analysis, and RNA analysis when
performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA,
DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL,
NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN,
RET), interrogation for sequence variants and copy number variants or
rearrangements, if performed
PA 81460 CPT
Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial
encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS],
myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy,
ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic
neuropathy [LHON]), genomic sequence, must include sequence
analysis of entire mitochondrial genome with heteroplasmy detection
PA 81465 CPT
Whole mitochondrial genome large deletion analysis panel (eg, Kearns-
Sayre syndrome, chronic progressive external ophthalmoplegia),
including heteroplasmy detection, if performed
PA 81470 CPT
X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic
XLID); genomic sequence analysis panel, must include sequencing of at
least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,
IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and
SLC16A2
PA 81471 CPT
X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic
XLID); duplication/deletion gene analysis, must include analysis of at
least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,
IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and
SLC16A2
PA 81479 CPT Unlisted molecular pathology procedure
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
34
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81490 CPT
Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using
immunoassays, utilizing serum, prognostic algorithm reported as a
disease activity score
PA 81493 CPT
Coronary artery disease, mRNA, gene expression profiling by real-time
RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm
reported as a risk score
PA 81504 CPT
Oncology (tissue of origin), microarray gene expression profiling of >
2000 genes, utilizing formalin-fixed paraffin-embedded tissue,
algorithm reported as tissue similarity scores
PA 81507 CPT
Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of
selected regions using maternal plasma, algorithm reported as a risk
score for each trisomy
PA 81518 CPT
Oncology (breast), mRNA, gene expression profiling by real-time RT-
PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithms reported as percentage
risk for metastatic recurrence and likelihood of benefit from extended
endocrine therapy
PA 81519 CPT
Oncology (breast), mRNA, gene expression profiling by real-time RT-
PCR of 21 genes, util izing formalin-fixed paraffin embedded tissue,
algorithm reported as recurrence score
PA 81520 CPT
Oncology (breast), mRNA gene expression profiling by hybrid capture
of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed
paraffin-embedded tissue, algorithm reported as a recurrence risk
score
PA 81521 CPT
Oncology (breast), mRNA, microarray gene expression profiling of 70
content genes and 465 housekeeping genes, utilizing fresh frozen or
formalin-fixed paraffin-embedded tissue, algorithm reported as index
related to risk of distant metastasis
PA 81522 CPT
Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12
genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-
embedded tissue, algorithm reported as recurrence risk score
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
35
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81525 CPT
Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR
of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed
paraffin-embedded tissue, algorithm reported as a recurrence score
PA 81535 CPT
Oncology (gynecologic), l ive tumor cell culture and chemotherapeutic
response by DAPI stain and morphology, predictive algorithm reported
as a drug response score; first single drug or drug combination
PA 81536 CPT
Oncology (gynecologic), l ive tumor cell culture and chemotherapeutic
response by DAPI stain and morphology, predictive algorithm reported
as a drug response score; each additional single drug or drug
combination (List separately in addition to code for primary
procedure)
PA 81538 CPT
Oncology (lung), mass spectrometric 8-protein signature, including
amyloid A, utilizing serum, prognostic and predictive algorithm
reported as good versus poor overall survival
PA 81540 CPT
Oncology (tumor of unknown origin), mRNA, gene expression profiling
by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to
classify tumor into main cancer type and subtype, utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as a probability of
a predicted main cancer type and subtype
PA 81541 CPT
Oncology (prostate), mRNA gene expression profiling by real-time RT-
PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as a disease-
specific mortality risk score
PA 81542 CPT
Oncology (prostate), mRNA, microarray gene expression profiling of 22
content genes, util izing formalin-fixed paraffin-embedded tissue,
algorithm reported as metastasis risk score
PA 81545 CPT
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine
needle aspirate, algorithm reported as a categorical result (eg, benign
or suspicious)
PA 81551 CPT
Oncology (prostate), promoter methylation profiling by real-time PCR
of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-
embedded tissue, algorithm reported as a l ikelihood of prostate cancer
detection on repeat biopsy
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
36
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 81595 CPT
Cardiology (heart transplant), mRNA, gene expression profiling by real-
time quantitative PCR of 20 genes (11 content and 9 housekeeping),
util izing subfraction of peripheral blood, algorithm reported as a
rejection risk score
PA 81596 CPT
Infectious disease, chronic hepatitis C virus (HCV) infection, six
biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total
bil irubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm
reported as scores for fibrosis and necroinflammatory activity in liver
PA 83950 CPT Oncoprotein; HER-2/neu
PA 83951 CPT Oncoprotein; des-gamma-carboxy-prothrombin (DCP)
PA 84145 CPT Procalcitonin (PCT)
PA 86305 CPT Human epididymis protein 4 (HE4)
PA 90378 CPT Respiratory syncytial virus, monoclonal antibody, recombinant, for
intramuscular use, 50 mg, each
PA 90867 CPT
Therapeutic repetitive transcranial magnetic stimulation (TMS)
treatment; initial, including cortical mapping, motor threshold
determination, delivery and management
PA 90868 CPT Therapeutic repetitive transcranial magnetic stimulation (TMS)
treatment; subsequent delivery and management, per session
PA 90869 CPT
Therapeutic repetitive transcranial magnetic stimulation (TMS)
treatment; subsequent motor threshold re-determination with
delivery and management
PA 90912 CPT
Biofeedback training, perineal muscles, anorectal or urethral sphincter,
including EMG and/or manometry, when performed; initial 15 minutes
of one-on-one physician or other qualified health care professional
contact with the patient
PA 90913 CPT
Biofeedback training, perineal muscles, anorectal or urethral sphincter,
including EMG and/or manometry, when performed; each additional
15 minutes of one-on-one physician or other qualified health care
professional contact with the patient (List separatel y in addition to
code for primary procedure)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
37
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 91200 CPT Liver elastography, mechanically induced shear wave (eg, vibration),
without imaging, with interpretation and report
PA 97151 CPT
