Spreadsheet: 05f8e8b1-f78e-4eaf-9fbc-d9e01653bec4
Sheet: Sheet1

2014-01-01 00:00:00
QUALIS REVIEW PRE-AUTHORIZATION LIST
PHONE: [PHONE]                                 FAX: [PHONE]
 |  |  |  | http://qualishealth.org/healthcare-professionals/idaho-medicaid | http://qualishealth.org/healthcare-professionals/idaho-medicaid | http://qualishealth.org/healthcare-professionals/idaho-medicaid | http://qualishealth.org/healthcare-professionals/idaho-medicaid | http://qualishealth.org/healthcare-professionals/idaho-medicaid
All surgical procedures on this list require pre-authorization for inpatient and outpatient services.
For convenience, use the Find & Select icon in the upper right to search codes
PROCEDURE |  | ICD-9-CM Procedure October 2013 |  |  | CPT Code January 2014
Ear and [NAME]
Cochlear Device Implantation, |  | 20.96 | 20.97 | 20.98 | 69930
with and without
Mastoidectomy
Note: Restricted to age 0 –21 |  | 21.84 | 21.86 | 21.87
Rhinoplasty |  | 21.84 | 21.86 | 21.87 | 30400 | 30410 | 30420 | 30430 | 30435 | 30450
 |  | 21.89 |  |  | 30460 | 30462 | 30465
Septoplasty |  | 21.5 |  |  | 30520
Arthrodesis (Spinal Fusion) |  | 78.59 |  |  | 22532 | 22533 | 22534 | 22548 | 22551 | 22552
 |  | 81.00 | 81.01 | 81.02 | 22554 | 22556 | 22558 | 22585 | 22586 | 22590 | 22595
 |  | 81.03 | 81.04 | 81.05
 |  | 81.06 | 81.07 | 81.08
Note: Artificial disc not a |  | 81.30 | 81.31 | 81.32 | 22600 | 22610 | 22612 | 22614 | 22630
covered benefit. |  | 81.33 | 81.34 | 81.35 | 22632 | 22633 | 22634 | 22800 | 22802 | 22804
 |  | 81.36 | 81.37 | 81.38 | 22808 | 22810 | 22812 | 22830 | 22840 | 22841
 |  | 81.39 | 81.62 | 81.63 | 22842 | 22843 | 22844 | 22845 | 22846 | 22847
 |  | 81.64 |  |  | 22848 | 22849 | 22851 | 27280
Unlisted neck, thorax procedure |  | 78.41 |  |  | 21899
Unlisted spine procedure |  | 78.71 |  |  | 22899
Laminectomy/Diskectomy |  | 03.02 |  |  | 63001 | 63003 | 63005 | 63011 | 63012 | 63015
Laminoplasty |  | 03.09 |  |  | 63016 | 63017 | 63020 | 63030 | 63035 | 63040
 |  | 03.29 |  |  | 63042 | 63043 | 63044 | 63045 | 63046 | 63047
 |  | 03.1 |  |  | 63048 | 63050 | 63051 | 63055 | 63056 | 63057
 |  | 03.6 |  |  | 63064 | 63066 | 63075 | 63076 | 63077 | 63078
 |  | 80.50 |  |  | 63170 | 63172 | 63173 | 63180 | 63182
 |  | 80.51 |  |  | 63185 | 63190 | 63191 | 63194 | 63195 | 63196 | 63197 | 63198 | 63199 | 63200
Spinal Neurostimulator |  | 03.93 | 03.94 |  | 63650 | 63655
electrode array( Implant,
replacement or removal)
Spinal Neurostimulator pulse |  | 86.94 | 86.95 | 86.96 | 63685
generator receiver (Insertion or |  | 86.97 | 86.97
replacement)
[NAME]
[NAME]* |  | 86.94 | 86.95 | 86.96 | 64590
(Insertion or replacement) |  | 86.97 | 86.98
* The same ICD9 codes, 86.94 through 86.98, are utilized for both Gastric and [NAME] replacement or insertion procedures,
however please note that Qualis Health only conducts pre-authorization for Gastric Neurostimulator procedures and the Medical Care Unit at Idaho
