Cigna prior authorization, page 10

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
22845*	Anterior instrumentation; 2 to 3 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22846*	Anterior instrumentation; 4 to 7 vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22847*	Anterior instrumentation; 8 or more vertebral segments	Master Precertification List For Health Care Providers, Pg 25 Original policy
22848*	Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum	Master Precertification List For Health Care Providers, Pg 25 Original policy
22849*	Reinsertion of spinal fixation device	Master Precertification List For Health Care Providers, Pg 25 Original policy
22850*	Removal of posterior nonsegmental instrumentation (eg, Harrington rod)	Master Precertification List For Health Care Providers, Pg 25 Original policy
22852*	Removal of posterior segmental instrumentation	Master Precertification List For Health Care Providers, Pg 26 Original policy
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	Master Precertification List For Health Care Providers, Pg 26 Original policy
22854*	Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect	Master Precertification List For Health Care Providers, Pg 26 Original policy
22855*	Removal of anterior instrumentation	Master Precertification List For Health Care Providers, Pg 26 Original policy
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	Master Precertification List For Health Care Providers, Pg 26 Original policy
22857*	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar	Master Precertification List For Health Care Providers, Pg 26 Original policy
22858*	Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical	Master Precertification List For Health Care Providers, Pg 26 Original policy
22859*	Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect	Master Precertification List For Health Care Providers, Pg 26 Original policy
22860*	Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar	Master Precertification List For Health Care Providers, Pg 26 Original policy
22861*	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical	Master Precertification List For Health Care Providers, Pg 26 Original policy
22862*	Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar	Master Precertification List For Health Care Providers, Pg 26 Original policy
22867*	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level	Master Precertification List For Health Care Providers, Pg 26 Original policy
22868*	Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level	Master Precertification List For Health Care Providers, Pg 26 Original policy
22869*	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level	Master Precertification List For Health Care Providers, Pg 26 Original policy
22870*	Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level	Master Precertification List For Health Care Providers, Pg 26 Original policy
22899*	Unlisted procedure, spine	Master Precertification List For Health Care Providers, Pg 26 Original policy
22999*	Unlisted procedure, abdomen, musculoskeletal system	Master Precertification List For Health Care Providers, Pg 26 Original policy
23000*	Removal of subdeltoid calcareous deposits, open	Master Precertification List For Health Care Providers, Pg 26 Original policy
23020*	Capsular contracture release (eg, Sever type procedure)	Master Precertification List For Health Care Providers, Pg 26 Original policy
23120*	Claviculectomy; partial	Master Precertification List For Health Care Providers, Pg 26 Original policy
23130*	Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release	Master Precertification List For Health Care Providers, Pg 26 Original policy
23145*	Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft)	Master Precertification List For Health Care Providers, Pg 26 Original policy
23155*	Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)	Master Precertification List For Health Care Providers, Pg 27 Original policy
23172*	Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula	Master Precertification List For Health Care Providers, Pg 27 Original policy
23174*	Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck	Master Precertification List For Health Care Providers, Pg 27 Original policy
23410*	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute	Master Precertification List For Health Care Providers, Pg 27 Original policy
23412*	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic	Master Precertification List For Health Care Providers, Pg 27 Original policy
23415*	Coracoacromial ligament release, with or without acromioplasty	Master Precertification List For Health Care Providers, Pg 27 Original policy
23420*	Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)	Master Precertification List For Health Care Providers, Pg 27 Original policy
23430*	Tenodesis of long tendon of biceps	Master Precertification List For Health Care Providers, Pg 27 Original policy
23440*	Resection or transplantation of long tendon of biceps	Master Precertification List For Health Care Providers, Pg 27 Original policy
23450*	Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation	Master Precertification List For Health Care Providers, Pg 27 Original policy
23455*	Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)	Master Precertification List For Health Care Providers, Pg 27 Original policy
23460*	Capsulorrhaphy, anterior, any type; with bone block	Master Precertification List For Health Care Providers, Pg 27 Original policy
23462*	Capsulorrhaphy, anterior, any type; with coracoid process transfer	Master Precertification List For Health Care Providers, Pg 27 Original policy
23465*	Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block	Master Precertification List For Health Care Providers, Pg 27 Original policy
23466*	Capsulorrhaphy, glenohumeral joint, any type multidirectional instability	Master Precertification List For Health Care Providers, Pg 27 Original policy
23470*	Arthroplasty, glenohumeral joint; hemiarthroplasty	Master Precertification List For Health Care Providers, Pg 27 Original policy
23472*	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)	Master Precertification List For Health Care Providers, Pg 27 Original policy
23473*	Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component	Master Precertification List For Health Care Providers, Pg 27 Original policy
23474*	Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component	Master Precertification List For Health Care Providers, Pg 27 Original policy
23700*	Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)	Master Precertification List For Health Care Providers, Pg 27 Original policy
23929*	Unlisted procedure, shoulder	Master Precertification List For Health Care Providers, Pg 27 Original policy
24300*	Manipulation, elbow, under anesthesia	Master Precertification List For Health Care Providers, Pg 27 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

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