Behavior identification assessment, administered by a physician or
other qualified health care professional, each 15 minutes of the
physician's or other qualified health care professional's time face-to-
face with patient and/or guardian(s)/caregiver(s) administering
assessments and discussing findings and recommendations, and non-
face-to-face analyzing past data, scoring/interpreting the assessment,
and preparing the report/treatment plan
PA 97152 CPT
Behavior identification-supporting assessment, administered by one
technician under the direction of a physician or other qualified health
care professional, face-to-face with the patient, each 15 minutes
PA 97153 CPT
Adaptive behavior treatment by protocol, administered by technician
under the direction of a physician or other qualified health care
professional, face-to-face with one patient, each 15 minutes
PA 97154 CPT
Group adaptive behavior treatment by protocol, administered by
technician under the direction of a physician or other qualified health
care professional, face-to-face with two or more patients, each 15
minutes
PA 97155 CPT
Adaptive behavior treatment with protocol modification, administered
by physician or other qualified health care professional, which may
include simultaneous direction of technician, face-to-face with one
patient, each 15 minutes
PA 97156 CPT
Family adaptive behavior treatment guidance, administered by
physician or other qualified health care professional (with or without
the patient present), face-to-face with guardian(s)/caregiver(s), each
15 minutes
PA 97157 CPT
Multiple-family group adaptive behavior treatment guidance,
administered by physician or other qualified health care professional
(without the patient present), face-to-face with multiple sets of
guardians/caregivers, each 15 minutes
PA 97158 CPT
Group adaptive behavior treatment with protocol modification,
administered by physician or other qualified health care professional,
face-to-face with multiple patients, each 15 minutes
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
38
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 0095T Category III Code
Removal of total disc arthroplasty (artificial disc), anterior approach,
each additional interspace, cervical (List separately in addition to code
for primary procedure)
PA 0098T Category III Code
Revision including replacement of total disc arthroplasty (artificial
disc), anterior approach, each additional interspace, cervical (List
separately in addition to code for primary procedure)
PA 0111U CPT
Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and
NRAS (codons 12, 13, and 61) gene analysis, utilizing formalin-fixed
paraffin-embedded tissue
PA 0037U CPT
Targeted genomic sequence analysis, solid organ neoplasm, DNA
analysis of 324 genes, interrogation for sequence variants, gene copy
number amplifications, gene rearrangements, microsatellite instability
and tumor mutational burden
PA 0143U CPT
Drug assay, definitive, 120 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0144U CPT
Drug assay, definitive, 160 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0145U CPT
Drug assay, definitive, 65 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0146U CPT
Drug assay, definitive, 80 or more drugs or metabolites, urine, by
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
39
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 0147U CPT
Drug assay, definitive, 85 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0148U CPT
Drug assay, definitive, 100 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0149U CPT
Drug assay, definitive, 60 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0150U CPT
Drug assay, definitive, 120 or more drugs or metabolites, urine,
quantitative liquid chromatography with tandem mass spectrometry
(LC-MS/MS) using multiple reaction monitoring (MRM), with drug or
metabolite description, comments including sample validation, per
date of service
PA 0152U CPT
Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA,
PCR and next-generation sequencing, plasma, detection of >1,000
potential microbial organisms for significant positive pathogens
PA 0153U CPT
Oncology (breast), mRNA, gene expression profiling by next-generation
sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded
tissue, algorithm reported as a triple negative breast cancer clinical
subtype(s) with information on immune cell involvement
PA 0154U CPT
FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C
[c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C
[c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3)
PA 0155U CPT
PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic
subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K,
p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E,
p.Q546R, p.H1047L, p.H1047R, p.H1047Y)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
40
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 0156U CPT Copy number (eg, intellectual disability, dysmorphology), sequence
analysis
PA 0157U CPT
APC (APC regulator of WNT signaling pathway) (eg, familial
adenomatosis polyposis [FAP]) mRNA sequence analysis (List
separately in addition to code for primary procedure)
PA 0158U CPT
MLH1 (mutL homolog 1) (eg, hereditary non-polyposis colorectal
cancer, Lynch syndrome) mRNA sequence analysis (List separately in
addition to code for primary procedure)
PA 0159U CPT
MSH2 (mutS homolog 2) (eg, hereditary colon cancer, Lynch
syndrome) mRNA sequence analysis (List separately in addition to code
for primary procedure)
PA 0160U CPT
MSH6 (mutS homolog 6) (eg, hereditary colon cancer, Lynch
syndrome) mRNA sequence analysis (List separately in addition to code
for primary procedure)
PA 0161U CPT
PMS2 (PMS1 homolog 2, mismatch repair system component) (eg,
hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA
sequence analysis (List separately in addition to code for primary
procedure)
PA 0162U CPT
Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence
analysis panel (MLH1, MSH2, MSH6, PMS2) (List separately in addition
to code for primary procedure)
PA 0164T Category III Code
Removal of total disc arthroplasty, (artificial disc), anterior approach,
each additional interspace, lumbar (List separately in addition to code
for primary procedure)
PA 0165T Category III Code
Revision including replacement of total disc arthroplasty (artificial
disc), anterior approach, each additional interspace, lumbar (List
separately in addition to code for primary procedure)
PA 0169U CPT
NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-
methyltransferase) (eg, drug metabolism) gene analysis, common
variants
PA 0171U CPT Targeted genomic sequence analysis panel, acute myeloid leukemia,
myelodysplastic syndrome, and myeloproliferative neoplasms, DNA
analysis, 23 genes, interrogation for sequence variants,
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
41
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
rearrangements and minimal residual disease, reported as
presence/absence
PA 0172U CPT
Oncology (solid tumor as indicated by the label), somatic mutation
analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA
repair associated) and analysis of homologous recombination
deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue,
algorithm quantifying tumor genomic instability score
PA 0173U CPT Psychiatry (ie, depression, anxiety), genomic analysis panel, includes
variant analysis of 14 genes
PA 0175U CPT Psychiatry (eg, depression, anxiety), genomic analysis panel, variant
analysis of 15 genes
PA 0178U CPT
