Cigna prior authorization, page 17

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
43241*	Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter	Master Precertification List For Health Care Providers, Pg 43 Original policy
43243*	Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices	Master Precertification List For Health Care Providers, Pg 43 Original policy
43244*	Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices	Master Precertification List For Health Care Providers, Pg 43 Original policy
43245*	Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)	Master Precertification List For Health Care Providers, Pg 43 Original policy
43247*	Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)	Master Precertification List For Health Care Providers, Pg 43 Original policy
43248*	Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire	Master Precertification List For Health Care Providers, Pg 43 Original policy
43249*	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)	Master Precertification List For Health Care Providers, Pg 43 Original policy
43250*	Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps	Master Precertification List For Health Care Providers, Pg 43 Original policy
43251*	Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique	Master Precertification List For Health Care Providers, Pg 43 Original policy
43252*	Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy	Master Precertification List For Health Care Providers, Pg 43 Original policy
43254*	Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection	Master Precertification List For Health Care Providers, Pg 43 Original policy
43255*	Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method	Master Precertification List For Health Care Providers, Pg 44 Original policy
43257*	Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease	Master Precertification List For Health Care Providers, Pg 44 Original policy
43266*	Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43270*	Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43284*	Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed	Master Precertification List For Health Care Providers, Pg 44 Original policy
43289*	Unlisted laparoscopy procedure, esophagus	Master Precertification List For Health Care Providers, Pg 44 Original policy
43290*	Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon	Master Precertification List For Health Care Providers, Pg 44 Original policy
43497*	Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])	Master Precertification List For Health Care Providers, Pg 44 Original policy
43499*	Unlisted procedure, esophagus	Master Precertification List For Health Care Providers, Pg 44 Original policy
43631	Gastrectomy, partial, distal; with gastroduodenostomy	Master Precertification List For Health Care Providers, Pg 44 Original policy
43632	Gastrectomy, partial, distal; with gastrojejunostomy	Master Precertification List For Health Care Providers, Pg 44 Original policy
43633	Gastrectomy, partial, distal; with Roux-en-Y reconstruction	Master Precertification List For Health Care Providers, Pg 44 Original policy
43634	Gastrectomy, partial, distal; with formation of intestinal pouch	Master Precertification List For Health Care Providers, Pg 44 Original policy
43644*	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43645*	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption	Master Precertification List For Health Care Providers, Pg 44 Original policy
43659*	Unlisted laparoscopy procedure, stomach	Master Precertification List For Health Care Providers, Pg 44 Original policy
43770*	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43771*	Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only	Master Precertification List For Health Care Providers, Pg 44 Original policy
43772*	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only	Master Precertification List For Health Care Providers, Pg 44 Original policy
43773*	Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only	Master Precertification List For Health Care Providers, Pg 44 Original policy
43774*	Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components	Master Precertification List For Health Care Providers, Pg 44 Original policy
43775*	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43842	Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty	Master Precertification List For Health Care Providers, Pg 44 Original policy
43843	Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty	Master Precertification List For Health Care Providers, Pg 44 Original policy
43845	Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)	Master Precertification List For Health Care Providers, Pg 44 Original policy
43846	Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy	Master Precertification List For Health Care Providers, Pg 44 Original policy
43847	Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption	Master Precertification List For Health Care Providers, Pg 44 Original policy
43848	Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device	Master Precertification List For Health Care Providers, Pg 45 Original policy
43860	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy	Master Precertification List For Health Care Providers, Pg 45 Original policy
43865	Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy	Master Precertification List For Health Care Providers, Pg 45 Original policy
43881*	Implantation or replacement of gastric neurostimulator electrodes, antrum, open	Master Precertification List For Health Care Providers, Pg 45 Original policy
43886*	Gastric restrictive procedure, open; revision of subcutaneous port component only	Master Precertification List For Health Care Providers, Pg 45 Original policy
43888*	Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only	Master Precertification List For Health Care Providers, Pg 45 Original policy
43889*	Gastric restrictive procedure, transoral, endoscopic sleeve gastroplasty (ESG), including argon plasma coagulation, when performed	Master Precertification List For Health Care Providers, Pg 45 Original policy
43999*	Unlisted procedure, stomach	Master Precertification List For Health Care Providers, Pg 45 Original policy
44132	Donor enterectomy (including cold preservation), open; from cadaver donor	Master Precertification List For Health Care Providers, Pg 45 Original policy
44133	Donor enterectomy (including cold preservation), open; partial, from living donor	Master Precertification List For Health Care Providers, Pg 45 Original policy
44135	Intestinal allotransplantation; from cadaver donor	Master Precertification List For Health Care Providers, Pg 45 Original policy
44136	Intestinal allotransplantation; from living donor	Master Precertification List For Health Care Providers, Pg 45 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.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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