Cigna prior authorization, page 11

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
24999*	Unlisted procedure, humerus or elbow	Master Precertification List For Health Care Providers, Pg 27 Original policy
25259*	Manipulation, wrist, under anesthesia	Master Precertification List For Health Care Providers, Pg 27 Original policy
25999*	Unlisted procedure, forearm or wrist	Master Precertification List For Health Care Providers, Pg 27 Original policy
26989*	Unlisted procedure, hands or fingers	Master Precertification List For Health Care Providers, Pg 27 Original policy
27096*	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed	Master Precertification List For Health Care Providers, Pg 27 Original policy
27125*	Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)	Master Precertification List For Health Care Providers, Pg 27 Original policy
27130*	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft	Master Precertification List For Health Care Providers, Pg 27 Original policy
27132*	Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft	Master Precertification List For Health Care Providers, Pg 27 Original policy
27134*	Revision of total hip arthroplasty; both components, with or without autograft or allograft	Master Precertification List For Health Care Providers, Pg 27 Original policy
27137*	Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft	Master Precertification List For Health Care Providers, Pg 27 Original policy
27138*	Revision of total hip arthroplasty; femoral component only, with or without allograft	Master Precertification List For Health Care Providers, Pg 27 Original policy
27175*	Treatment of slipped femoral epiphysis; by traction, without reduction	Master Precertification List For Health Care Providers, Pg 28 Original policy
27198*	Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27275*	Manipulation, hip joint, requiring general anesthesia	Master Precertification List For Health Care Providers, Pg 28 Original policy
27278*	Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s]), without placement of transfixation device	Master Precertification List For Health Care Providers, Pg 28 Original policy
27279*	Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixation device	Master Precertification List For Health Care Providers, Pg 28 Original policy
27280*	Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed	Master Precertification List For Health Care Providers, Pg 28 Original policy
27299*	Unlisted procedure, pelvis or hip joint	Master Precertification List For Health Care Providers, Pg 28 Original policy
27332*	Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral	Master Precertification List For Health Care Providers, Pg 28 Original policy
27333*	Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral	Master Precertification List For Health Care Providers, Pg 28 Original policy
27334*	Arthrotomy, with synovectomy, knee; anterior OR posterior	Master Precertification List For Health Care Providers, Pg 28 Original policy
27335*	Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area	Master Precertification List For Health Care Providers, Pg 28 Original policy
27355*	Excision or curettage of bone cyst or benign tumor of femur;	Master Precertification List For Health Care Providers, Pg 28 Original policy
27356*	Excision or curettage of bone cyst or benign tumor of femur; with allograft	Master Precertification List For Health Care Providers, Pg 28 Original policy
27357*	Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27358*	Excision or curettage of bone cyst or benign tumor of femur; with internal fixation	Master Precertification List For Health Care Providers, Pg 28 Original policy
27360*	Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27403*	Arthrotomy with meniscus repair, knee	Master Precertification List For Health Care Providers, Pg 28 Original policy
27405*	Repair, primary, torn ligament and/or capsule, knee; collateral	Master Precertification List For Health Care Providers, Pg 28 Original policy
27412*	Autologous chondrocyte implantation, knee	Master Precertification List For Health Care Providers, Pg 28 Original policy
27415*	Osteochondral allograft, knee, open	Master Precertification List For Health Care Providers, Pg 28 Original policy
27416*	Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])	Master Precertification List For Health Care Providers, Pg 28 Original policy
27418*	Anterior tibial tubercleplasty (eg, Maquet type procedure)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27420*	Reconstruction of dislocating patella; (eg, Hauser type procedure)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27422*	Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27424*	Reconstruction of dislocating patella; with patellectomy	Master Precertification List For Health Care Providers, Pg 28 Original policy
27425*	Lateral retinacular release, open	Master Precertification List For Health Care Providers, Pg 28 Original policy
27427*	Ligamentous reconstruction (augmentation), knee; extra-articular	Master Precertification List For Health Care Providers, Pg 28 Original policy
27428*	Ligamentous reconstruction (augmentation), knee; intra-articular (open)	Master Precertification List For Health Care Providers, Pg 28 Original policy
27429*	Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular	Master Precertification List For Health Care Providers, Pg 29 Original policy
27438*	Arthroplasty, patella; with prosthesis	Master Precertification List For Health Care Providers, Pg 29 Original policy
27440*	Arthroplasty, knee, tibial plateau;	Master Precertification List For Health Care Providers, Pg 29 Original policy
27441*	Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy	Master Precertification List For Health Care Providers, Pg 29 Original policy
27442*	Arthroplasty, femoral condyles or tibial plateau(s), knee;	Master Precertification List For Health Care Providers, Pg 29 Original policy
27443*	Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy	Master Precertification List For Health Care Providers, Pg 29 Original policy
27446*	Arthroplasty, knee, condyle and plateau; medial OR lateral compartment	Master Precertification List For Health Care Providers, Pg 29 Original policy
27447*	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)	Master Precertification List For Health Care Providers, Pg 29 Original policy
27486*	Revision of total knee arthroplasty, with or without allograft; 1 component	Master Precertification List For Health Care Providers, Pg 29 Original policy
27487*	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component	Master Precertification List For Health Care Providers, Pg 29 Original policy
27570*	Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)	Master Precertification List For Health Care Providers, Pg 29 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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