2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient/Outpatient
Procedure
Co
de
Procedure Code Description Specialty-Servicing Provider Approved Denied Denial Reason
Overturned on
Appeal
Inpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Neurological
0 1 Medical Necessity
Inpatient 20931
ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient 22214
OSTEOTOMY OF SPINE, POSTERIOR APPROACH, FOR CORRECTION OF DEFORMITY, SINGLE SEGMENT; LUMBAR
Surgery, Neurological
1 0
Inpatient 22612
ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL ; LUMBAR (WITH LATERAL
TRANSVERSE TECHNIQUE, WHEN PERFORMED)
Surgery, Neurological
1 0
Inpatient 22614
SPINE FUSION, EXTRA SEGMENT
Surgery, Neurological
1 0
Inpatient
22633
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
Surgery, Neurological
1 0
Inpatient
22840
POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS
ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW
FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Neurological
1 0
Inpatient
22843
POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND
SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Surgery, Neurological
1 0
Inpatient 22845
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
0 1 Medical Necessity
Outpatient 22845
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Neurological
1 0
Inpatient 22846
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
0 1 Medical Necessity
Inpatient
22853
INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR
INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL
DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTE
Surgery, Neurological
1 0
Outpatient
27096
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
Surgery, Orthopedic
1 0
Outpatient
27096
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
Anesthesiology
1 0
Outpatient
27096
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
Pain Management
2 0
Outpatient
27096
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
Hospital
1 0
Outpatient
27096
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
Radiology
4 1 Medical Necessity
Outpatient 27130
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft
or allograft
Radiology
3 0
Outpatient 27447
Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total
knee arthroplasty
Radiology
10 1
Medical Necessity
Outpatient 33208 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
Hospital
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 33249
Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual
chamber
Hospital
1 0
Outpatient 33263
Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual
lead system
Hospital
1 0
Outpatient 62321
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances
Radiology
4 4
Medical Necessity
Outpatient 62323
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances
Pain Management
3 1
Medical Necessity
Outpatient 62323
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances
Radiology
6 1
Medical Necessity
Outpatient 62323
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances
Hospital
2 2
Administrative and
Medical Necessity
Outpatient 62323
Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances
Surgery, Orthopedic
0 1
Medical Necessity
Inpatient
63047
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S) (EG; SPINAL OR LATERAL RECESS STENOSIS) SINGLE
VERTEBRAL SEGMENT; LUMBAR
Surgery, Orthopedic
1 1 Medical Necessity
Inpatient
63048
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL ORLATERAL RECESS STENOSIS)), SINGLE
VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT,CERVICAL, THORACIC OR LUMB
Surgery, Neurological
1 0
Outpatient 64479 INJ FORAMEN EPIDURAL C/T
Radiology
3 0
Outpatient 64479 INJ FORAMEN EPIDURAL C/T
Hospital
2 1
Medical Necessity
Outpatient 64483 INJ FORAMEN EPIDURAL L/S
Radiology
13 2
Medical Necessity
Outpatient 64483 INJ FORAMEN EPIDURAL L/S
Pain Management
1 1
Medical Necessity
Outpatient 64483 INJ FORAMEN EPIDURAL L/S
Surgery, Orthopedic
3 0
Outpatient 64484 INJ FORAMEN EPIDURAL ADD-ON
Radiology
5 2
Outpatient 64484 INJ FORAMEN EPIDURAL ADD-ON
Surgery, Orthopedic
3 0
Outpatient 64484 INJ FORAMEN EPIDURAL ADD-ON
Pain Management
1 0
Outpatient 64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), cervical or thoracic; single level
Radiology
8 3
Medical Necessity
Outpatient 64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), cervical or thoracic; single level
Surgery, Orthopedic
1 0
Outpatient 64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), cervical or thoracic; single level
Pain Management
1 0
Outpatient 64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), cervical or thoracic; single level
Internal Medicine
1 0
Outpatient 64491
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image
guidance, cervical or thoracic; second level
Radiology
7 2
Medical Necessity
Outpatient 64491
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image
guidance, cervical or thoracic; second level
Surgery, Orthopedic
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 64491
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image
guidance, cervical or thoracic; second level
Pain Management
1 0
Outpatient 64491
diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image
guidance, cervical or thoracic; second level
Internal Medicine
1 0
Outpatient 64492
diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with image guidance, cervical
or thoracic; third and any additional level(s)
Radiology
4 1
Medical Necessity
Outpatient 64492
diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with image guidance, cervical
or thoracic; third and any additional level(s)
Surgery, Orthopedic
1 0
Outpatient 64492
diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with image guidance, cervical
or thoracic; third and any additional level(s)
Pain Management
1 0
Outpatient 64493
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), lumbar or sacral; single level
Radiology
6 2
Outpatient 64493
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), lumbar or sacral; single level
Surgery, Orthopedic
2 0
Outpatient 64493
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint)
with image guidance (fluoroscopy or CT), lumbar or sacral; single level
Pain Management
2 1
Outpatient 64494
single level, Injection(s), diagnostic or therapeutic agent, paravertebral facet joint (or nerves innervating that joint) with
image guidance (fluoroscopy or CT), lumbar or sacral; second level
Radiology
6 1
Medical Necessity
Outpatient 64495
Injection(s), diagnostic or therapeutic agent, paravertebral facet joint with image guidance (fluoroscopy or CT), lumbar
or sacral; third and any additional level(s)
Radiology
1 0
Outpatient 64633
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical
or thoracic, single facet joint
Radiology
4 2
Medical Necessity
Outpatient 64634
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical
or thoracic, single facet joint
Radiology
4 0
Outpatient 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, single facet joint
Radiology
4 0
Outpatient 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, single facet joint
Hospital
2 1
Medical Necessity
Outpatient 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, single facet joint
Pain Management
1 0
Outpatient 64636
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, each additional facet joint
Radiology
4 0
Outpatient 64636
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, each additional facet joint
Hospital
2 1
Medical Necessity
Outpatient 64636
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar
or sacral, each additional facet joint
Pain Management
1 0
Outpatient 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)
Hospital
1 0
Outpatient 70450 Computed tomography, head or brain; without contrast material
Internal Medicine
2 0
Outpatient 70450 Computed tomography, head or brain; without contrast material
Hospital
4 0
Outpatient 70450 Computed tomography, head or brain; without contrast material