Peanut allergen-specific quantitative assessment of multiple epitopes
using enzyme-linked immunosorbent assay (ELISA), blood, report of
minimum eliciting exposure for a clinical reaction
PA 0362T Category III Code
Exposure behavioral follow-up assessment, includes physician or other
qualified health care professional direction with interpretation and
report, administered by physician or other qualified health care
professional with the assistance of one or more technicians; first 30
minutes of technician(s) time, face-to-face with the patient
PA 0373T Category III Code
Exposure adaptive behavior treatment with protocol modification
requiring two or more technicians for severe maladaptive behavior(s);
first 60 minutes of technicians' time, face-to-face with patient
PA 0402T Category III Code Collagen cross-linking of cornea (including removal of the corneal
epithelium and intraoperative pachymetry when performed)
PA 0537T Category III Code
Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-
derived T lymphocytes for development of genetically modified
autologous CAR-T cells, per day
PA 0538T Category III Code
Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-
derived T lymphocytes for transportation (eg, cryopreservation,
storage)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
42
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA 0539T Category III Code Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and
preparation of CAR-T cells for administration
PA 0540T Category III Code Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell
administration, autologous
PA A7007 HCPCS Large volume nebulizer, disposable, unfilled, used with aerosol
compressor
PA A7008 HCPCS Large volume nebulizer, disposable, prefilled, used with aerosol
compressor
PA A7025 HCPCS High frequency chest wall oscillation system vest, replacement for use
with patient-owned equipment, each
PA A7026 HCPCS High frequency chest wall oscillation system hose, replacement for use
with patient-owned equipment, each
PA A9277 HCPCS Transmitter; External, for use with interstitial continous glucose
monitoring system
PA A9278 HCPCS Receiver (monitor); external, for use with interstitial continuous
glucose monitoring system
PA B4149 HCPCS
Enteral formula, manufactured blenderized natural foods with intact
nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit
PA B4150 HCPCS
Enteral formula, nutritionally complete with intact nutrients, includes
proteins, fats, carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
PA B4152 HCPCS
Enteral formula, nutritionally complete, calorically dense (equal to or
greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats,
carbohydrates, vitamins and minerals, may include fiber, administered
through an enteral feeding tube, 100 calories = 1 unit
PA B4153 HCPCS
Enteral formula, nutritionally complete, hydrolyzed proteins (amino
acids and peptide chain), includes fats, carbohydrates, vitamins and
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
43
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA B4154 HCPCS
Enteral formula, nutritionally complete, for special metabolic needs,
excludes inherited disease of metabolism, includes altered
composition of proteins, fats, carbohydrates, vitamins and/or
minerals, may include fiber, administered through an enteral feeding
tube, 100 calories = 1 unit
PA B4155 HCPCS
Enteral formula, nutritionally incomplete/modular nutrients, includes
specific nutrients, carbohydrates (e.g., glucose polymers),
proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium
chain triglycerides) or combination, administered through an enteral
feeding tube, 100 calories = 1 unit
PA B4157 HCPCS
Enteral formula, nutritionally complete, for special metabolic needs for
inherited disease of metabolism, includes proteins, fats,
carbohydrates, vitamins and minerals, may include fiber, administered
through an enteral feeding tube, 100 calories = 1 unit
PA B4158 HCPCS
Enteral formula, for pediatrics, nutritionally complete with intact
nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber and/or iron, administered through an
enteral feeding tube, 100 calories = 1 unit
PA B4159 HCPCS
Enteral formula, for pediatrics, nutritionally complete soy based with
intact nutrients, includes proteins, fats, carbohydrates, vitamins and
minerals, may include fiber and/or iron, administered through an
enteral feeding tube, 100 calories = 1 unit
PA B4160 HCPCS
Enteral formula, for pediatrics, nutritionally complete calorically dense
(equal to or greater than 0.7 kcal/ml) with intact nutrients, includes
proteins, fats, carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit
PA B4161 HCPCS
Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide
chain proteins, includes fats, carbohydrates, vitamins and minerals,
may include fiber, administered through an enteral feeding tube, 100
calories = 1 unit
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
44
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA B4162 HCPCS
Enteral formula, for pediatrics, special metabolic needs for inherited
disease of metabolism, includes proteins, fats, carbohydrates, vitamins
and minerals, may include fiber, administered through an enteral
feeding tube, 100 calories = 1 unit
PA B4164 HCPCS Parenteral nutrition solution: carbohydrates (dextrose), 50% or less
(500 ml = 1 unit), home mix
PA B4168 HCPCS Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) -
home mix
PA B4172 HCPCS Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1
unit) - home mix
PA B4176 HCPCS Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1
unit) - home mix
PA B4178 HCPCS Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml =
1 unit), home mix
PA B4180 HCPCS Parenteral nutrition solution: carbohydrates (dextrose), greater than
50% (500 ml = 1 unit), home mix
PA B4185 HCPCS Parenteral nutrition solution, per 10 grams lipids
PA B4187 HCPCS Omegaven, 10 g l ipids
PA B4189 HCPCS
Parenteral nutrition solution: compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 10 to 51 g of protein, premix
PA B4193 HCPCS
Parenteral nutrition solution: compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, 52 to 73 g of protein, premix
PA B4216 HCPCS Parenteral nutrition; additives (vitamins, trace elements, Heparin,
electrolytes), home mix, per day
PA B5100 HCPCS
Parenteral nutrition solution compounded amino acid and
carbohydrates with electrolytes, trace elements, and vitamins,
including preparation, any strength, hepatic-HepatAmine-premix
PA C9122 HCPCS Mometasone furoate sinus implant, 10 mcg (Sinuva)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
45
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA C9756 HCPCS
Intraoperative near-infrared fluorescence lymphatic mapping of lymph
node(s) (sentinel or tumor draining) with administration of
indocyanine green (ICG) (List separately in addition to code for primary
procedure)
PA D0423 HCPCS genetic test for susceptibility to diseases - specimen analysis
PA D2390 HCPCS resin-based composite crown, anterior
PA D2510 HCPCS inlay - metallic - one surface
PA D2520 HCPCS inlay - metallic - two surfaces
PA D2530 HCPCS inlay - metallic - three or more surfaces
PA D2542 HCPCS onlay - metallic-two surfaces
PA D2543 HCPCS onlay - metallic-three surfaces
PA D2544 HCPCS onlay - metallic-four or more surfaces
PA D2610 HCPCS inlay - porcelain/ceramic - one surface
PA D2620 HCPCS inlay - porcelain/ceramic - two surfaces
PA D2630 HCPCS inlay - porcelain/ceramic - three or more surfaces
PA D2642 HCPCS onlay - porcelain/ceramic - two surfaces
