Cigna prior authorization, page 25

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
77436*	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting	Master Precertification List For Health Care Providers, Pg 59 Original policy
77437*	Surface radiation therapy; superficial, delivery, </=150 kV, per fraction (eg, electronic brachytherapy)	Master Precertification List For Health Care Providers, Pg 59 Original policy
77438*	Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction	Master Precertification List For Health Care Providers, Pg 59 Original policy
77439*	Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment	Master Precertification List For Health Care Providers, Pg 59 Original policy
77469*	Intraoperative radiation treatment management	Master Precertification List For Health Care Providers, Pg 59 Original policy
77470*	Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)	Master Precertification List For Health Care Providers, Pg 59 Original policy
77499*	Unlisted procedure, therapeutic radiology treatment management	Master Precertification List For Health Care Providers, Pg 59 Original policy
77520*	Proton treatment delivery; simple, without compensation	Master Precertification List For Health Care Providers, Pg 59 Original policy
77522*	Proton treatment delivery; simple, with compensation	Master Precertification List For Health Care Providers, Pg 59 Original policy
77523*	Proton treatment delivery; intermediate	Master Precertification List For Health Care Providers, Pg 59 Original policy
77525*	Proton treatment delivery; complex	Master Precertification List For Health Care Providers, Pg 59 Original policy
77761*	Intracavitary radiation source application; simple	Master Precertification List For Health Care Providers, Pg 59 Original policy
77762*	Intracavitary radiation source application; intermediate	Master Precertification List For Health Care Providers, Pg 59 Original policy
77763*	Intracavitary radiation source application; complex	Master Precertification List For Health Care Providers, Pg 59 Original policy
77767*	Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel	Master Precertification List For Health Care Providers, Pg 59 Original policy
77768*	Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions	Master Precertification List For Health Care Providers, Pg 60 Original policy
77770*	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel	Master Precertification List For Health Care Providers, Pg 60 Original policy
77771*	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels	Master Precertification List For Health Care Providers, Pg 60 Original policy
77772*	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels	Master Precertification List For Health Care Providers, Pg 60 Original policy
77778*	Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed	Master Precertification List For Health Care Providers, Pg 60 Original policy
77789*	Surface application of low dose rate radionuclide source	Master Precertification List For Health Care Providers, Pg 60 Original policy
77790*	Supervision, handling, loading of radiation source	Master Precertification List For Health Care Providers, Pg 60 Original policy
77799*	Unlisted procedure, clinical brachytherapy	Master Precertification List For Health Care Providers, Pg 60 Original policy
78429*	Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan	Master Precertification List For Health Care Providers, Pg 60 Original policy
78430*	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan	Master Precertification List For Health Care Providers, Pg 60 Original policy
78431*	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan	Master Precertification List For Health Care Providers, Pg 60 Original policy
78432*	Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability);	Master Precertification List For Health Care Providers, Pg 60 Original policy
78433*	Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan	Master Precertification List For Health Care Providers, Pg 60 Original policy
78434*	Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress	Master Precertification List For Health Care Providers, Pg 60 Original policy
78459*	Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study;	Master Precertification List For Health Care Providers, Pg 60 Original policy
78491*	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic)	Master Precertification List For Health Care Providers, Pg 60 Original policy
78492*	Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic)	Master Precertification List For Health Care Providers, Pg 60 Original policy
78608*	Brain imaging, positron emission tomography (PET); metabolic evaluation	Master Precertification List For Health Care Providers, Pg 60 Original policy
78609*	Brain imaging, positron emission tomography (PET); perfusion evaluation	Master Precertification List For Health Care Providers, Pg 60 Original policy
78811*	Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)	Master Precertification List For Health Care Providers, Pg 60 Original policy
78812*	Positron emission tomography (PET) imaging; skull base to mid-thigh	Master Precertification List For Health Care Providers, Pg 60 Original policy
78813*	Positron emission tomography (PET) imaging; whole body	Master Precertification List For Health Care Providers, Pg 61 Original policy
78814*	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)	Master Precertification List For Health Care Providers, Pg 61 Original policy
78815*	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh	Master Precertification List For Health Care Providers, Pg 61 Original policy
78816*	Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body	Master Precertification List For Health Care Providers, Pg 61 Original policy
79005*	Radiopharmaceutical therapy, by oral administration	Master Precertification List For Health Care Providers, Pg 61 Original policy
79101*	Radiopharmaceutical, therapy, by intravenous administration	Master Precertification List For Health Care Providers, Pg 61 Original policy
81162*	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)	Master Precertification List For Health Care Providers, Pg 61 Original policy
81163*	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis	Master Precertification List For Health Care Providers, Pg 61 Original policy
81164*	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements)	Master Precertification List For Health Care Providers, Pg 61 Original policy
81165*	BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis	Master Precertification List For Health Care Providers, Pg 61 Original policy
81166*	BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements)	Master Precertification List For Health Care Providers, Pg 61 Original policy
81167*	BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements)	Master Precertification List For Health Care Providers, Pg 61 Original policy
81195*	Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM)	Master Precertification List For Health Care Providers, Pg 61 Original policy
81212*	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants	Master Precertification List For Health Care Providers, Pg 61 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

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