Medicaid conducts pre-authorization for Cranial Neurostimulator procedures. Similarly, CPT code, 64590, is utilized for both Gastric
Neurostimulators and Peripheral Neurostimulator procedures, while Qualis Health conducts pre-authorization only for Gastric Neurostimulators, the
Medical Care Unit at Idaho Medicaid conducts pre-authorization for Peripheral Neurostimulators
[NAME], [NAME] |  | 44.99 |  |  | 43659
[NAME] |  | 43.82 |  |  | 43644 | 43645 | 43770 | 43771 | 43772 | 43773 | 43774 | 43775 | 43842 | 43843
 |  |  |  |  | 43845 | 43846 | 43847 | 43848
 |  | 44.31 | 44.39
 |  | 44.95
Note: Procedure must be performed in a Medicare approved Bariatric Surgery Center (BSC) or
[NAME] (BSCE)
Revision of gastroduodenal |  | 44.5 |  |  | 43850
anastomosis with
reconstruction; without
vagotomy
Panniculectomy, Excessive Skin |  | 86.83 |  |  | 15833 | 15836 | 15830 | 15847 | 15877
Removal for Leg and Arm
Hysterectomy |  | 57.84 | 65.61 |  | 51925 | 58180 | 58956 | 58953 | 58954 | 59135 | 59525 | 58150 | 58152 | 58200
Abdominal |  | 68.31 | 68.39 |  | 58951 | 59135 | 59525 | 58210 | 58550 | 58260 | 58262 | 58263 | 58267 | 58270
 |  | 68.41 | 68.49 |  | 58552 | 58553 | 58554 | 58275 | 58280 | 58290 | 58291 | 58292 | 58293 | 58294
 |  | 68.61 | 68.69 |  | 58541 | 58542 | 58543 | 58544 | 58548 | 58570 | 58571 | 58572 | 58573
Vaginal |  | 68.51 | 68.59
Laparoscopic |  | 68.71 | 68.79 |  | 58285
Radical |  | 68.9
Other and Unspecified
Reduction Mammoplasty
Unilateral, Bilateral |  | 85.31 | 85.32 |  | 19318
Total Hip Replacement |  | 81.51 |  |  | 27130 | 27132 | 27134 | 27137 | 27138
Revision |  | 81.53
 |  | 00.70 | 00.71
 |  | 00.72 | 00.73
 |  | 00.74 | 00.75
 |  | 00.76 | 00.77
 |  | 00.85 | 00.86
 |  | 00.87
Partial Hip Replacement |  | 81.52 |  |  | 27125
Total & Partial Knee |  | 81.54 | 81.55 |  | 27445 | 27446 | 27447 | 27486 | 27487
Replacement |  | 00.80 | 00.81
Revision |  | 00.82 | 00.83
 |  | 00.84
Vein Ablation and Ligation
Injection of sclerosing solution, |  | 39.92 | 38.89 |  | 36470 | 36471 | 36475 | 36476 | 36478 | 36479
Endovenous Ablation
Ligation, Division and Stripping |  | 38.59 |  |  | 37500 | 37700 | 37718 | 37722 | 37735 | 37760 | 37780 | 37785
Cellular Transplants-The following procedures must be performed in a Medicare approved facility:
Bone Marrow Transplant |  |  |  |  | 38241
Autologous |  | 41.00 | 41.01 | 41.09
 |  | 41.04 | 41.07
Allogenic |  | 41.02 | 41.03 | 41.05 | 38240 | 38242
 |  | 41.06 | 41.08
Organ Transplants-The following procedures must be performed in a Medicare approved facility which is also approved by CMS for the requested type of transplant:
[NAME] prep of |  | Not available |  |  | 33944
cadaver [NAME]
Allograft prior to
transplant
Heart Transplant |  | 37.51 | 37.52 | 37.53 | 33945
 |  | 37.54
Intestinal Transplant |  | 46.97 |  |  | 44133 | 44135 | 44136 | 44715 | 44720 | 44721
Removal of Transplanted |  | 45.62 |  |  | 44137
Intestinal Allograft.