Radiology
12 0
Outpatient 70460 CT HEAD or Brain; with contrast material(s)
Internal Medicine
0 1
Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 70460 CT HEAD or Brain; with contrast material(s)
Radiology
0 1
Medical Necessity
Outpatient 70470
CT HEAD or Brain; with contrast material(s), CT HEAD or Brain; without contrast material, followed by contrast
material(s) and further sections
Hospital
1 0
Outpatient 70480 CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast material
Radiology
4 0
Outpatient 70480 CT Orbit, Sella, or Posterior Fossa or Outer, Middle, or Inner Ear; without contrast material
Hospital
2 0
Outpatient 70486 Computed tomography, maxillofacial area; without contrast material
Radiology
28 3
Outpatient 70486 Computed tomography, maxillofacial area; without contrast material
Hospital
5 0
Outpatient 70486 Computed tomography, maxillofacial area; without contrast material
Internal Medicine
1 0
Outpatient 70486 Computed tomography, maxillofacial area; without contrast material
Otolaryngology
2 0
Outpatient 70487 CT SINUS, Maxillofacial Area; with contrast material(s)
Radiology
1 0
Outpatient 70490 CT NECK Soft Tissue; without contrast material
Radiology
0 1
Medical Necessity
Outpatient 70491 CT NECK Soft Tissue; with contrast material(s)
Radiology
9 3
Medical Necessity
Outpatient 70491 CT NECK Soft Tissue; with contrast material(s)
Cancer Center
2 0
Outpatient 70491 CT NECK Soft Tissue; with contrast material(s)
Hospital
3 0
Outpatient 70492 CT NECK Soft Tissue; without contrast followed by contrast material(s) and further sections
Radiology
0 1
Medical Necessity
Outpatient 70496 CTA HEAD, without contrast, followed by contrast and further sections, including image post-processing
Radiology
4 1
Medical Necessity
Outpatient 70496 CTA HEAD, without contrast, followed by contrast and further sections, including image post-processing
Hospital
1 0
Outpatient 70498 CTA NECK, without contrast, followed by contrast and further sections, including image post-processing
Radiology
1 1
Medical Necessity
Outpatient 70543
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast
material(s) and further sequences
Radiology
4 1
Medical Necessity
70543
Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast
material(s) and further sequences
Hospital
1 0
Outpatient 70544 MRA Head; without contrast material(s)
Radiology
7 2 Medical Necessity
Outpatient 70546 MRA Head; without contrast material(s), followed by contrast material(s) and further sequences
Radiology
2 0
Outpatient 70549 MRA Neck; without contrast material(s), followed by contrast material(s) and further sequences
Radiology
3 0
Outpatient 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
Radiology
37 1
Medical Necessity
Outpatient 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
Hospital
16 1
Medical Necessity
Outpatient 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material
Surgery, Orthopedic
1 0
Outpatient 70553
MRI BRAIN (head); without contrast material, followed by contrast material(s) and further sequences
Radiology
63 2
Medical Necessity
Outpatient 70553
MRI BRAIN (head); without contrast material, followed by contrast material(s) and further sequences
Hospital
20 1
Medical Necessity
Outpatient 71250 CT CHEST (thorax); without contrast material
Radiology
34 7
Medical Necessity
Outpatient 71250 CT CHEST (thorax); without contrast material
Hospital
13 2
Administrative and
Medical Necessity
Outpatient 71250 CT CHEST (thorax); without contrast material
Cancer Center
1 0
Outpatient 71250 CT CHEST (thorax); without contrast material
Internal Medicine
1 0
Outpatient 71260 CT CHEST (thorax); with contrast material(s)
Radiology
37 2
Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 71260 CT CHEST (thorax); with contrast material(s)
Hospital
11 0
Outpatient 71260 CT CHEST (thorax); with contrast material(s)
Cancer Center
3 1
Medical Necessity
Outpatient 71260 CT CHEST (thorax); with contrast material(s)
Internal Medicine
1 0
Outpatient 71260 CT CHEST (thorax); with contrast material(s)
Cardiovascular Disease
1 0
Outpatient 71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)
Radiology
14 0
Outpatient 71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)
Hospital
3 0
Outpatient 71275
CTA CHEST; without contrast material(s), followed by contrast material(s) and further sections, including image post-
processing
Radiology
9 4
Administrative and
Medical Necessity
Outpatient 71275
CTA CHEST; without contrast material(s), followed by contrast material(s) and further sections, including image post-
processing
Hospital
6 1 Medical Necessity
Outpatient 71275
CTA CHEST; without contrast material(s), followed by contrast material(s) and further sections, including image post-
processing
Internal Medicine
1 0
Outpatient 71550 MRI CHEST (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast
Radiology
3 0
Outpatient 71552
MRI CHEST (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by
contrast material(s) and further sequences
Radiology
1 0
Outpatient 71552
MRI CHEST (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by
contrast material(s) and further sequences
Hospital
1 0
Outpatient 72125 Computed tomography, cervical spine; without contrast material
Radiology
1 1
Medical Necessity
Outpatient 72126 Computed tomography, cervical spine; with contrast material
Hospital
1 0
Outpatient 72128 CT Lumbar Spine; without contrast material
Radiology
1 0
Outpatient 72131 CT Lumbar Spine; without contrast material
Radiology
4 3
Medical Necessity
Outpatient 72132 CT Lumbar Spine; with contrast material
Radiology
2 0
Outpatient 72141 MRI Cervical Spine, (spinal canal and contents); without contrast material
Radiology
39 14
Medical Necessity
Outpatient 72141 MRI Cervical Spine, (spinal canal and contents); without contrast material
Hospital
4 0
Outpatient 72141 MRI Cervical Spine, (spinal canal and contents); without contrast material
Surgery, Orthopedic
7 1
Medical Necessity
Outpatient 72146 MRI Thoracic Spine, (spinal canal and contents); without contrast material
Radiology
10 3
Medical Necessity
Outpatient 72146 MRI Thoracic Spine, (spinal canal and contents); without contrast material
Hospital
1 0
Outpatient 72148 MRI Lumbar Spine, (spinal canal and contents); without contrast material
Radiology
51 20
Medical Necessity
Outpatient 72148 MRI Lumbar Spine, (spinal canal and contents); without contrast material
Hospital
7 3
Medical Necessity
Overturned
Outpatient 72148 MRI Lumbar Spine, (spinal canal and contents); without contrast material
Surgery, Orthopedic
4 0
Outpatient 72156
MRI Cervical Spine, (spinal canal and contents); without contrast material, followed by contrast material(s) and further
sequences
Radiology
9 1
Outpatient 72157
MRI Thoracic Spine, (spinal canal and contents), without contrast material, followed by contrast material(s) and further
sequences
Radiology
6 0
Outpatient 72158
MRI Lumbar Spine, (spinal canal and contents), without contrast material, followed by contrast material(s) and further
sequences
Radiology
6 2
Medical Necessity
Outpatient 72192 Computed tomography, pelvis; without contrast material
Hospital
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 72194 CT PELVIS; without contrast material, followed by contrast material(s) and further sections
Radiology
0 2
Medical Necessity
Outpatient 72195 MRI PELVIS; without contrast material(s)
Radiology
5 0
Outpatient 72195 MRI PELVIS; without contrast material(s)
Hospital
2 0
Outpatient 72197
MRI Lumbar Spine, (spinal canal and contents), without contrast material, followed by contrast material(s) and further
se
quences, MRI PELVIS; without contrast material(s), followed by contrast material(s) and further sequences
Radiology
15 0
Outpatient 72197
MRI Lumbar Spine, (spinal canal and contents), without contrast material, followed by contrast material(s) and further
se
quences, MRI PELVIS; without contrast material(s), followed by contrast material(s) and further sequences