PA D2643 HCPCS onlay - porcelain/ceramic - three surfaces
PA D2644 HCPCS onlay - porcelain/ceramic - four or more surfaces
PA D2650 HCPCS inlay - resin-based composite - one surface
PA D2651 HCPCS inlay - resin-based composite - two surfaces
PA D2652 HCPCS inlay - resin-based composite - three or more surfaces
PA D2662 HCPCS onlay - resin-based composite - two surfaces
PA D2663 HCPCS onlay - resin-based composite - three surfaces
PA D2664 HCPCS onlay - resin-based composite - four or more surfaces
PA D2710 HCPCS crown - resin-based composite (indirect)
PA D2712 HCPCS crown - 3/4 resin-based composite (indirect)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
46
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA D2720 HCPCS crown - resin with high noble metal
PA D2721 HCPCS crown - resin with predominantly base metal
PA D2722 HCPCS crown - resin with noble metal
PA D2740 HCPCS crown - porcelain/ceramic substrate
PA D2750 HCPCS crown - porcelain fused to high noble metal
PA D2751 HCPCS crown - porcelain fused to predominantly base metal
PA D2752 HCPCS crown - porcelain fused to noble metal
PA D2780 HCPCS crown - 3/4 cast high noble metal
PA D2781 HCPCS crown - 3/4 cast predominantly base metal
PA D2782 HCPCS crown - 3/4 cast noble metal
PA D2783 HCPCS crown - 3/4 porcelain/ceramic
PA D2790 HCPCS crown - full cast high noble metal
PA D2791 HCPCS crown - full cast predominantly base metal
PA D2792 HCPCS crown - full cast noble metal
PA D2794 HCPCS crown - titanium
PA D2929 HCPCS prefabricated porcelain/ceramic crown - primary tooth
PA D2930 HCPCS prefabricated stainless steel crown - primary tooth
PA D2931 HCPCS prefabricated stainless steel crown - permanent tooth
PA D2932 HCPCS prefabricated resin crown
PA D2933 HCPCS prefabricated stainless steel crown with resin window
PA D2934 HCPCS prefabricated esthetic coated stainless steel crown - primary tooth
PA D6058 HCPCS abutment supported porcelain/ceramic crown
PA D6059 HCPCS abutment supported porcelain fused to metal crown (high noble
metal)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
47
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA D6060 HCPCS abutment supported porcelain fused to metal crown (predominantly
base metal)
PA D6061 HCPCS abutment supported porcelain fused to metal crown (noble metal)
PA D6062 HCPCS abutment supported cast metal crown (high noble metal)
PA D6063 HCPCS abutment supported cast metal crown (predominantly base metal)
PA D6064 HCPCS abutment supported cast metal crown (noble metal)
PA D6065 HCPCS implant supported porcelain/ceramic crown
PA D6066 HCPCS implant supported porcelain fused to metal crown (titanium, titanium
alloy, high noble metal)
PA D6067 HCPCS implant supported metal crown (titanium, titanium alloy, high noble
metal)
PA D6068 HCPCS abutment supported retainer for porcelain/ceramic FPD
PA D6069 HCPCS abutment supported retainer for porcelain fused to metal FPD (high
noble metal)
PA D6070 HCPCS abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
PA D6071 HCPCS abutment supported retainer for porcelain fused to metal FPD (noble
metal)
PA D6072 HCPCS abutment supported retainer for cast metal FPD (high noble metal)
PA D6073 HCPCS abutment supported retainer for cast metal FPD (predominantly base
metal)
PA D6074 HCPCS abutment supported retainer for cast metal FPD (noble metal)
PA D6075 HCPCS implant supported retainer for ceramic FPD
PA D6076 HCPCS implant supported retainer for porcelain fused to metal FPD (titanium,
titanium alloy, or high noble metal)
PA D6077 HCPCS implant supported retainer for cast metal FPD (titanium, titanium
alloy, or high noble metal)
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
48
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA D6085 HCPCS provisional implant crown
PA D6194 HCPCS abutment supported retainer crown for FPD (titanium)
PA D6205 HCPCS pontic - indirect resin based composite
PA D6210 HCPCS pontic - cast high noble metal
PA D6211 HCPCS pontic - cast predominantly base metal
PA D6212 HCPCS pontic - cast noble metal
PA D6214 HCPCS pontic - titanium
PA D6240 HCPCS pontic - porcelain fused to high noble metal
PA D6241 HCPCS pontic - porcelain fused to predominantly base metal
PA D6242 HCPCS pontic - porcelain fused to noble metal
PA D6245 HCPCS pontic - porcelain/ceramic
PA D6250 HCPCS pontic - resin with high noble metal
PA D6251 HCPCS pontic - resin with predominantly base metal
PA D6252 HCPCS pontic - resin with noble metal
PA D6545 HCPCS retainer - cast metal for resin bonded fixed prosthesis
PA D6548 HCPCS retainer - porcelain/ceramic for resin bonded fixed prosthesis
PA D6600 HCPCS retainer inlay - porcelain/ceramic, two surfaces
PA D6601 HCPCS retainer inlay - porcelain/ceramic, three or more surfaces
PA D6602 HCPCS retainer inlay - cast high noble metal, two surfaces
PA D6603 HCPCS retainer inlay - cast high noble metal, three or more surfaces
PA D6604 HCPCS retainer inlay - cast predominantly base metal, two surfaces
PA D6605 HCPCS retainer inlay - cast predominantly base metal, three or more surfaces
PA D6606 HCPCS retainer inlay - cast noble metal, two surfaces
PA D6607 HCPCS retainer inlay - cast noble metal, three or more surfaces
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
49
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA D6608 HCPCS retainer onlay - porcelain/ceramic, two surfaces
PA D6609 HCPCS retainer onlay - porcelain/ceramic, three or more surfaces
PA D6610 HCPCS retainer onlay - cast high noble metal, two surfaces
PA D6611 HCPCS retainer onlay - cast high noble metal, three or more surfaces
PA D6612 HCPCS retainer onlay - cast predominantly base metal, two surfaces
PA D6613 HCPCS retainer onlay - cast predominantly base metal, three or more surfaces
PA D6614 HCPCS retainer onlay - cast noble metal, two surfaces
PA D6615 HCPCS retainer onlay - cast noble metal, three or more surfaces
PA D6624 HCPCS retainer inlay - titanium
PA D6634 HCPCS retainer onlay - titanium
PA D6710 HCPCS retainer crown - indirect resin based composite
PA D6720 HCPCS retainer crown - resin with high noble metal
PA D6721 HCPCS retainer crown - resin with predominantly base metal
PA D6722 HCPCS retainer crown - resin with noble metal
PA D6740 HCPCS retainer crown - porcelain/ceramic
PA D6750 HCPCS retainer crown - porcelain fused to high noble metal
PA D6751 HCPCS retainer crown - porcelain fused to predominantly base metal
PA D6752 HCPCS retainer crown - porcelain fused to noble metal
PA D6780 HCPCS retainer crown - 3/4 cast high noble metal
PA D6781 HCPCS retainer crown - 3/4 cast predominantly base metal
PA D6782 HCPCS retainer crown - 3/4 cast noble metal
PA D6783 HCPCS retainer crown - 3/4 porcelain/ceramic
PA D6790 HCPCS retainer crown - full cast high noble metal
PA D6791 HCPCS retainer crown - full cast predominantly base metal
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
50
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA D6792 HCPCS retainer crown - full cast noble metal
PA D6794 HCPCS retainer crown - titanium
PA D8010 HCPCS limited orthodontic treatment of the primary dentition
PA D8020 HCPCS limited orthodontic treatment of the transitional dentition
PA D8030 HCPCS limited orthodontic treatment of the adolescent dentition
PA D8050 HCPCS interceptive orthodontic treatment of the primary dentition
PA D8060 HCPCS interceptive orthodontic treatment of the transitional dentition
PA D8070 HCPCS comprehensive orthodontic treatment of the transitional dentition
PA D8080 HCPCS comprehensive orthodontic treatment of the adolescent dentition
PA D8210 HCPCS removable appliance therapy