Complete
[NAME] |  | 55.61 |  |  | 50323 | 50325 | 50327 | 50328 | 50329 | 50360
 |  | 55.69 |  |  | 50365 | 50380
Pancreatectomy, total/subtotal, |  | 52.6 |  |  | 48160
with autologous transplant
of pancreas/pancreatic islet
cells
[NAME] |  | 50.51 | 50.59 |  | 47135 | 47136 | 47143 | 47144 | 47145 | 47146 | 47146 | 47147
Note: Liver from live donor not a covered benefit
Lung transplant |  | 33.50 | 33.51 | 33.52 | 32850 | 32851 | 32852 | 32853 | 32854 | 32855
Note: Restricted to age 0 – 21 |  |  |  |  | 32856
Combined heart-lung |  | 33.6 |  |  | 33935
transplant
Cardiac related Devices:
Implantation of Patient- |  | 89.50 |  |  | 33282
Activated Cardiac Event
Recorder
Replacement/repair of heart |  | 37.63 |  |  | 33981 | 33982 | 33983
ventricle assist device
Endovascular Repair of |  | 39.71 |  |  | 34803
Infrarenal [NAME]
Aneurysm, using 2 Dock
limbs
Alcohol and Drug Rehabilitation and Detoxification
Inpatient Only
Alcohol Rehabilitation |  | 94.61 |  |  | 90899
Alcohol Detoxification |  | 94.62 |  |  | 90899
Alcohol Rehabilitation and |  | 94.63 |  |  | 90899
detoxification
Drug Rehabilitation |  | 94.64 |  |  | 90899
Drug Detoxification |  | 94.65 |  |  | 90899
Drug Rehabilitation and |  | 94.66 |  |  | 90899
detoxification
Combined alcohol and drug |  | 94.67 |  |  | 90899
rehabilitation
Combined alcohol and drug |  | 94.68 |  |  | 90899
detoxification
Combined alcohol and drug |  | 94.69 |  |  | 90899
rehabilitation and
detoxification
ICD-9 Diagnosis PSYCHIATRIC ADMISSIONS FOR IN-PATIENT ONLY
 |  | 291.0 | 291.1 | 291.2 | 291.3 | 291.4 | 291.5 | 291.81 | 291.82 | 291.89 | 291.9 | 292.0 | 292.11 | 292.12
 |  | 292.2 | 292.81 | 292.82 | 292.83 | 292.84 | 292.85 | 292.89 | 292.9 | 293.0 | 293.1 | 293.81 | 293.82 | 293.83
 |  | 293.84 | 293.89 | 293.9 | 294.0 | 294.10 | 294.11 | 294.11 | 294.20 | 294.21 | 294.8 | 294.9 | 295.00 | 295.01
 |  | 295.02 | 295.03 | 295.03 | 295.04 | 295.05 | 295.10 | 295.11 | 295.12 | 295.13 | 295.14 | 295.15 | 295.20 | 295.21
 |  | 295.22 | 295.23 | 295.24 | 295.25 | 295.30 | 295.31 | 295.32 | 295.33 | 295.34 | 295.35 | 295.40 | 295.41 | 295.42
 |  | 295.43 | 295.44 | 295.45 | 295.50 | 295.51 | 295.52 | 295.53 | 295.54 | 295.55 | 295.60 | 295.61 | 295.62 | 295.63
 |  | 295.64 | 295.65 | 295.70 | 295.71 | 295.72 | 295.73 | 295.74 | 295.75 | 295.80 | 295.81 | 295.82 | 295.83 | 295.84
 |  | 295.85 | 295.90 | 295.91 | 295.92 | 295.93 | 295.94 | 295.95 | 296.00 | 296.01 | 296.02 | 296.03 | 296.04 | 296.05
 |  | 296.06 | 296.10 | 296.11 | 296.12 | 296.13 | 296.14 | 296.15 | 296.16 | 296.20 | 296.21 | 296.22 | 296.23 | 296.24
 |  | 296.25 | 296.26 | 296.30 | 296.31 | 296.32 | 296.33 | 296.34 | 296.35 | 296.36 | 296.40 | 296.41 | 296.42 | 296.43
 |  | 296.44 | 296.45 | 296.46 | 296.50 | 296.51 | 296.52 | 296.53 | 296.54 | 296.55 | 296.56 | 296.60 | 296.61 | 296.62
 |  | 296.63 | 296.64 | 296.65 | 296.66 | 296.7 | 296.80 | 296.81 | 296.82 | 296.89 | 296.90 | 296.99 | 297.0 | 297.1
 |  | 297.2 | 297.3 | 297.8 | 297.9 | 298.0 | 298.1 | 298.2 | 298.3 | 298.4 | 298.8 | 298.9 | 299.00 | 299.01
 |  | 299.10 | 299.11 | 299.80 | 299.81 | 299.90 | 299.91 | 300.00 | 300.01 | 300.02 | 300.09 | 300.10 | 300.11 | 300.12
 |  | 300.13 | 300.14 | 300.15 | 300.16 | 300.19 | 300.20 | 300.21 | 300.22 | 300.23 | 300.29 | 300.3 | 300.4 | 300.5