Hospital
3 0
Outpatient 73200 CT Upper Extremity; without contrast material
Radiology
7 0
Outpatient 73218 MRI Upper Extremity, other than joint; without contrast material(s)
Radiology
6 1
Outpatient 73218 MRI Upper Extremity, other than joint; without contrast material(s)
Surgery, Orthopedic
1 0
Outpatient 73220
MRI Upper Extremity, other than joint; without contrast material(s), followed by contrast material(s) and further
sequences
Radiology
1 2
Medical Necessity
Outpatient 73220
MRI Upper Extremity, other than joint; without contrast material(s), followed by contrast material(s) and further
sequences
Hospital
2 0
Outpatient 73221 MRI Upper Extremity, any joint; without contrast material(s)
Radiology
51 15
Medical Necessity
Outpatient 73221 MRI Upper Extremity, any joint; without contrast material(s)
Hospital
5 1
Medical Necessity
Outpatient 73221 MRI Upper Extremity, any joint; without contrast material(s)
Internal Medicine
1 0
Outpatient 73221 MRI Upper Extremity, any joint; without contrast material(s)
Surgery, Orthopedic
19 2
Medical Necessity
Outpatient 73222 MRI Upper Extremity, any joint; with contrast material(s)
Radiology
7 1
Medical Necessity
Outpatient 73222 MRI Upper Extremity, any joint; with contrast material(s)
Surgery, Orthopedic
1 0
Outpatient 73222 MRI Upper Extremity, any joint; with contrast material(s)
Cardiovascular Disease
1 0
Outpatient 73223
Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by
contrast material(s) and further sequences
Radiology
1 0
Outpatient 73700 CT Lower Extremity; without contrast material
Radiology
10 3
Administrative and
Medical Necessity
Outpatient 73700 CT Lower Extremity; without contrast material
Hospital
1 0
Outpatient 73700 CT Lower Extremity; without contrast material
Surgery, Orthopedic
1 0
Outpatient 73701 Computed tomography, lower extremity; with contrast material(s)
Radiology
0 1
Medical Necessity
Outpatient 73718 MRI Lower Extremity, other than joint; without contrast material(s)
Radiology
7 7
Administrative and
Medical Necessity
Outpatient 73718 MRI Lower Extremity, other than joint; without contrast material(s)
Hospital
1 1
Medical Necessity
Outpatient 73718 MRI Lower Extremity, other than joint; without contrast material(s)
Internal Medicine
0 1
Medical Necessity
Outpatient 73718 MRI Lower Extremity, other than joint; without contrast material(s)
Surgery, Orthopedic
3 0
Outpatient 73718 MRI Lower Extremity, other than joint; without contrast material(s)
Podiatry
1 1
Medical Necessity
Outpatient 73720
MRI Lower Extremity, other than joint; without contrast material(s), followed by contrast material(s) and further
sequences
Radiology
3 1
Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 73721
MRI Lower Extremity, other than joint; without contrast material(s), followed by contrast material(s) and further
sequences
Hospital
3 0
Outpatient 73721 MRI Lower Extremity, any joint; without contrast material(s)
Radiology
101 20
Medical Necessity
Outpatient 73721 MRI Lower Extremity, any joint; without contrast material(s)
Hospital
7 2
Medical Necessity
Outpatient 73721 MRI Lower Extremity, any joint; without contrast material(s)
Surgery, Orthopedic
26 1
Medical Necessity
Outpatient 73721 MRI Lower Extremity, any joint; without contrast material(s)
Podiatry
1 0
Outpatient 73722 MRI Lower Extremity, any joint; with contrast material(s)
Radiology
4 0
Outpatient 73722 MRI Lower Extremity, any joint; with contrast material(s)
Surgery, Orthopedic
2 0
Outpatient 73722 MRI Lower Extremity, any joint; with contrast material(s)
Internal Medicine
1 0
Outpatient 73723 MRI Lower Extremity, any joint; without contrast material(s), followed by contrast material(s) and further sequences
Radiology
2 1
Medical Necessity
Outpatient 73723 MRI Lower Extremity, any joint; without contrast material(s), followed by contrast material(s) and further sequences
Hospital
3 0
Outpatient 74150 Computed tomography, abdomen; without contrast material
Hospital
1 0
Outpatient 74160 CT ABDOMEN; with contrast material(s)
Radiology
3 4
Medical Necessity
Outpatient 74160 CT ABDOMEN; with contrast material(s)
Hospital
1 1
Medical Necessity
Outpatient 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections
Radiology
3 1
Medical Necessity
Outpatient 74174
Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if
performed, and image postprocessing
Hospital
2 0
Outpatient 74176 Computed tomography; abdomen and pelvis; without contrast material
Radiology
22 5
Medical Necessity
Outpatient 74176 Computed tomography; abdomen and pelvis; without contrast material
Hospital
4 0
Outpatient 74176 Computed tomography; abdomen and pelvis; without contrast material
Internal Medicine
1 0
Outpatient 74176 Computed tomography; abdomen and pelvis; without contrast material
Urology
1 0
Outpatient 74177 Computed tomography; abdomen and pelvis; with contrast material(s)
Radiology
67 3
Administrative and
Medical Necessity
Outpatient 74177 Computed tomography; abdomen and pelvis; with contrast material(s)
Hospital
21 2
Medical Necessity
Outpatient 74177 Computed tomography; abdomen and pelvis; with contrast material(s)
Cancer Center
1 2
Medical Necessity
Outpatient 74177 Computed tomography; abdomen and pelvis; with contrast material(s)
Cardiovascular Disease
1 0
Outpatient 74178
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
Radiology
15 5
Medical Necessity
Outpatient 74178
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
Hospital
3 3
Medical Necessity
Outpatient 74178
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
Cardiovascular Disease
1 0
Outpatient 74178
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
Urology
2 0
Outpatient 74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)
Radiology
1 0
Outpatient 74183 MRI ABDOMEN; without contrast material(s), followed by with contrast material(s) and further sequences
Radiology
17 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 74183 MRI ABDOMEN; without contrast material(s), followed by with contrast material(s) and further sequences
Hospital
5 0
Outpatient 75559
Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary
procedure)
Radiology
1 0
Outpatient 75561 Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences;
Radiology
4 1
Medical Necessity
Outpatient 75561 Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences;
Hospital
4 0
Outpatient 75565 Cardiac MRI for morphology and function without contrast material; with stress imaging
Radiology
1 0
Outpatient 75571 CT, HEART, without contrast with quantitative evaluation of coronary calcium
Radiology
1 5
Medical Necessity
Outpatient 75571 CT, HEART, without contrast with quantitative evaluation of coronary calcium
Hospital
0 2
Medical Necessity
Outpatient 75571 CT, HEART, without contrast with quantitative evaluation of coronary calcium
Internal Medicine
0 1
Medical Necessity
Outpatient 75572
Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D
im
age postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
Hospital
1 0
Outpatient 75574
CT, HEART, coronary arteries and bypass grafts (when present), with contrast, including 3D image post processing
(including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous
structures, if performed)
Radiology
3 2
Medical Necessity
Outpatient 75574
CT, HEART, coronary arteries and bypass grafts (when present), with contrast, including 3D image post processing
(including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous
structures, if performed)
Hospital
3 0
Outpatient 75635
CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, without contrast material(s), followed by
contrast material(s) and further sections, including image post-processing
Radiology
2 1
Medical Necessity
Outpatient 76380 CT Limited or Localized Follow-up study
Radiology
1 0
Outpatient 77047 Magnetic resonance imaging, breast, without contrast material; bilateral
Radiology
2 1
Medical Necessity
Outpatient 77049