PA D8220 HCPCS fixed appliance therapy
PA D8660 HCPCS pre-orthodontic treatment examination to monitor growth and
development
PA D8670 HCPCS periodic orthodontic treatment visit
PA D8680 HCPCS orthodontic retention (removal of appliances, construction and
placement of retainer(s))
PA D8681 HCPCS removable orthodontic retainer adjustment
PA D8690 HCPCS orthodontic treatment (alternative billing to a contract fee)
PA E0193 HCPCS Powered air flotation bed (low air loss therapy)
PA E0194 HCPCS Air fluidized bed
PA E0250 HCPCS Hospital bed, fixed height, with any type side rails, with mattress
PA E0251 HCPCS Hospital bed, fixed height, with any type side rails, without mattress
PA E0255 HCPCS Hospital bed, variable height, hi -lo, with any type side rails, with
mattress
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
51
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E0256 HCPCS Hospital bed, variable height, hi -lo, with any type side rails, without
mattress
PA E0260 HCPCS Hospital bed, semi-electric (head and foot adjustment), with any type
side rails, with mattress
PA E0261 HCPCS Hospital bed, semi-electric (head and foot adjustment), with any type
side rails, without mattress
PA E0265 HCPCS Hospital bed, total electric (head, foot, and height adjustments), with
any type side rails, with mattress
PA E0266 HCPCS Hospital bed, total electric (head, foot, and height adjustments), with
any type side rails, without mattress
PA E0270 HCPCS Hospital bed, institutional type includes: oscillating, circulating and
Stryker frame, with mattress
PA E0277 HCPCS Powered pressure-reducing air mattress
PA E0290 HCPCS Hospital bed, fixed height, without side rails, with mattress
PA E0291 HCPCS Hospital bed, fixed height, without side rails, without mattress
PA E0292 HCPCS Hospital bed, variable height, hi -lo, without side rails, with mattress
PA E0293 HCPCS Hospital bed, variable height, hi -lo, without side rails, without mattress
PA E0294 HCPCS Hospital bed, semi-electric (head and foot adjustment), without side
rails, with mattress
PA E0295 HCPCS Hospital bed, semi-electric (head and foot adjustment), without side
rails, without mattress
PA E0296 HCPCS Hospital bed, total electric (head, foot, and height adjustments),
without side rails, with mattress
PA E0297 HCPCS Hospital bed, total electric (head, foot, and height adjustments),
without side rails, without mattress
PA E0300 HCPCS Pediatric crib, hospital grade, fully enclosed, with or without top
enclosure
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
52
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E0301 HCPCS
Hospital bed, heavy-duty, extra wide, with weight capacity greater
than 350 pounds, but less than or equal to 600 pounds, with any type
side rails, without mattress
PA E0302 HCPCS Hospital bed, extra heavy-duty, extra wide, with weight capacity
greater than 600 pounds, with any type side rails, without mattress
PA E0303 HCPCS
Hospital bed, heavy-duty, extra wide, with weight capacity greater
than 350 pounds, but less than or equal to 600 pounds, with any type
side rails, with mattress
PA E0304 HCPCS Hospital bed, extra heavy-duty, extra wide, with weight capacity
greater than 600 pounds, with any type side rails, with mattress
PA E0328 HCPCS
Hospital bed, pediatric, manual, 360 degree side enclosures, top of
headboard, footboard and side rails up to 24 in above the spring,
includes mattress
PA E0329 HCPCS
Hospital bed, pediatric, electric or semi-electric, 360 degree side
enclosures, top of headboard, footboard and side rails up to 24 in
above the spring, includes mattress
PA E0350 HCPCS Control unit for electronic bowel irrigation/evacuation system
PA E0352 HCPCS
Disposable pack (water reservoir bag, speculum, valving mechanism,
and collection bag/box) for use with the electronic bowel
irrigation/evacuation system
PA E0370 HCPCS Air pressure elevator for heel
PA E0371 HCPCS Nonpowered advanced pressure reducing overlay for mattress,
standard mattress length and width
PA E0372 HCPCS Powered air overlay for mattress, standard mattress length and width
PA E0373 HCPCS Nonpowered advanced pressure reducing mattress
PA E0457 HCPCS Chest shell (cuirass)
PA E0459 HCPCS Chest wrap
PA E0462 HCPCS Rocking bed, with or without side rails
PA E0480 HCPCS Percussor, electric or pneumatic, home model
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
53
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E0482 HCPCS Cough stimulating device, alternating positive and negative airway
pressure
PA E0483 HCPCS High Frequency Chest Compression Device – Airway Clearance Vests
PA E0484 HCPCS Oscillatory positive expiratory pressure device, nonelectric, any type,
each
PA E0485 HCPCS
Oral device/appliance used to reduce upper airway collapsibility,
adjustable or nonadjustable, prefabricated, includes fitting and
adjustment
PA E0565 HCPCS Compressor, air power source for equipment which is not self-
contained or cylinder driven
PA E0575 HCPCS Nebulizer, ultrasonic, large volume
PA E0636 HCPCS Multipositional patient support system, with integrated lift, patient
accessible controls
PA E0650 HCPCS Pneumatic compressor, nonsegmental home model
PA E0651 HCPCS Pneumatic compressor, segmental home model without calibrated
gradient pressure
PA E0652 HCPCS Pneumatic compressor, segmental home model with calibrated
gradient pressure
PA E0691 HCPCS Ultraviolet l ight therapy system, includes bulbs/lamps, timer and eye
protection; treatment area 2 sq ft or less
PA E0692 HCPCS Ultraviolet l ight therapy system panel, includes bulbs/lamps, timer and
eye protection, 4 ft panel
PA E0693 HCPCS Ultraviolet l ight therapy system panel, includes bulbs/lamps, timer and
eye protection, 6 ft panel
PA E0694 HCPCS Ultraviolet multidirectional l ight therapy system in 6 ft cabinet,
includes bulbs/lamps, timer, and eye protection
PA E0720 HCPCS Transcutaneous electrical nerve stimulation (TENS) device, 2 lead,
localized stimulation
PA E0730 HCPCS Transcutaneous electrical nerve stimulation (TENS) device, 4 or more
leads, for multiple nerve stimulation
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
54
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E0731 HCPCS Form-fitting conductive garment for delivery of TENS or NMES (with
conductive fibers separated from the patient's skin by layers of fabric)
PA E0745 HCPCS Neuromuscular stimulator, electronic shock unit
PA E0747 HCPCS Osteogenesis stimulator, electrical, noninvasive, other than spinal
applications
PA E0748 HCPCS Osteogenesis stimulator, electrical, noninvasive, spinal applications
PA E0749 HCPCS Osteogenesis stimulator, electrical, surgically implanted
PA E0760 HCPCS Osteogenesis stimulator, low intensity ultrasound, noninvasive
PA E0762 HCPCS Transcutaneous electrical joint stimulation device system, includes all
accessories
PA E0764 HCPCS
Functional neuromuscular stimulation, transcutaneous stimulation of
sequential muscle groups of ambulation with computer control, used
for walking by spinal cord injured, entire system, after completion of
training program
PA E0766 HCPCS Electrical stimulation device used for cancer treatment, includes all
accessories, any type
PA E0770 HCPCS
Functional electrical stimulator, transcutaneous stimulation of nerve
and/or muscle groups, any type, complete system, not otherwise
specified
PA E0782 HCPCS Infusion pump, implantable, nonprogrammable (includes all
components, e.g., pump, catheter, connectors, etc.)
PA E0783 HCPCS Infusion pump system, implantable, programmable (includes all
components, e.g., pump, catheter, connectors, etc.)
