Prior Authorization List Changes

HPSM periodically updates our list of codes requiring prior authorization to reflect current clinical guidelines. You can review these changes or archived Prior Authorization Required (PAR) Lists below.

Note that with our 2020 Q3 update, all codes that do not require a prior authorization have been removed from our list. Services requiring a prior authorization or codes listed as conditional can still be found on our list.

 Addition of codes that do not require authorization

  • Q2 2020 (effective 7/1/2020): 86328, 86769, 87635, 90632, 90867, 90868, 93662, 96116, 96121, 96130, 96131, 96132, 96136, 96137, 96138, 96139, 96370, C9057, C9058, C9803, G2010, G2012, G2023, G2024, U0001, U0002, U0003, U0004

 Removals of prior authorization requirements

  • Q3 2020 (effective 10/1/2020): 90849, 99152, Z5822, Z5900, Z5902, Z5904, Z5906, Z5908, Z5910, Z5912, Z5914, Z5916, Z5918, Z5920, Z5922, Z5924.
  • Q4 2019 (effective 1/1/2020): L1902, L3670, L4361, G0480, G0481, G0482, G0483
  • Q3 2019 (effective 10/01/2019): A4281, A4282, A4283, A4284, A4285, A4286, J9355, L0180, L1830, J1453, J0881
  • Q2 2019 (effective 07/01/2019): L0120, L4350, 11102, 11103, 11104, 11105, 11106, 11107, 81329, E0114, E0147, E0148, E0149, E0153, E0154, E0155, E0156, L1820, L3660, L3808, L3908
  • Q1 2019 (effective 04/01/2019): E0602, E0603, 01480, 11042, 11043, 11044, 11047, 14040, 17110, 17111, 20605, 27650, 28124, 28193, 28415, 73700, Z7506.
  • Q4 2018 (effective 01/01/2019 unless otherwise noted): Z4304, Z4309, Z4312, Z4313, Z4306, 92552, 92557, 63057, J0606 (retroactively effective to 1/1/2018), and J0604 (retroactively effective to 1/1/2018)
  • Q3 2018 (effective 09/01/2018): 87631, 87632, A9520, A9515, 93976, A9588, A9587, 51728, 91040, 71045, 74018, 77399, 97803, 81203, 81243, 81244, 81245, 81246, 81275, 81292, 81294, 81295, 81297, 81298, 81300, 81317, 81319, 81370, 8138
  • Q2 2018 (effective 07/01/2018): 11100, 11101, 92082, 66821, 52005, 52356, 94621, 97802, 91200, 78014, V5011, 58300, 93295, 31237, 31238, 31239, 31240, 38222, 76999, 78205, 78206, 81220, 80299, 87633, 43259, G0248, G0249, G0250, L3650, 69990, 64859, E0100, E0143, E0163, A6545, L3762, L4316, L3170, and 33320

 Additions of prior authorization requirements:

  • Q3 2020 (effective 10/1/2020): 15820, 15821, 30462, 36475, 36476, 36478, 36479, 67901, 67902, 67903, 67904, 67906, 67908, 67911, 90378, 90867, 90868, 96105, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, G0154, J3304.
  • Q2 2020 (effective 7/1/2020): 58150, 58180, 58200, 58210, 58260, 58262, 58290, 58292, 81432, 81541, 81542, 81599, C9053, C9056
  • Q4 2019 (effective 1/1/2020): Q5103, Q5104, 0504T, V2531
  • Q3 2019 (effective 10/01/2019): J0570, A9606, J0129, 19499, 99152, 81215, 81217, C9044, C9045, J2326, J9036, Q5115, J9023, 95012, J1428, 27441, Q2041
  • Q2 2019 (effective 07/01/2019): J7311, J0887, J3262, A0130, A0425, A0426, A0428, T2005, 81455, C9408, J0584, J0599, J2186, J3245, J3397, J7177, J9153, J9229, Q5107
  • Q1 2019 (effective 04/01/2019): Q9995, 10004 – 10012, 11102 – 11107, 76391, 77046-77049, 81163 – 81167, 81173, 81174, 81204, 81177 - 81190, 81234, 81239, 81271, 81274, 81284 – 81286, 81289, 81306, 81312, 81329, 81336, 81337, 81343 - 81345, 81518, 81216, V5171, V5172, V5181, V5211 – V5215, V5221, A9513, C9038, J9044, J9057, J9173, J9311, J9312, Q2042, C9036, J0517, J0567, J1301, J1628, J1746, J3316, J3398, J7170, J9312, Q5109
  • Q4 2018 (effective 01/01/2019): Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, and Q4182
  • Q3 2018 (effective 09/01/2018): G0422, G0423, A4281, A4282, A4283, A4284, A4285, A4286, Q4159, Q4160, K0903
  • Q2 2018 (updated 07/01/2018): 27090, 27091, 27125, 27130, 27132, 27134, 27236, 27137, 27138, 27438, 27446, 27447, 27486, 27487 and 27488