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD
real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral
Radiology
23 2
Medical Necessity
Outpatient 77049
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD
real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral
Hospital
4 0
Outpatient 77049
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD
real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral
Cardiovascular Disease
1 0
Outpatient 77049
Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD
real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral
Women's Imaging Center
1 0
Outpatient 78451
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at
rest or stress
Radiology
1 1
Medical Necessity
Outpatient 78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies,
at rest and/or
Radiology
20 3
Administrative and
Med
ical Necessity
Outpatient 78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies,
at rest and/or
Hospital
8 5
Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies,
at rest and/or
Cardiovascular Disease
7 2
Medical Necessity
Outpatient 78452
Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall
motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies,
at rest and/or
Internal Medicine
2 0
Outpatient 78492 PET CARDIAC, myocardial imaging, perfusion; multiple studies at rest and/or stress
Radiology
1 0
Outpatient 78815
PET/CT imaging, (concurrently acquired CT for attenuation correction and anatomical localization); skull base to mid-
thigh
Radiology
11 3
Medical Necessity
Outpatient 78815
PET/CT imaging, (concurrently acquired CT for attenuation correction and anatomical localization); skull base to mid-
thigh
Hospital
6 2
Medical Necessity
Outpatient 78815
PET/CT imaging, (concurrently acquired CT for attenuation correction and anatomical localization); skull base to mid-
thigh
Cancer Center
2 0
Outpatient 78816 PET/CT Imaging, (concurrently acquired CT attenuation correction and anatomical localization); whole body
Radiology
1 1
Medical Necessity
Outpatient 78816 PET/CT Imaging, (concurrently acquired CT attenuation correction and anatomical localization); whole body
Cancer Center
1 0
Outpatient 90378 Synagis
Uknown
2 0
Outpatient 93350 ECHO TRANSTHORACIC
Radiology
2 1
Medical Necessity
Outpatient 93351
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically
induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring,
with supervision by a physician or other qualified health care professional
Radiology
8 0
Outpatient 93351
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically
induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring,
with supervision by a physician or other qualified health care professional
Hospital
4 3
Medical Necessity
Outpatient 93351
Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when
performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically
induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring,
with supervision by a physician or other qualified health care professional
Cardiovascular Disease
1 0
Outpatient 93451 Right heart catheterization without left heart cath or coronaries
Radiology
1 0
Outpatient 93458
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary
angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural
injection(s) for left ventriculography, when performed
Radiology
5 1
Medical Necessity
Outpatient 95782
Polysomnography, younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a
technologist
Radiology
1 0
Outpatient 95805 POLYSOMNOGRAPHY, 4 OR MORE
Radiology
1 0
Outpatient 95810 POLYSOMNOGRAPHY, 4 OR MORE
Radiology
9 11
Administrative and
Medical Necessity
Outpatient 95811 POLYSOMNOGRAPHY W/CPAP
Radiology
15 5
Medical Necessity
Outpatient 95811 POLYSOMNOGRAPHY W/CPAP
Hospital
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 95811 POLYSOMNOGRAPHY W/CPAP
Sleep Medicine
0 1
Medical Necessity
Outpatient 95812 POLYSOMNOGRAPHY W/CPAP
Cardiovascular Disease
1 0
Outpatient 95861 NEEDLE ELECTROMYOGRAPHY, TWO EXTREMITIES WITH OR WITHOUT RELATED PARASPINAL AREAS
Orthopedic, Pediatric
0 1
Medical Necessity Overturned
Outpatient 95938
SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES
OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS
Orthopedic, Pediatric
0 1
Medical Necessity Overturned
Outpatient 95939
CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL MOTOR STIMULATION); IN UPPER AND LOWER
LIMBS
Orthopedic, Pediatric
0 1
Medical Necessity Overturned
Outpatient 95941
CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY MONITORING, FROM OUTSIDE THE OPERATING ROOM
(REMOTE OR NEARBY) OR FOR MONITORING OF MORE THAN ONE CASE WHILE IN THE OPERATING ROOM, PER
HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Orthopedic, Pediatric
0 1
Medical Necessity Overturned
Inpatient DRG
DRG Rate
Internal Medicine
1 0
Outpatient
0054T
COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-
GUIDANCE BASED ON FLUOROSCOPIC IMAGES
Surgery, Orthopedic
0 1 Medical Necessity
Outpatient
0191T
INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL
APPROACH, INTO THE TRABECULAR MESHWORK; INITIAL INSERTION
Opthalmology
1 0
Outpatient 0501T Noninvasive estimated coronary fractional flow reserve (FFR) from CT angiography data
Radiology
1 1
Medical Necessity
Outpatient 0502T Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
Radiology
0 1
Medical Necessity
Outpatient 0503T Anatomical data review in comparison with estimated FFR model to reconcile discordant data, interpretation and report
Radiology
0 1
Medical Necessity
Outpatient 0504T Noninvasive estimated coronary fractional flow reserve (FFR) from CT angiography data
Radiology
0 1
Medical Necessity
Inpatient 15769
GRAFTING OF AUTOLOGOUS SOFT TISSUE, OTHER, HARVESTED BY DIRECT EXCISION (EG, FAT, DERMIS, FASCIA)
Neurology
1 0
Outpatient
15772
GRAFTING OF AUTOLOGOUS FAT HARVESTED BY LIPOSUCTION TECHNIQUE TO TRUNK, BREASTS, SCALP, ARMS,
AND/OR LEGS; EACH ADDITIONAL 50 CC INJECTATE, OR PART THERE OF (LIST SEPARATELY IN ADDITION TO CODE
FOR PRIMARY PROCEDURE)
Surgery, Plastic
1 0
Outpatient
15777
IMPLANTATION OF BIOLOGIC IMPLANT (EG, ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE,
BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Plastic
3 0
Outpatient 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID
Opthalmology
1 0
Outpatient 19316 MASTOPEXY
Surgery, Plastic
1 0
Outpatient
19318
BREAST REDUCTION
Surgery, Plastic
2 0
Outpatient 19325 BREAST AUGMENTATION WITH IMPLANT
Surgery, Plastic
1 0
Outpatient 19325 BREAST AUGMENTATION WITH IMPLANT
Surgery, Oncology
1 0
Outpatient 19350 NIPPLE/AREOLA RECONSTRUCTION
Surgery, Plastic
1 0
Inpatient 19357
TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
Surgery, Plastic
1 0
Outpatient 19357 TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
Surgery, Plastic
4 0
Outpatient 19357 TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
Surgery, Oncology
1 0
Outpatient 19357 TISSUE EXPANDER PLACEMENT IN BREAST RECONSTRUCTION, INCLUDING SUBSEQUENT EXPANSION(S)
Surgery
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient 19361
BREAST RECONSTRUCTION; WITH LATISSIMUS DORSI FLAP
Surgery, Plastic
1 0
Outpatient 19370
REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL
CAPSULECTOMY
Surgery, Plastic
1 0
Outpatient 19370
REVISION OF PERI-IMPLANT CAPSULE, BREAST, INCLUDING CAPSULOTOMY, CAPSULORRHAPHY, AND/OR PARTIAL
CAPSULECTOMY
Surgery, Oncology
1 0
Outpatient 19371 PERI-IMPLANT CAPSULECTOMY, BREAST, COMPLETE, INCLUDING REMOVAL OF ALL INTRACAPSULAR CONTENTS
Surgery, Plastic
1 0
Outpatient 19380
REVISION OF RECONSTRUCTED BREAST (EG, SIGNIFICANT REMOVAL OF TISSUE, RE-ADVANCEMENT AND/OR RE-
INSET OF FLAPS IN AUTOLOGOUS RECONSTRUCTION OR SIGNIFICANT CAPSULAR REVISION COMBINED WITH SOFT
TISSUE EXCISION IN IMPLANT-BASED RECONSTRUCTION)
Surgery, Plastic
1 0
Inpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Orthopedic
3 4 Medical Necessity
Inpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Neurological