PA E0785 HCPCS Implantable intraspinal (epidural/intrathecal) catheter used with
implantable infusion pump, replacement
PA E0786 HCPCS Implantable programmable infusion pump, replacement (excludes
implantable intraspinal catheter)
PA E0935 HCPCS Continuous passive motion exercise device for use on knee only
PA E0936 HCPCS Continuous passive motion exercise device for use other than knee
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
55
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E1035 HCPCS
Multi-positional patient transfer system, with integrated seat,
operated by care giver, patient weight capacity up to and including 300
lbs
PA E1036 HCPCS
Multi-positional patient transfer system, extra-wide, with integrated
seat, operated by caregiver, patient weight capacity greater than 300
lbs
PA E1050 HCPCS Fully-reclining wheelchair, fixed full-length arms, swing-away
detachable elevating legrests
PA E1060 HCPCS Fully-reclining wheelchair, detachable arms, desk or full-length, swing-
away detachable elevating legrests
PA E1070 HCPCS Fully-reclining wheelchair, detachable arms (desk or full-length) swing-
away detachable footrest
PA E1083 HCPCS Hemi-wheelchair, fixed full-length arms, swing-away detachable
elevating legrest
PA E1084 HCPCS Hemi-wheelchair, detachable arms desk or full-length arms, swing-
away detachable elevating legrests
PA E1085 HCPCS Hemi-wheelchair, fixed full-length arms, swing-away detachable
footrests
PA E1086 HCPCS Hemi-wheelchair, detachable arms, desk or full-length, swing-away
detachable footrests
PA E1087 HCPCS High strength lightweight wheelchair, fixed full-length arms, swing-
away detachable elevating legrests
PA E1088 HCPCS High strength lightweight wheelchair, detachable arms desk or full-
length, swing-away detachable elevating legrests
PA E1089 HCPCS High-strength lightweight wheelchair, fixed-length arms, swing-away
detachable footrest
PA E1090 HCPCS High-strength lightweight wheelchair, detachable arms, desk or full-
length, swing-away detachable footrests
PA E1092 HCPCS Wide heavy-duty wheelchair, detachable arms (desk or full-length),
swing-away detachable elevating legrests
PA E1093 HCPCS Wide heavy-duty wheelchair, detachable arms, desk or full-length
arms, swing-away detachable footrests
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
56
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E1100 HCPCS Semi-reclining wheelchair, fixed full-length arms, swing-away
detachable elevating legrests
PA E1110 HCPCS Semi-reclining wheelchair, detachable arms (desk or full-length)
elevating legrest
PA E1130 HCPCS Standard wheelchair, fixed full-length arms, fixed or swing-away
detachable footrests
PA E1140 HCPCS Wheelchair, detachable arms, desk or full-length, swing-away
detachable footrests
PA E1150 HCPCS Wheelchair, detachable arms, desk or full-length swing-away
detachable elevating legrests
PA E1160 HCPCS Wheelchair, fixed full-length arms, swing-away detachable elevating
legrests
PA E1161 HCPCS Manual adult size wheelchair, includes ti lt in space
PA E1170 HCPCS Amputee wheelchair, fixed full-length arms, swing-away detachable
elevating legrests
PA E1171 HCPCS Amputee wheelchair, fixed full-length arms, without footrests or
legrest
PA E1172 HCPCS Amputee wheelchair, detachable arms (desk or full-length) without
footrests or legrest
PA E1180 HCPCS Amputee wheelchair, detachable arms (desk or full-length) swing-away
detachable footrests
PA E1190 HCPCS Amputee wheelchair, detachable arms (desk or full-length) swing-away
detachable elevating legrests
PA E1195 HCPCS Heavy-duty wheelchair, fixed full-length arms, swing-away detachable
elevating legrests
PA E1200 HCPCS Amputee wheelchair, fixed full-length arms, swing-away detachable
footrest
PA E1220 HCPCS Wheelchair; specially sized or constructed, (indicate brand name,
model number, if any) and justification
PA E1221 HCPCS Wheelchair with fixed arm, footrests
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
57
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E1222 HCPCS Wheelchair with fixed arm, elevating legrests
PA E1223 HCPCS Wheelchair with detachable arms, footrests
PA E1224 HCPCS Wheelchair with detachable arms, elevating legrests
PA E1229 HCPCS Wheelchair, pediatric size, not otherwise specified
PA E1230 HCPCS Power operated vehicle (3- or 4-wheel nonhighway), specify brand
name and model number
PA E1231 HCPCS Wheelchair, pediatric size, ti lt-in-space, rigid, adjustable, with seating
system
PA E1232 HCPCS Wheelchair, pediatric size, ti lt-in-space, folding, adjustable, with
seating system
PA E1233 HCPCS Wheelchair, pediatric size, ti lt-in-space, rigid, adjustable, without
seating system
PA E1234 HCPCS Wheelchair, pediatric size, ti lt-in-space, folding, adjustable, without
seating system
PA E1235 HCPCS Wheelchair, pediatric size, rigid, adjustable, with seating system
PA E1236 HCPCS Wheelchair, pediatric size, folding, adjustable, with seating system
PA E1237 HCPCS Wheelchair, pediatric size, rigid, adjustable, without seating system
PA E1238 HCPCS Wheelchair, pediatric size, folding, adjustable, without seating system
PA E1239 HCPCS Power wheelchair, pediatric size, not otherwise specified
PA E1240 HCPCS Lightweight wheelchair, detachable arms, (desk or full-length) swing-
away detachable, elevating legrest
PA E1250 HCPCS Lightweight wheelchair, fixed full-length arms, swing-away detachable
footrest
PA E1260 HCPCS Lightweight wheelchair, detachable arms (desk or full-length) swing-
away detachable footrest
PA E1270 HCPCS Lightweight wheelchair, fixed full-length arms, swing-away detachable
elevating legrests
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
58
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E1280 HCPCS Heavy-duty wheelchair, detachable arms (desk or full-length) elevating
legrests
PA E1285 HCPCS Heavy-duty wheelchair, fixed full-length arms, swing-away detachable
footrest
PA E1290 HCPCS Heavy-duty wheelchair, detachable arms (desk or full-length) swing-
away detachable footrest
PA E1295 HCPCS Heavy-duty wheelchair, fixed full-length arms, elevating legrest
PA E1590 HCPCS Hemodialysis machine
PA E1615 HCPCS Deionizer water purification system, for hemodialysis
PA E1625 HCPCS Water softening system, for hemodialysis
PA E2291 HCPCS Back, planar, for pediatric size wheelchair including fixed attaching
hardware
PA E2292 HCPCS Seat, planar, for pediatric size wheelchair including fixed attaching
hardware
PA E2293 HCPCS Back, contoured, for pediatric size wheelchair including fixed attaching
hardware
PA E2398 HCPCS Wheelchair accessory, dynamic positioning hardware for back
PA E2402 HCPCS Negative pressure wound therapy electrical pump, stationary or
portable
PA E2500 HCPCS Speech generating device, digitized speech, using prerecorded
messages, less than or equal to 8 minutes recording time
PA E2502 HCPCS
Speech generating device, digitized speech, using prerecorded
messages, greater than 8 minutes but less than or equal to 20 minutes
recording time
PA E2504 HCPCS
Speech generating device, digitized speech, using prerecorded
messages, greater than 20 minutes but less than or equal to 40
minutes recording time
PA E2506 HCPCS Speech generating device, digitized speech, using prerecorded
messages, greater than 40 minutes recording time
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
59
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA E2508 HCPCS Speech generating device, synthesized speech, requiring message