 Retired codes (no longer covered, deleted from list)

  • Q2 2020 (effective 7/1/2020): 96101, 96119
  • Q4 2019 (effective 01/01/2020): X4300-X4304, X4310, X4312, X4500, X4501, X4504, X4522, X4526, X4530, X4532, X4540, X4542, X4544, Z5822, Z5900, Z5902, Z5904, Z5906, Z5908, Z5910, Z5912, Z5914, Z5916, Z5918, Z5920, Z5922, Z5924, Z5928, Z5930, Z5932, Z5934, Z5936, Z5940, Z5942, Z5944, Z5950, Z5952, Z5954, Z5956, Z5958, Z5964, Z5966, Z5968
  • Q1 2019 (effective 04/01/2019): 10022, 11100, 11101, 20005, 27370, 33282, 33284, 43760, 50395, 64508, 64550, 66220,81211, 81213, 76001, 77058, 77059, 78270-78272, 92275, 95975, 95978, 95979, 96111, 96118, V5170, V5180 V5210, V5220, J9310, J0833, Q5102, C9275, C9497, C9741, K0903, Q4131, Q4172, C8904, C8907, C9744

 Changes to prior authorization conditions:

  • Q3 2020 (effective 10/1/2020): 20912, 21210, 36482, 36483, 67900, 90846, 90847, 90869, J1950, X4300, X4301, X4302, X4303, X4304, X4310, X4312, X4500, X4501, X4504.
  • Q2 2020 (effective 7/1/2020): 90846, 90869, 99306, 99501, 99502, 99600, J9179, Q3014, S9988, S9996
  • Q4 2019 (effective 1/1/2020): Conditional requirements were changed for 27 codes: 92507, 92508, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532. Additionally, 34 codes are now CareAdvantage-only benefits; for Medi-Cal members these codes should be billed to FFS rather than HPSM: C9133, C9136, C9137, C9141, J7175, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, J7199, J7200, J7201, J7202, J7203, J7205, J7207, J7208, J7209, J7210, J7211
  • Q3 2019 (effective 10/01/2019): 90586, J0604, J7170, A0130, A0380, A0425, A0426, A0428, T2001
  • Q1 2019 (effective 04/01/2019): removed no longer applicable comments from G0475,G0480, G0481, G0482, G0483, A9276, A9277, A9278
  • Q3 2018 (effective 09/01/2018): Providers may now request authorization for a 12 month period for codes 11055, 11056 and 11057 when rendered in a SNF/LTC facility as part of an authorized stay.

 Formatting Updates

  • Q3 2020 (effective 10/1/2020): all codes that do not require a prior authorization removed from list. Services requiring a prior authorization or codes listed as conditional can still be found on list.
  • Q4 2018 (effective 01/01/2019): removed comments from 17 codes that were no longer applicable, due to these codes no longer requiring prior authorization.
  • Q2 2018 (updated 07/01/2018): Introduced a change log and archive to catalog authorization requirement changes.