Cigna prior authorization, page 24

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
76390*	Magnetic resonance spectroscopy	Master Precertification List For Health Care Providers, Pg 57 Original policy
76391*	Magnetic resonance (eg, vibration) elastography	Master Precertification List For Health Care Providers, Pg 57 Original policy
76497*	Unlisted computed tomography procedure (eg, diagnostic, interventional)	Master Precertification List For Health Care Providers, Pg 57 Original policy
76498*	Unlisted magnetic resonance procedure (eg, diagnostic, interventional)	Master Precertification List For Health Care Providers, Pg 57 Original policy
76873*	Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning	Master Precertification List For Health Care Providers, Pg 57 Original policy
76965*	Ultrasonic guidance for interstitial radioelement application	Master Precertification List For Health Care Providers, Pg 57 Original policy
77046*	Magnetic resonance imaging, breast, without contrast material; unilateral	Master Precertification List For Health Care Providers, Pg 57 Original policy
77047*	Magnetic resonance imaging, breast, without contrast material; bilateral	Master Precertification List For Health Care Providers, Pg 57 Original policy
77048*	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral	Master Precertification List For Health Care Providers, Pg 57 Original policy
77049*	Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral	Master Precertification List For Health Care Providers, Pg 57 Original policy
77084*	Magnetic resonance (eg, proton) imaging, bone marrow blood supply	Master Precertification List For Health Care Providers, Pg 57 Original policy
77261*	Therapeutic radiology treatment planning; simple	Master Precertification List For Health Care Providers, Pg 57 Original policy
77262*	Therapeutic radiology treatment planning; intermediate	Master Precertification List For Health Care Providers, Pg 58 Original policy
77263*	Therapeutic radiology treatment planning; complex	Master Precertification List For Health Care Providers, Pg 58 Original policy
77280*	Therapeutic radiology simulation-aided field setting; simple	Master Precertification List For Health Care Providers, Pg 58 Original policy
77285*	Therapeutic radiology simulation-aided field setting; intermediate	Master Precertification List For Health Care Providers, Pg 58 Original policy
77290*	Therapeutic radiology simulation-aided field setting; complex	Master Precertification List For Health Care Providers, Pg 58 Original policy
77293*	Respiratory motion management simulation	Master Precertification List For Health Care Providers, Pg 58 Original policy
77295*	3-dimensional radiotherapy plan, including dose-volume histograms	Master Precertification List For Health Care Providers, Pg 58 Original policy
77300*	Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician	Master Precertification List For Health Care Providers, Pg 58 Original policy
77301*	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications	Master Precertification List For Health Care Providers, Pg 58 Original policy
77306*	Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77307*	Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77316*	Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77317*	Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77318*	Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77321*	Special teletherapy port plan, particles, hemibody, total body	Master Precertification List For Health Care Providers, Pg 58 Original policy
77331*	Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician	Master Precertification List For Health Care Providers, Pg 58 Original policy
77332*	Treatment devices, design and construction; simple (simple block, simple bolus)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77333*	Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77334*	Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)	Master Precertification List For Health Care Providers, Pg 58 Original policy
77336*	Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy	Master Precertification List For Health Care Providers, Pg 58 Original policy
77338*	Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan	Master Precertification List For Health Care Providers, Pg 58 Original policy
77370*	Special medical radiation physics consultation	Master Precertification List For Health Care Providers, Pg 58 Original policy
77371*	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi- source Cobalt 60 based	Master Precertification List For Health Care Providers, Pg 58 Original policy
77372*	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based	Master Precertification List For Health Care Providers, Pg 58 Original policy
77373*	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions	Master Precertification List For Health Care Providers, Pg 59 Original policy
77387*	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed	Master Precertification List For Health Care Providers, Pg 59 Original policy
77399*	Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services	Master Precertification List For Health Care Providers, Pg 59 Original policy
77402*	Radiation treatment delivery, >=1 MeV; simple	Master Precertification List For Health Care Providers, Pg 59 Original policy
77407*	Radiation treatment delivery, >=1 MeV; intermediate	Master Precertification List For Health Care Providers, Pg 59 Original policy
77412*	Radiation treatment delivery, >=1 MeV; complex	Master Precertification List For Health Care Providers, Pg 59 Original policy
77417*	Therapeutic radiology port image(s)	Master Precertification List For Health Care Providers, Pg 59 Original policy
77423*	High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)	Master Precertification List For Health Care Providers, Pg 59 Original policy
77424*	Intraoperative radiation treatment delivery, x-ray, single treatment session	Master Precertification List For Health Care Providers, Pg 59 Original policy
77425*	Intraoperative radiation treatment delivery, electrons, single treatment session	Master Precertification List For Health Care Providers, Pg 59 Original policy
77427*	Radiation treatment management, 5 treatments	Master Precertification List For Health Care Providers, Pg 59 Original policy
77431*	Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only	Master Precertification List For Health Care Providers, Pg 59 Original policy
77432*	Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)	Master Precertification List For Health Care Providers, Pg 59 Original policy
77435*	Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions	Master Precertification List For Health Care Providers, Pg 59 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

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