Cigna prior authorization, page 28

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
93455*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography	Master Precertification List For Health Care Providers, Pg 67 Original policy
93456*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization	Master Precertification List For Health Care Providers, Pg 67 Original policy
93457*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization	Master Precertification List For Health Care Providers, Pg 67 Original policy
93458*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed	Master Precertification List For Health Care Providers, Pg 67 Original policy
93459*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography	Master Precertification List For Health Care Providers, Pg 67 Original policy
93460*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed	Master Precertification List For Health Care Providers, Pg 67 Original policy
93461*	Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography	Master Precertification List For Health Care Providers, Pg 67 Original policy
93580*	Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant	Master Precertification List For Health Care Providers, Pg 67 Original policy
93581*	Percutaneous transcatheter closure of a congenital ventricular septal defect with implant	Master Precertification List For Health Care Providers, Pg 67 Original policy
93582*	Percutaneous transcatheter closure of patent ductus arteriosus	Master Precertification List For Health Care Providers, Pg 67 Original policy
93619*	Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia	Master Precertification List For Health Care Providers, Pg 67 Original policy
93620*	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording	Master Precertification List For Health Care Providers, Pg 67 Original policy
93621*	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium	Master Precertification List For Health Care Providers, Pg 67 Original policy
93622*	Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording	Master Precertification List For Health Care Providers, Pg 68 Original policy
93653*	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry	Master Precertification List For Health Care Providers, Pg 68 Original policy
93654*	Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia with right atrial pacing and recording and catheter ablation of arrhythmogenic focus, including intracardiac electrophysiologic 3-dimensional mapping, right ventricular pacing and recording, left atrial pacing and recording from coronary sinus or left atrium, and His bundle recording, when performed; with treatment of ventricular tachycardia or focus of ventricular ectopy including left ventricular pacing and recording, when performed	Master Precertification List For Health Care Providers, Pg 68 Original policy
93655*	Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia	Master Precertification List For Health Care Providers, Pg 68 Original policy
93656*	Comprehensive electrophysiologic evaluation with transseptal catheterizations, insertion and repositioning of multiple electrode catheters, induction or attempted induction of an arrhythmia including left or right atrial pacing/recording, and intracardiac catheter ablation of atrial fibrillation by pulmonary vein isolation, including intracardiac electrophysiologic 3-dimensional mapping, intracardiac echocardiography with imaging supervision and interpretation, right ventricular pacing/recording, and His bundle recording, when performed	Master Precertification List For Health Care Providers, Pg 68 Original policy
93657*	Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation	Master Precertification List For Health Care Providers, Pg 68 Original policy
93799*	Unlisted cardiovascular service or procedure	Master Precertification List For Health Care Providers, Pg 68 Original policy
94799*	Unlisted pulmonary service or procedure	Master Precertification List For Health Care Providers, Pg 68 Original policy
95782*	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
95783*	Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
95805*	Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness	Master Precertification List For Health Care Providers, Pg 68 Original policy
95807*	Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
95808*	Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
95810*	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
95811*	Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist	Master Precertification List For Health Care Providers, Pg 68 Original policy
96920*	Excimer laser treatment for psoriasis; total area less than 250 sq cm	Master Precertification List For Health Care Providers, Pg 69 Original policy
96921*	Excimer laser treatment for psoriasis; 250 sq cm to 500 sq cm	Master Precertification List For Health Care Providers, Pg 69 Original policy
96922*	Excimer laser treatment for psoriasis; over 500 sq cm	Master Precertification List For Health Care Providers, Pg 69 Original policy
97153	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97154	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97155	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97156	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97157	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97158	Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes	Master Precertification List For Health Care Providers, Pg 69 Original policy
97610	Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day	Master Precertification List For Health Care Providers, Pg 69 Original policy
99183*	Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session	Master Precertification List For Health Care Providers, Pg 69 Original policy
99199*	Unlisted special service, procedure or report	Master Precertification List For Health Care Providers, Pg 69 Original policy
99512	Home visit for hemodialysis	Master Precertification List For Health Care Providers, Pg 69 Original policy
A0430	Ambulance service, conventional air services, transport, one way (fixed wing)	Master Precertification List For Health Care Providers, Pg 69 Original policy
A0435	Fixed wing air mileage, per statute mile	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2004*	Xcellistem, 1 mg	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2005*	Microlyte matrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2019*	Kerecis omega3 marigen shield, per square centimeter	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2020*	Ac5 advanced wound system (ac5)	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2021*	Neomatrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2043	Biobrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 69 Original policy
A2044	Biobrane glove, each	Master Precertification List For Health Care Providers, Pg 69 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.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.