0 1 Medical Necessity
Inpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Orthopedic
0 1 Administrative
Inpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Orthopedic
3 4 Medical Necessity
Outpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEP
ARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Orthopedic
1 0
Outpatient 20930
ALLOGRAFT, MORSELIZED, OR PLACEMENT OF OSTEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY (LIST
SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Neurological
1 0
Inpatient 20931
ALLOGRAFT, STRUCTURAL, FOR SPINE SURGERY ONLY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient 20936
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS,
OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
2 1 Medical Necessity
Outpatient 20936
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS,
OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
0 1 Medical Necessity
Outpatient 21046
EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL OSTEOTOMY (EG, LOCALLY
AGGRESSIVE OR DESTRUCTIVE LESION (S)
Surgery, Oral & Maxillofacial
1 0
Outpatient 21145
RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE
GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)
Surgery
1 0
Outpatient 21147
RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION,
REQUIRING BONE GRAFTS(INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR
MULTIPLE OSTEOTOMIES)
Surgery
1 0
Outpatient 21196 RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; IN INTERNAL RIGID FIXATION
Surgery
2 0
Outpatient 21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT)
Surgery, Oral & Maxillofacial
0 1 Medical Necessity
Inpatient 22214
OSTEOTOMY OF SPINE, POSTERIOR APPROACH, FOR CORRECTION OF DEFORMITY, SINGLE SEGMENT; LUMBAR
Surgery, Orthopedic
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient 22216
REVISE, EXTRA SPINE SEGMENT
Surgery, Orthopedic
1 0
Inpatient 22551
ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATIO N, DISCECTOMY, OSTEOPHYTECTOMY
AND DECOMPRESSION OF SPINAL CORD AN D/OR NERVE ROOTS; CERVICAL BELOW C2
Surgery, Orthopedic
0 1 Medical Necessity
Outpatient 22551
ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATIO N, DISCECTOMY, OSTEOPHYTECTOMY
AND DECOMPRESSION OF SPINAL CORD AN D/OR NERVE ROOTS; CERVICAL BELOW C2
Surgery, Orthopedic
1 0
Outpatient 22551
ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATIO N, DISCECTOMY, OSTEOPHYTECTOMY
AND DECOMPRESSION OF SPINAL CORD AN D/OR NERVE ROOTS; CERVICAL BELOW C2
Surgery, Neurological
1 0
Inpatient 22552
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)
Surgery, Orthopedic
1 1 Medical Necessity
Outpatient 22552
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)
Surgery, Orthopedic
1 0
Outpatient 22552
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)
Surgery, Neurological
1 0
Inpatient 22558
ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DESKECTOMY TO PREPARE INTERSPACE
(OTHER THAN FOR DECOMPRESSION); LUMBAR
Surgery, Orthopedic
2 1 Medical Necessity
Inpatient 22585
EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (USE 22585
ONLY FOR CODES 22554,22556,22558)
Surgery, Orthopedic
1 0
Inpatient 22612
ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL ; LUMBAR (WITH LATERAL
TRANSVERSE TECHNIQUE, WHEN PERFORMED)
Surgery, Orthopedic
2 1 Medical Necessity
Outpatient 22612
ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL ; LUMBAR (WITH LATERAL
TRANSVERSE TECHNIQUE, WHEN PERFORMED)
Surgery, Orthopedic
1 0
Inpatient 22614
SPINE FUSION, EXTRA SEGMENT
Surgery, Orthopedic
1 0
Outpatient 22614 SPINE FUSION, EXTRA SEGMENT
Surgery, Orthopedic
1 0
Inpatient
22630
ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO
PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR
Surgery, Orthopedic
0 1 Medical Necessity
Inpatient
22633
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
Surgery, Orthopedic
1 0
Inpatient
22634
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 INTERSP
Surgery, Orthopedic
1 0
Inpatient
22808
ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 VERTEBRAL SEGMENTS
Surgery, Orthopedic
0 1 Medical Necessity
Outpatient 22830 EXPLORATION OF SPINAL FUSION
Surgery, Orthopedic
1 0
Inpatient
22840
POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS
ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW
FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PRO
Surgery, Orthopedic
0 2 Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 22840
POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS
ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW
FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PRO
Surgery, Orthopedic
1 0
Inpatient
22842
POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND
SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient
22843
POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND
SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY
PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient 22845
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient
22845
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
1 1 Medical Necessity
Outpatient 22845
ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient
22846
ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
0 1 Medical Necessity
Inpatient 22847
ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient
22847
ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR
PRIMARY PROCEDURE)
Surgery, Orthopedic
1 0
Inpatient
22853
INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR
INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL
DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTE
Surgery, Orthopedic
3 3 Medical Necessity
Outpatient 22853
INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR
INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL
DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTERSPACE
Surgery, Neurological
0 1
Medical Necessity
Outpatient 22853
INSERTION OF INTERBODY BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE, MESH) WITH INTEGRAL ANTERIOR
INSTRUMENTATION FOR DEVICE ANCHORING (EG, SCREWS, FLANGES), WHEN PERFORMED, TO INTERVERTEBRAL
DISC SPACE IN CONJUNCTION WITH INTERBODY ARTHRODESIS, EACH INTETERSPACE
Surgery, Orthopedic
1 0
Outpatient 22856
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
Surgery, Orthopedic
0 1
Medical Necessity
Outpatient 22867
INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION,
IN
CLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL
Surgery, Orthopedic
0 1
Medical Necessity
Outpatient 22869
INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT OPEN
DECO
MPRESSION OR FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, LUMBAR; SINGLE LEVEL
Surgery, Orthopedic
0 1
Medical Necessity
Inpatient
22899
UNLISTED PROCEDURE, SPINE
Surgery, Orthopedic
1 0
Inpatient
23472
ARTHROPLASTY GLENOHUMERAL JOINT; TOAL SHOULDER (GLENOID AND PROXIMAL HUMERAL
REPLACEMENT(EG, TOTAL SHOULDER))
Surgery, Orthopedic
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient
27130
ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP
ARTHROPLASTY) WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
Surgery, Orthopedic
1 0
Outpatient 27130
ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP
ARTHROPLASTY) WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT
Surgery, Orthopedic
1 0
Outpatient 27132
CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR
ALLOGRAFT
Surgery, Orthopedic
0 1
Medical Necessity
Outpatient 27447
ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT
PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)
Surgery, Orthopedic
6 0
Inpatient
27599
UNLISTED PROCEDURE, FEMUR OR KNEE
Surgery, Orthopedic
1 0
Inpatient
27600
UNLISTED PROCEDURE, FEMUR OR KNEE
Surgery, Orthopedic
1 0
Outpatient 29862
ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDEMENT/ SHAVING OF ARTICULAR CARTALIGE (CHONDROPLASTY),
ABRASION ARTHROSCOPY, AND/ OR RESECTION OF LABRUM