formulation by spelling and access by physical contact with the device
PA E2510 HCPCS
Speech generating device, synthesized speech, permitting multiple
methods of message formulation and multiple methods of device
access
PA E2511 HCPCS Speech generating software program, for personal computer or
personal digital assistant
PA E2512 HCPCS Accessory for speech generating device, mounting system
PA E2599 HCPCS Accessory for speech generating device, not otherwise classified
PA G0277 HCPCS Hyperbaric oxygen under pressure, full body chamber, per 30 minute
interval
PA G0283 HCPCS Electrical stimulation (unattended), to one or more areas for
indication(s) other than wound care, as part of a therapy plan of care
PA K0001 HCPCS Standard wheelchair
PA K0002 HCPCS Standard hemi (low seat) wheelchair
PA K0003 HCPCS Lightweight wheelchair
PA K0004 HCPCS High strength, lightweight wheelchair
PA K0005 HCPCS Ultralightweight wheelchair
PA K0006 HCPCS Heavy-duty wheelchair
PA K0007 HCPCS Extra heavy-duty wheelchair
PA K0008 HCPCS Custom manual wheelchair/base
PA K0009 HCPCS Other manual wheelchair/base
PA K0010 HCPCS Standard-weight frame motorized/power wheelchair
PA K0011 HCPCS
Standard-weight frame motorized/power wheelchair with
programmable control parameters for speed adjustment, tremor
dampening, acceleration control and braking
PA K0012 HCPCS Lightweight portable motorized/power wheelchair
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
60
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0013 HCPCS Custom motorized/power wheelchair base
PA K0014 HCPCS Other motorized/power wheelchair base
PA K0455 HCPCS Infusion pump used for uninterrupted parenteral administration of
medication, (e.g., epoprostenol or treprostinol)
PA K0552 HCPCS Supplies for external non-insulin drug infusion pump, syringe type
cartridge, sterile, each
PA K0554 HCPCS Receiver (monitor), dedicated, for use with therapeutic glucose
continuous monitor system
PA K0601 HCPCS Replacement battery for external infusion pump owned by patient,
si lver oxide, 1.5 volt, each
PA K0602 HCPCS Replacement battery for external infusion pump owned by patient,
si lver oxide, 3 volt, each
PA K0603 HCPCS Replacement battery for external infusion pump owned by patient,
alkaline, 1.5 volt, each
PA K0604 HCPCS Replacement battery for external infusion pump owned by patient,
l ithium, 3.6 volt, each
PA K0605 HCPCS Replacement battery for external infusion pump owned by patient,
l ithium, 4.5 volt, each
PA K0606 HCPCS Automatic external defibrillator, with integrated electrocardiogram
analysis, garment type
PA K0607 HCPCS Replacement battery for automated external defibrillator, garment
type only, each
PA K0608 HCPCS Replacement garment for use with automated external defibrillator,
each
PA K0609 HCPCS Replacement electrodes for use with automated external defibrillator,
garment type only, each
PA K0672 HCPCS Addition to lower extremity orthotic, removable soft interface, all
components, replacement only, each
PA K0730 HCPCS Controlled dose inhalation drug delivery system
PA K0743 HCPCS Suction pump, home model, portable, for use on wounds
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
61
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0744 HCPCS Absorptive wound dressing for use with suction pump, home model,
portable, pad size 16 sq in or less
PA K0745 HCPCS Absorptive wound dressing for use with suction pump, home model,
portable, pad size more than 16 sq in but less than or equal to 48 sq in
PA K0746 HCPCS Absorptive wound dressing for use with suction pump, home model,
portable, pad size greater than 48 sq in
PA K0800 HCPCS Power operated vehicle, group 1 standard, patient weight capacity up
to and including 300 pounds
PA K0801 HCPCS Power operated vehicle, group 1 heavy-duty, patient weight capacity
301 to 450 pounds
PA K0802 HCPCS Power operated vehicle, group 1 very heavy-duty, patient weight
capacity 451 to 600 pounds
PA K0806 HCPCS Power operated vehicle, group 2 standard, patient weight capacity up
to and including 300 pounds
PA K0807 HCPCS Power operated vehicle, group 2 heavy-duty, patient weight capacity
301 to 450 pounds
PA K0808 HCPCS Power operated vehicle, group 2 very heavy-duty, patient weight
capacity 451 to 600 pounds
PA K0812 HCPCS Power operated vehicle, not otherwise classified
PA K0813 HCPCS Power wheelchair, group 1 standard, portable, sling/solid seat and
back, patient weight capacity up to and including 300 pounds
PA K0814 HCPCS Power wheelchair, group 1 standard, portable, captain's chair, patient
weight capacity up to and including 300 pounds
PA K0815 HCPCS Power wheelchair, group 1 standard, sling/solid seat and back, patient
weight capacity up to and including 300 pounds
PA K0816 HCPCS Power wheelchair, group 1 standard, captain's chair, patient weight
capacity up to and including 300 pounds
PA K0820 HCPCS Power wheelchair, group 2 standard, portable, sling/solid seat/back,
patient weight capacity up to and including 300 pounds
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
62
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0821 HCPCS Power wheelchair, group 2 standard, portable, captain's chair, patient
weight capacity up to and including 300 pounds
PA K0822 HCPCS Power wheelchair, group 2 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
PA K0823 HCPCS Power wheelchair, group 2 standard, captain's chair, patient weight
capacity up to and including 300 pounds
PA K0824 HCPCS Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
PA K0825 HCPCS Power wheelchair, group 2 heavy-duty, captain's chair, patient weight
capacity 301 to 450 pounds
PA K0826 HCPCS Power wheelchair, group 2 very heavy-duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
PA K0827 HCPCS Power wheelchair, group 2 very heavy-duty, captain's chair, patient
weight capacity 451 to 600 pounds
PA K0828 HCPCS Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back,
patient weight capacity 601 pounds or more
PA K0829 HCPCS Power wheelchair, group 2 extra heavy-duty, captain's chair, patient
weight 601 pounds or more
PA K0830 HCPCS Power wheelchair, group 2 standard, seat elevator, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
PA K0831 HCPCS Power wheelchair, group 2 standard, seat elevator, captain's chair,
patient weight capacity up to and including 300 pounds
PA K0835 HCPCS Power wheelchair, group 2 standard, single power option, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
PA K0836 HCPCS Power wheelchair, group 2 standard, single power option, captain's
chair, patient weight capacity up to and including 300 pounds
PA K0837 HCPCS Power wheelchair, group 2 heavy-duty, single power option, sling/solid
seat/back, patient weight capacity 301 to 450 pounds
PA K0838 HCPCS Power wheelchair, group 2 heavy-duty, single power option, captain's
chair, patient weight capacity 301 to 450 pounds
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
63
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0839 HCPCS Power wheelchair, group 2 very heavy-duty, single power option
sling/solid seat/back, patient weight capacity 451 to 600 pounds
PA K0840 HCPCS Power wheelchair, group 2 extra heavy-duty, single power option,
sling/solid seat/back, patient weight capacity 601 pounds or more
PA K0841 HCPCS
Power wheelchair, group 2 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including 300
pounds
PA K0842 HCPCS Power wheelchair, group 2 standard, multiple power option, captain's
chair, patient weight capacity up to and including 300 pounds