 |  | 300.6 | 300.7 | 300.81 | 300.82 | 300.89 | 300.9 | 301.0 | 301.10 | 301.11 | 301.12 | 301.13 | 301.20 | 301.21
 |  | 301.22 | 301.3 | 301.4 | 301.50 | 301.51 | 301.59 | 301.6 | 301.7 | 301.81 | 301.82 | 301.83 | 301.84 | 301.89
 |  | 301.9 | 302.0 | 302.1 | 302.2 | 302.3 | 302.4 | 302.50 | 302.51 | 302.52 | 302.53 | 302.6 | 302.70 | 302.71
 |  | 302.72 | 302.73 | 302.74 | 302.75 | 302.76 | 302.79 | 302.81 | 302.82 | 302.83 | 302.84 | 302.85 | 302.89 | 302.9
 |  | 303.00 | 303.01 | 303.02 | 303.03 | 303.90 | 303.91 | 303.92 | 303.93 | 304.00 | 304.01 | 304.02 | 304.03 | 304.10
 |  | 304.11 | 304.12 | 304.13 | 304.14 | 304.20 | 304.21 | 304.22 | 304.23 | 304.30 | 304.31 | 304.32 | 304.33 | 304.40
 |  | 304.41 | 304.42 | 304.43 | 304.50 | 304.51 | 304.52 | 304.53 | 304.60 | 304.61 | 304.62 | 304.63 | 304.70 | 304.71
 |  | 304.72 | 304.73 | 304.80 | 304.81 | 304.82 | 304.83 | 304.90 | 304.91 | 304.92 | 304.93 | 305.00 | 305.01 | 305.02
 |  | 305.03 | 305.1 | 305.20 | 305.21 | 305.22 | 305.23 | 305.30 | 305.31 | 305.32 | 305.33 | 305.40 | 305.41 | 305.42
 |  | 305.43 | 305.50 | 305.51 | 305.52 | 305.53 | 305.60 | 305.61 | 305.62 | 305.63 | 305.70 | 305.71 | 305.72 | 305.73
 |  | 305.80 | 305.81 | 305.82 | 305.83 | 305.90 | 305.91 | 305.92 | 305.93 | 306.0 | 306.1 | 306.2 | 306.3 | 306.4
 |  | 306.50 | 306.51 | 306.52 | 306.53 | 306.59 | 306.6 | 306.7 | 306.8 | 306.9 | 307.0 | 307.1 | 307.20 | 307.21
 |  | 307.22 | 307.23 | 307.3 | 307.40 | 307.41 | 307.42 | 307.43 | 307.44 | 307.45 | 307.46 | 307.47 | 307.48 | 307.49
 |  | 307.50 | 307.51 | 307.52 | 307.53 | 307.54 | 307.59 | 307.6 | 307.7 | 307.80 | 307.81 | 307.89 | 307.9 | 308.0
 |  | 308.1 | 308.2 | 308.3 | 308.4 | 308.9 | 309.0 | 309.1 | 309.21 | 309.22 | 309.23 | 309.24 | 309.28 | 309.29
 |  | 309.3 | 309.4 | 309.81 | 309.82 | 309.83 | 309.89 | 309.9 | 310.0 | 310.1 | 310.2 | 310.81 | 310.89 | 310.9
 |  | 312.00 | 312.01 | 312.02 | 312.03 | 312.10 | 312.11 | 312.12 | 312.13 | 312.20 | 312.21 | 312.22 | 312.23 | 312.30
 |  | 312.31 | 312.32 | 312.33 | 312.34 | 312.35 | 312.39 | 312.4 | 312.81 | 312.82 | 312.89 | 312.9 | 313.0 | 313.1
 |  | 313.21 | 313.22 | 313.23 | 313.3 | 313.81 | 313.82 | 313.83 | 313.89 | 313.9 | 314.00 | 314.01 | 314.1 | 314.2
 |  | 314.8 | 314.9
 |  |  | Psychiatric Admissions-Inpatient only
ICD-9 Diagnosis PHYSICAL REHAB ADMISSIONS FOR IN-PATIENT ONLY
Physical Rehabilitation -Inpatient |  |  | V57.0 | V57.1 | V57.21 | V57.22 | V57.3 | V57.4 | V57.81 | V57.89 | V57.9
Only
Care involving use of |  |  |  | This includes admission to all rehabilitation facilities, regardless of
rehabilitation procedures |  |  |  | diagnosis.
 |  |  | All admissions to Long Term Acute Care Facilities (LTAC)
 | Current Procedural Terminology (CPT®) is copyright American Medical Association 2014. All rights reserved.
 | CPT is a registered trademark of the American Medical Association.
 | Approved List of V-Codes That May Be Used for Principal Diagnoses
 | The V-Codes in the current ICD-9 CM book, Tabular List for V-Codes, listed as acceptable codes for use as a principal diagnosis
 | will be used for pre-authorization and concurrent review purposes.
 | Only these V-Codes will be accepted by the Qualis Health clinical reviewers when performing pre-authorization or concurrent
 | review for Idaho Medicaid participants.