Surgery, Orthopedic
2 0
Outpatient 29863 ARTHROSCOPY, HIP, SURGICAL; WITH SYNOVECTOMY
Surgery, Orthopedic
1 0
Outpatient 29914 ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)
Surgery, Orthopedic
4 0
Outpatient 29914 ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROPLASTY (IE, TREATMENT OF CAM LESION)
Sports Medicine
1 0
Outpatient 29915 ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)
Surgery, Orthopedic
1 0
Outpatient 29915 ARTHROSCOPY, HIP, SURGICAL; WITH ACETABULOPLASTY (IE, TREATMENT OF PINCER LESION)
Sports Medicine
1 0
Outpatient 29916 ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR
Surgery, Orthopedic
4 0
Outpatient 29916 ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL REPAIR
Sports Medicine
1 0
Outpatient 30140 SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD
Gynecology
2 0
Outpatient 30520
SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR
REPLACEMENT WITH GRAFT
Otolaryngology
2 0
Outpatient 31237 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDE- MENT (SEPARATE PROCEDURE)
Otolaryngology
1 0
Outpatient 31240 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA RESECTION
Otolaryngology
2 0
Outpatient 31254 NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; PARTIAL (ANTERIOR)
Otolaryngology
4 0
Outpatient 31255 NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR)
Otolaryngology
4 0
Outpatient 31256 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY;
Otolaryngology
3 0
Outpatient 31257
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING
SPHENOIDOTOMY
Otolaryngology
1 0
Outpatient 31259
NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING
SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS
Otolaryngology
1 0
Outpatient 31267
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM
MAXILLARY SINUS
Otolaryngology
3 0
Outpatient 31276
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE
FROM FRONTAL SINUS, WHEN PERFORMED
Otolaryngology
2 0
Outpatient 31295
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION) MAXILLARY SINUS OSTIUM,
TRANSNASAL OR VIA CANINE FOSSA
Otolaryngology
4 0
Outpatient 31296 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION) FRONTAL SINUS OSTIUM
Otolaryngology
2 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 31297 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION) SPHENOID SINUS OSTIUM
Otolaryngology
1 0
Outpatient 31298
NASAL/SINUS ENDOSCOPY, SURGICAL, WITH DILATION (EG, BALLOON DILATION) FRONTAL AND SPHENOID SINUS
OSTIA
Otolaryngology
3 0
Inpatient
33405
REPLACEMENT, AORTIC VALVE, OPEN, WITH CARDIOPULMONARY BYPASS; WITH PROSTHETIC VALVE OTHER THAN
HOMOGRAFT OR STENTLESS VALVE
Surgery, Thoracic
1 0
Inpatient
33477
TRANSCATHETER PULMONARY VALVE IMPLANTATION, PERCUTANEOUS APPROACH, INCLUDING PRE-STENTING OF
THE VALVE DELIVERY SITE, WHEN PERFORMED
Pediatric Cardiology
0 1 Medical Necessity
Inpatient
33523
CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); SIX OR MORE VENOUS GRAFTS
(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
Surgery, Thoracic
1 0
Inpatient
33536
CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR MORE CORONARY ARTERIAL GRAFTS
Surgery, Thoracic
1 0
Inpatient
35221
REPAIR BLOOD VESSEL, DIRECT; INTRA-ABDOMINAL
Surgery, Oncology
1 0
Outpatient 36470 INJECTION OF SCLEROSANT; SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA)
Vascular & Interventional Radiology
1 0
Outpatient 36471 INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG
Vascular & Interventional Radiology
2 0
Outpatient 36475
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED
Surgery
6 0
Outpatient 36475
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED
Surgery, General Vascular
2 0
Outpatient 36475
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED
Vascular & Interventional Radiology
1 0
Outpatient 36475
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED
Cardiovascular Disease
2 0
Outpatient 36478
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED
Surgery
4 0
Outpatient 36478
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED
Vascular & Interventional Radiology
1 0
Outpatient 36478
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED
Radiology
1 0
Outpatient 36479
ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE
AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH
THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE F
Surgery
2 0
Inpatient
36561
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT;
AGE 5 YEARS OR OLDER
Surgery
1 0
Outpatient 37765 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; 10-20 STAB INCISIONS
Surgery
1 0
Inpatient
38724
CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION)
Surgery
1 0
Inpatient
43281
LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED;
WITHOUT IMPLANTATION OF MESH
Surgery
1 0
Inpatient
43644
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y
GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)
Surgery
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient
43774
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE
DEVICE AND SUBCUTANEOUS PORT COMPONENTS
Surgery
1 0
Outpatient 43774
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE
DEVICE AND SUBCUTANEOUS PORT COMPONENTS
Surgery
1 0
Inpatient
43775
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE
GASTRECTOMY)
Surgery
2 0
Inpatient
44140
COLECTOMY, PARTIAL; WITH ANASTOMOSIS
Surgery
1 0
Inpatient
44204
LAPAROSCOPY, SURGICAL;COLECTOMY, PARTIAL, WITH ANASTOMOSIS
Surgery
1 0
Inpatient
44207
LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC
ANASTOMOSIS)
Surgery, Colon & Rectal
2 0
Inpatient
44620
CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE;
Surgery
1 0
Inpatient
46730
REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; PERINEAL OR SACROPERINEAL APPROACH
Pediatric Surgery
1 0
Inpatient
48140
PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT SPLENECTOMY;
Surgery
1 0
Inpatient
48150
PANCREATECTOMY, PROXIMAL SUBTOTAL, WITH DUODENECTOMY, PARTIAL GASTRECTOMY,
CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITH
PANCREATOJEJUNOSTOMY
Surgery, Oncology
1 0
Inpatient
48152
PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL DUODENECTOMY, PARTIAL GASTRECTOMY,
CHOLECYSTOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITHOUT
PANCREATOJEJUNOSTOMY
Surgery, Oncology
1 0
Inpatient
48153
PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL DUODENECTOMY, CHOLEDOCHOENTEROSTOMY
AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE- TYPE PROCEDURE); WITH
PANCREATOJEJUNOSTOMY
Surgery, Oncology
1 0
Inpatient
48154
PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL DUODENECTOMY, CHOLEDOCHOENTEROSTOMY
AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE- TYPE PROCEDURE); WITHOUT
PANCREATOJEJUNOSTOMY
Surgery, Oncology
1 0
Inpatient
49205
EXC/DESTRUCTION OPEN ABDOMINAL TUMORS >10.0
Surgery, Gynecologic
1 0
Outpatient 49505 REPAIR INITIAL INIGUINAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE
Surgery
1 0
Outpatient 58322 ARTIFICIAL INSEMINATION; INTRA-UTERINE
Endocrinology, Reproductive
0 1 Administrative
Inpatient
58720
SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)
Surgery, Gynecologic
1 0
Inpatient
61548
HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, TRANSNASAL OR TRANSSEPTAL APPROACH,
NO
NSTEREOTACTIC
Neurology
1 0
Inpatient
61782
STEREOTACTIC COMPUTER-ASSISTED (NAVIGATIONAL) PROCEDURE; CRANIAL , EXTRADURAL (LIST SEPARATELY IN
ADDITION TO CODE FOR PRIMARY PROC EDURE)
Neurology
1 0
Inpatient
62165
NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY TUMOR, TRANSNASAL OR TRANS-SPHENOIDAL
APPROACH
Neurology
1 0
Inpatient
62201
VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; STEREOTACTIC METHOD
Pediatric Surgery
1 0
Inpatient
63012
LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS WITH
DECO
MPRESSION OF CAUDIA EQUINA AND NERVE ROOTS SPONDYLOLISTHESIS, LUMBAR(GILL TYPE PROCEDURE)
Surgery, Orthopedic
0 1 Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient
63046
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL OR LATERAL RECESS STENOSIS)), SINGLE
VERTEBRAL SEGMENT; THORACIC
Surgery, Neurological
1 0
Inpatient
63047
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S) (EG; SPINAL OR LATERAL RECESS STENOSIS) SINGLE
VERTEBRAL SEGMENT; LUMBAR
Surgery, Neurological
1 0
Outpatient 63047
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S) (EG; SPINAL OR LATERAL RECESS STENOSIS) SINGLE
VERTEBRAL SEGMENT; LUMBAR
Surgery, Orthopedic
1 1
Medical Necessity
Inpatient
63048
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL ORLATERAL RECESS STENOSIS)), SINGLE
VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT,CERVICAL, THORACIC OR LUMBAR
Surgery, Orthopedic
1 0
Outpatient 63048
LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF
SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL ORLATERAL RECESS STENOSIS)), SINGLE
VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT,CERVICAL, THORACIC OR LUMBAR
Surgery, Orthopedic
1 1
Medical Necessity
Inpatient
64999
UNLISTED PROCEDURE, NERVOUS SYSTEM
Neurology
1 0
Outpatient 66982
EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE
PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR
PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTIN
Opthalmology
2 0
Outpatient 66984
EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (1 STAGE
PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR
PHACOEMULSIFICATION); WITHOUT ENDOSCOPIC CYCLOPHOTOCOAGULATION
Opthalmology
13 0
Outpatient 67904 REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR RESECTION, EXTERNAL APPROACH
Opthalmology
1 0
Outpatient 67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-LEVATOR RESECTION (FASANELLA-SERVAT TYPE)
Opthalmology
1 0
Inpatient
76937
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS
SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION
OF VASCULAR NEEDLE ENTRY, WITH PERMANENT RECORDING AND REPORTING
Surgery
1 0
Inpatient
77001
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY
OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER
MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER
Surgery
1 0
Outpatient 77067
SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED
DETECTION (CAD) WHEN PERFORMED
Radiology
1 0
Outpatient 89290
BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC
DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS
Endocrinology, Reproductive
0 1
Medical Necessity
Outpatient 89291
BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC
DI
AGNOSIS); GREATER THAN 5 EMBRYOS
Endocrinology, Reproductive
0 1
Medical Necessity
Outpatient 90836
PSYCHOTHERAPY, 45 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT
SER
VICE (LIST SEPARATELY IN ADDITION TO THE CODE FOR PRIMARY PROCEDURE)
Unknown
1 0
Outpatient 90867
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; INITIAL, INCLUDING
CORTICAL MAPPING, MOTOR THRESHOLD DETERMINATION, DELIVERY AND MANAGEMENT
Psychiatry
0 1
Medical Necessity
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient 90868
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; SUBSEQUENT DELIVERY
AND MANAGEMENT, PER SESSION
Psychiatry
0 1
Medical Necessity
Outpatient 90869
THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; SUBSEQUENT MOTOR
THRESHOLD RE-DETERMINATION WITH DELIVERY AND MANAGEMENT
Psychiatry
0 1
Medical Necessity
Outpatient 92136
OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH INTRAOCULAR LENS POWER
CALCULATION
Opthalmology
1 0
Outpatient 95700
ELECTROENCEPHALOGRAM (EEG) CONTINUOUS RECORDING, WITH VIDEO WHEN PERFORMED, SETUP, PATIENT
EDUCATION, AND TAKEDOWN WHEN PERFORMED, ADMINISTERED IN PERSON BY EEG TECHNOLOGIST, MINIMUM
OF 8 CHANNELS
Neurology
1 0
Outpatient 95715
ELECTROENCEPHALOGRAM WITH VIDEO (VEEG), REVIEW OF DATA, TECHNICAL DESCRIPTION BY EEG
TECHNOLOGIST, EACH INCREMENT OF 12-26 HOURS WITH INTERMITTENT MONITORINGAND MAINTENANCE
Neurology
1 0
Inpatient
95716
ELECTROENCEPHALOGRAM WITH VIDEO (VEEG), REVIEW OF DATA, TECHNICAL DESCRIPTION BY EEG
TECHNOLOGIST, EACH INCREMENT OF 12-26 HOURS WITH CONTINUOUS, REAL-TIME MONITORING AND
MAINTENANCE
Neurology
1 0
Inpatient
95720
ELECTROENCEPHALOGRAM (EEG), CONTINUOUS RECORDING, PHYSICIAN OR OTHER QUALIFIED HEALTH CARE
PROFESSIONAL REVIEW OF RECORDED EVENTS, ANALYSIS OF SPIKE AND SEIZURE DETECTION, EACH INCREMENT
OF GREATER THAN 12 HOURS, UP TO 26 HOURS OF EEG RECORDING, INTERPRETATION
Neurology
1 0
Outpatient 95720
ELECTROENCEPHALOGRAM (EEG), CONTINUOUS RECORDING, PHYSICIAN OR OTHER QUALIFIED HEALTH CARE
PROFESSIONAL REVIEW OF RECORDED EVENTS, ANALYSIS OF SPIKE AND SEIZURE DETECTION, EACH INCREMENT
OF GREATER THAN 12 HOURS, UP TO 26 HOURS OF EEG RECORDING, INTERPRERPRETATION
Neurology
1 0
Outpatient 95724
ELECTROENCEPHALOGRAM (EEG), CONTINUOUS RECORDING, PHYSICIAN OR OTHER QUALIFIED HEALTH CARE
PROFESSIONAL REVIEW OF RECORDED EVENTS, ANALYSIS OF SPIKE AND SEIZURE DETECTION, INTERPRETATION,
AND SUMMARY REPORT, COMPLETE STUDY GREATER THAN 60 HOURS, UP TO 84
Neurology
1 0
Inpatient
96416
CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED
CHEMOTHERAPY INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF A PORTABLE OR IMPLANTABLE PUMP
Pediatric Hematology-Oncology
1 0
Inpatient
96425
CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECNIQUE, INITIATION OF PROLONGED INFUSION
(MORE THAN 8 HOURS), REQUIRING THE USE OF A PORTABLE OR IMPLANTABLE PUMP
Pediatric Hematology-Oncology
1 0
Outpatient 99183
PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC
OXYGEN THERAPY, PER SESSION
Underseas Medicine
1 0
Outpatient 99183
PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC
OXYGEN THERAPY, PER SESSION
Surgery, Plastic
0 1
Medical Necessity
Inpatient
99233
SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH
REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION;
MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COO
Pediatric Hematology-Oncology
1 0
Outpatient A4595 ELECTRICAL STIMULATOR SUPPLIES, 2 LEAD, PER MONTH, (E.G. TENS, NMES)
Pediatric Sports Medicine
1 0
Outpatient C8900 Magnetic resonance angiography with contrast, abdomen
Hospital
1 0
Outpatient E0953
WHEELCHAIR ACCESSORY, LATERAL THIGH OR KNEE SUPPORT, ANY TYPE INCLUDING FIXED MOUNTING
HARDWARE, EACH
Internal Medicine
1 0
Outpatient E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, PREFABRICATED, INCLUDING FIXED HARDWARE, EACH
Internal Medicine
1 0
Outpatient E1007
WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL
SHEAR REDUCTION
Internal Medicine
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient E1012
WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG
REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH
Internal Medicine
1 0
Outpatient E1028
WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR
JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY
Internal Medicine
1 0
Outpatient E2300 WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM, ANY TYPE
Internal Medicine
0 1
Medical Necessity
Outpatient E2311
POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO
OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE,
MECHANICAL FUNCTION SELECTION SWITCH, AND FIXEDMOUNTING HARDWARE
Internal Medicine
1 0
Outpatient E2313
POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL
FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH
Internal Medicine
1 0
Outpatient E2363
POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED
GLASSMAT)
Internal Medicine
1 0
Outpatient E2377
POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND
MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE
Internal Medicine
1 0
Outpatient E2620
POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22
INCHES ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE
Internal Medicine
1 0
Outpatient E2624
SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES,
ANY DEPTH
Internal Medicine
1 0
Outpatient G0277 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL
Underseas Medicine
1 0
Outpatient G0277 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL
Surgery, Plastic
0 1
Medical Necessity
Outpatient H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
Psychiatry
7 0
Outpatient H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
Family Practice
1 0
Outpatient H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
Neurology & Psychiatry
2 0
Outpatient H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
Psychiatry, Child & Adolescent
1 0
Outpatient H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS
Unknown
1 0
Outpatient H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM
Psychiatry
1 0
Outpatient H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM
Family Practice
1 0
Inpatient ICU Intensive Care Unit
Internal Medicine
1 0
Outpatient J0129 Orencia
Uknown
0 1
Medical Necessity
Outpatient J0178 Eylea
Uknown
8 0
Outpatient J0490 Benlysta
Uknown
7 0
Outpatient J0517 Fasenra
Uknown
1 0
Outpatient J0585 Botox
Uknown
72 0
Outpatient J0881 Aranesp
Uknown
0 1
Medical Necessity
Outpatient J0897 Prolia
Uknown
10 0
Outpatient J0897 Xgeva
Uknown
1 0
Outpatient J1439 Injectafer
Uknown
8 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient J1555 Cuvitru
Uknown
2 0
Outpatient J1557 Gammaplex
Uknown
2 0
Outpatient J1559 Hizentra
Uknown
2 0
Outpatient J1561 Gammaked_Gamunex-C
Uknown
4 2
Medical Necessity
Outpatient J1569 Gammagard
Uknown
2 0
Outpatient J1744 Firazyr
Uknown
1 0
Outpatient J1745 Remicade
Uknown
25 0
Outpatient J1930 Somatuline_Depot
Uknown
2 0
Outpatient J2182 Nucala
Uknown
1 0
Outpatient J2323 Tysabri
Uknown
6 0
Outpatient J2350 Ocrevus
Uknown
10 0
Outpatient J2357 Xolair
Uknown
12 1
Medical Necessity
Outpatient J2505 Neulasta
Uknown
3 0
Outpatient J2506 Neulasta
Uknown
1 0
Outpatient J3032 Vyepti
Uknown
2 0
Outpatient J3262 Actemra IV
Uknown
1 3
Medical Necessity
Outpatient J3358 Stelara IV
Uknown
1 0
Outpatient J3380 Entyvio
Uknown
14 1
Medical Necessity
Outpatient J7318 Durolane
Uknown
0 1
Medical Necessity
Outpatient J7323 Euflexxa
Uknown
7 2
Medical Necessity
Outpatient J7324 Orthovisc
Uknown
21 1
Medical Necessity
Outpatient J7325 Synvisc
Uknown
18 0
Outpatient J7326 Gel-One
Uknown
0 3
Medical Necessity
Outpatient J7327 Monovisc
Uknown
8 2
Medical Necessity
Outpatient J7328 Gelsyn
Uknown
0 1
Medical Necessity
Outpatient J9022 Tecentriq
Uknown
2 0
Outpatient J9035 Avastin
Uknown
10 0
Outpatient J9042 Adcetris
Uknown
1 0
Inpatient
J9060
INJECTION, CISPLATIN, POWDER OR S0LUTION, 10 MG
Pediatric Hematology-Oncology
1 0
Outpatient J9145 Darzalex
Uknown
1 0
Outpatient J9173 Imfinzi
Uknown
1 0
Outpatient J9202 Zoladex
Uknown
3 0
Outpatient J9217 Eligard
Uknown
1 1
Medical Necessity
Outpatient J9217 Lupron_Depot_PC
Uknown
3 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient J9271 Keytruda
Uknown
12 2
Medical Necessity
Outpatient J9299 Opdivo
Uknown
2 0
Outpatient J9303 Vectibix
Uknown
1 0
Outpatient J9306 Perjeta
Uknown
3 0
Outpatient J9312 Rituxan
Uknown
11 0
Outpatient J9354 Kadcyla
Uknown
1 0
Outpatient J9355 Herceptin
Uknown
1 0
Outpatient J9358 Enhertu
Uknown
1 0
Inpatient
J9370
VINCRISTINE SULFATE (ONCOVIN) 1MG/1ML (1ML VIAL)
Pediatric Hematology-Oncology
1 0
Outpatient K0861
POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT
WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
Internal Medicine
1 0
Inpatient MED Medical
Hematology
1 0
Inpatient MED Medical
Internal Medicine
3 0
Inpatient MED Medical
Neurology
4 0
Inpatient MED
Medical
Oncology, Gynecologic
1 0
Inpatient MED
Medical
Pediatric Hematology-Oncology
2 0
Inpatient MED
Medical
Pediatric Surgery
2 0
Inpatient MED
Medical
Surgery
2 0
Inpatient MED
Medical
Surgery, Colon & Rectal
2 0
Inpatient MED
Medical
Surgery, Neurological
2 0
Inpatient MED
Medical
Surgery, Orthopedic
7 0
Inpatient MED
Medical
Surgery, Orthopedic
0 2 Medical Necessity
Inpatient MED
Medical
Surgery, Plastic
1 0
Inpatient MED
Medical
Surgery, Thoracic
1 0
Inpatient MED
Medical
Surgery, Thoracic
0 1 Administrative
Inpatient MEN
Mental Health
Psychiatry
1 0
Outpatient NPR PSYCHOTHERAPY, 60 MINUTES WITH PATIENT
Unknown
1 0
Outpatient NPR
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT,
WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND LOW LEVEL OF MEDICAL
DECISION MAKING. WHEN USING TIME FOR CODE SELECTION, 20-29 MINUTES OF
Unknown
1 0
Outpatient NPR UNLISTED EVALUATION AND MANAGEMENT SERVICE
Unknown
0 1
Medical Necessity
Outpatient NPR
FORM-FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (WITH CONDUCTIVE FIBERS SEPARATED
FROM THR PATIENT'S SKIN BY LAYERS OF FABRIC)
Pediatric Sports Medicine
0 1
Medical Necessity
Outpatient NPR NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT
Pediatric Sports Medicine
0 1
Medical Necessity
Outpatient Q0138 Feraheme
Uknown
2 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Outpatient Q5101 Zarxio
Uknown
8 0
Outpatient Q5103 Inflectra
Uknown
2 0
Outpatient Q5106 Retacrit
Uknown
1 1
Medical Necessity
Outpatient Q5107 Mvasi
Uknown
3 0
Outpatient Q5108 Fulphila
Uknown
1 0
Outpatient Q5111 Udenyca
Uknown
4 0
Outpatient Q5115 Truxima
Uknown
1 0
Outpatient Q5116 Trazimera
Uknown
2 0
Outpatient Q5117 Kanjinti
Uknown
1 0
Outpatient Q5119 Ruxience
Uknown
2 1
Medical Necessity
Outpatient RCANAL Anal Cancer
Hospital
2 0
Outpatient RCBONE BONE METASTASES
Hospital
0 1
Medical Necessity
Overturned
Outpatient RCBRAI BRAIN METASTASES
Hospital
4 0
Outpatient RCBREA BREAST CANCER
Hospital
14 0
Outpatient RCBREA BREAST CANCER
Cancer Center
6 0
Outpatient RCCERV CERVICAL CANCER
Hospital
3 0
Outpatient RCCNSN PRIMARY CNS NEOPLASMS
Hospital
1 0
Outpatient RCESOP Esophageal Cancer
Hospital
1 0
Outpatient RCHENE HEAD/NECK CARCINOMA
Hospital
6 1
Medical Necessity
Outpatient RCHENE HEAD/NECK CARCINOMA
Cancer Center
2 0
Outpatient RCLIVE Liver Cancer
Hospital
1 0
Outpatient RCMETS
Other Metastases
Hospital
3 0
Outpatient RCMETS Other Metastases
Cancer Center
1 1
Medical Necessity
Outpatient RCMUMY Multiple Myeloma
Unknown
1 0
Outpatient
RCNONC NON CANCER RADIATION THERAPY
Hospital
4 0
Outpatient
RCNONC NON CANCER RADIATION THERAPY
Cancer Center
1 0
Outpatient RCNSCL NON-SMALL CELL LUNG CANCER
Hospital
2 0
Outpatient RCOTHE CANCER TYPE OTHER
Hospital
3 0
Outpatient RCPANC PANCREATIC CANCER
Hospital
1 0
Outpatient RCPROS PROSTATE ADENOCARCINOMA
Hospital
1 0
Outpatient RCPROS PROSTATE ADENOCARCINOMA
Cancer Center
3 1
Medical Necessity
Outpatient RCPROS PROSTATE ADENOCARCINOMA
Urology
4 0
Outpatient RCSARC Soft Tissue Sarcoma
Hospital
2 0
Outpatient RCSKIN SKIN CANCER
Unknown
1 0
Propietary
2021 Colorado Prior Authorization Report- Aetna Life Insurance Company and Aetna Health Inc. as required by C.R.S. 10-16-112.5 (2)(c)(I)
Inpatient REH
Rehabilitation
Physical Medicine & Rehabilitation
2 0
Outpatient S4011 IN VITRO FERTILIZATION; INCLUDING BUT NOT LIMITED TO IDENTIFICATION
Endocrinology, Reproductive
0 2 Administrative
Outpatient S4016 FROZEN IN VITRO FERTILIZATION CYCLE, CASE RATE
Endocrinology, Reproductive
0 2 Administrative
Outpatient S4021 IN VITRO FERTILIZATION PROCEDURE CANCELLED AFTER ASPIRATION, CASE RATE
Endocrinology, Reproductive
0 1 Administrative
Outpatient S4022 ASSISTED OOCYTE FERTILIZATION, CASE RATE
Endocrinology, Reproductive
0 2 Administrative
Outpatient S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM
Psychiatry
1 0
Inpatient SA2
Sub-Acute Level 2
General Practice
1 0
Inpatient SNC
Skilled Nursing
Internal Medicine
1 0
Inpatient SNC
Skilled Nursing
Family Practice
1 0
Inpatient SNC
Skilled Nursing
Unknown
1 0
Inpatient SNS
Skilled Nursing Special
Internal Medicine
1 0
Inpatient SUR
Sugical
Surgery
7 0
Inpatient SUR
Sugical
Surgery, Colon & Rectal
1 0
Inpatient SUR
Sugical
Surgery, Orthopedic
3 0
Inpatient SUR
Sugical
Surgery, Oncology
1 0
Inpatient SUR
Sugical
Pediatric Cardiology
0 1 Medical Necessity
Inpatient SUR
Sugical
Surgery, Orthopedic
0 1 Administrative
Outpatient TOC PSYCHOTHERAPY, 60 MINUTES WITH PATIENT
Unknown
1 0
Propietary