PA K0843 HCPCS Power wheelchair, group 2 heavy-duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
PA K0848 HCPCS Power wheelchair, group 3 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
PA K0849 HCPCS Power wheelchair, group 3 standard, captain's chair, patient weight
capacity up to and including 300 pounds
PA K0850 HCPCS Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
PA K0851 HCPCS Power wheelchair, group 3 heavy-duty, captain's chair, patient weight
capacity 301 to 450 pounds
PA K0852 HCPCS Power wheelchair, group 3 very heavy-duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
PA K0853 HCPCS Power wheelchair, group 3 very heavy-duty, captain's chair, patient
weight capacity 451 to 600 pounds
PA K0854 HCPCS Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back,
patient weight capacity 601 pounds or more
PA K0855 HCPCS Power wheelchair, group 3 extra heavy-duty, captain's chair, patient
weight capacity 601 pounds or more
PA K0856 HCPCS Power wheelchair, group 3 standard, single power option, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
64
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0857 HCPCS Power wheelchair, group 3 standard, single power option, captain's
chair, patient weight capacity up to and including 300 pounds
PA K0858 HCPCS Power wheelchair, group 3 heavy-duty, single power option, sling/solid
seat/back, patient weight 301 to 450 pounds
PA K0859 HCPCS Power wheelchair, group 3 heavy-duty, single power option, captain's
chair, patient weight capacity 301 to 450 pounds
PA K0860 HCPCS Power wheelchair, group 3 very heavy-duty, single power option,
sling/solid seat/back, patient weight capacity 451 to 600 pounds
PA K0861 HCPCS
Power wheelchair, group 3 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including 300
pounds
PA K0862 HCPCS Power wheelchair, group 3 heavy-duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
PA K0863 HCPCS Power wheelchair, group 3 very heavy-duty, multiple power option,
sling/solid seat/back, patient weight capacity 451 to 600 pounds
PA K0864 HCPCS Power wheelchair, group 3 extra heavy-duty, multiple power option,
sling/solid seat/back, patient weight capacity 601 pounds or more
PA K0868 HCPCS Power wheelchair, group 4 standard, sling/solid seat/back, patient
weight capacity up to and including 300 pounds
PA K0869 HCPCS Power wheelchair, group 4 standard, captain's chair, patient weight
capacity up to and including 300 pounds
PA K0870 HCPCS Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient
weight capacity 301 to 450 pounds
PA K0871 HCPCS Power wheelchair, group 4 very heavy-duty, sling/solid seat/back,
patient weight capacity 451 to 600 pounds
PA K0877 HCPCS Power wheelchair, group 4 standard, single power option, sling/solid
seat/back, patient weight capacity up to and including 300 pounds
PA K0878 HCPCS Power wheelchair, group 4 standard, single power option, captain's
chair, patient weight capacity up to and including 300 pounds
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
65
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA K0879 HCPCS Power wheelchair, group 4 heavy-duty, single power option, sling/solid
seat/back, patient weight capacity 301 to 450 pounds
PA K0880 HCPCS Power wheelchair, group 4 very heavy-duty, single power option,
sling/solid seat/back, patient weight 451 to 600 pounds
PA K0884 HCPCS
Power wheelchair, group 4 standard, multiple power option,
sling/solid seat/back, patient weight capacity up to and including 300
pounds
PA K0885 HCPCS Power wheelchair, group 4 standard, multiple power option, captain's
chair, patient weight capacity up to and including 300 pounds
PA K0886 HCPCS Power wheelchair, group 4 heavy-duty, multiple power option,
sling/solid seat/back, patient weight capacity 301 to 450 pounds
PA K0890 HCPCS Power wheelchair, group 5 pediatric, single power option, sling/solid
seat/back, patient weight capacity up to and including 125 pounds
PA K0891 HCPCS Power wheelchair, group 5 pediatric, multiple power option, sling/solid
seat/back, patient weight capacity up to and including 125 pounds
PA K0898 HCPCS Power wheelchair, not otherwise classified
PA K0899 HCPCS Power mobility device, not coded by DME PDAC or does not meet
criteria
PA S1030 HCPCS Continuous noninvasive glucose monitoring device, purchase (for
physician interpretation of data, use CPT code)
PA S1031 HCPCS
Continuous noninvasive glucose monitoring device, rental, including
sensor, sensor replacement, and download to monitor (for physician
interpretation of data, use CPT code)
PA S1034 HCPCS
Artificial pancreas device system (e.g., low glucose suspend [LGS]
feature) including continuous glucose monitor, blood glucose device,
insulin pump and computer algorithm that communicates with all of
the devices
PA S1035 HCPCS Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial
pancreas device system
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
66
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA S1036 HCPCS Transmitter; external, for use with artificial pancreas device system
PA S1037 HCPCS Receiver (monitor); external, for use with artificial pancreas device
system
PA S2083 HCPCS Adjustment of gastric band diameter via subcutaneous port by
injection or aspiration of saline
PA S2112 HCPCS Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte
cells)
PA S3840 HCPCS DNA analysis for germline mutations of the RET proto-oncogene for
susceptibility to multiple endocrine neoplasia type 2
PA S3841 HCPCS Genetic testing for retinoblastoma
PA S3842 HCPCS Genetic testing for Von Hippel-Lindau disease
PA S3844 HCPCS DNA analysis of the connexin 26 gene (GJB2) for susceptibility to
congenital, profound deafness
PA S3845 HCPCS Genetic testing for alpha-thalassemia
PA S3846 HCPCS Genetic testing for hemoglobin E beta-thalassemia
PA S3849 HCPCS Genetic testing for Niemann-Pick disease
PA S3850 HCPCS Genetic testing for sickle cell anemia
PA S3852 HCPCS DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's
disease
PA S3853 HCPCS Genetic testing for myotonic muscular dystrophy
PA S3854 HCPCS Gene expression profiling panel for use in the management of breast
cancer treatment
PA S3861 HCPCS Genetic testing, sodium channel, voltage-gated, type V, alpha subunit
(SCN5A) and variants for suspected Brugada Syndrome
PA S3865 HCPCS Comprehensive gene sequence analysis for hypertrophic
cardiomyopathy
Note: DAKOTACARE does not compensate individuals who conduct utilization review for issuing denials of coverage nor does it provide financial incentives for utilization management decision-makers to encourage denials of appropriate coverage. SS-PHS-DOC-002D (07/20)
67
Medical Products and Services Requiring Notification or Preauthorization Notification or preauthorization does not guarantee benefits. Benefits are subject to all conditions of the
member’s health insurance coverage. Drug preauthorization requirements are not included here.
Code Code Type Code Description Requirement
PA S3866 HCPCS
Genetic analysis for a specific gene mutation for hypertrophic
cardiomyopathy (HCM) in an individual with a known HCM mutation in
the family
PA S3870 HCPCS
Comparative genomic hybridization (CGH) microarray testing for
developmental delay, autism spectrum disorder and/or intellectual
disability
PA S9988 HCPCS Services provided as part of a Phase I clinical trial
PA S9990 HCPCS Services provided as part of a Phase II clinical trial
PA S9991 HCPCS Services provided as part of a Phase III clinical trial