Cigna prior authorization, page 29

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
A2048*	Puraply mz, per milligram	Master Precertification List For Health Care Providers, Pg 69 Original policy
A4238	Supply allowance for adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service	Master Precertification List For Health Care Providers, Pg 69 Original policy
A4239	Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service	Master Precertification List For Health Care Providers, Pg 69 Original policy
A9276	Sensor; invasive (e.g., subcutaneous), disposable, for use with non- durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day supply	Master Precertification List For Health Care Providers, Pg 69 Original policy
A9277	Transmitter; external, for use with non-durable medical equipment interstitial continuous glucose monitoring system	Master Precertification List For Health Care Providers, Pg 70 Original policy
A9278	Receiver (monitor); external, for use with non-durable medical equipment interstitial continuous glucose monitoring system	Master Precertification List For Health Care Providers, Pg 70 Original policy
A9513*	Lutetium lu 177, dotatate, therapeutic, 1 millicurie	Master Precertification List For Health Care Providers, Pg 70 Original policy
A9606*	Radium ra-223 dichloride, therapeutic, per microcurie	Master Precertification List For Health Care Providers, Pg 70 Original policy
A9607*	Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie	Master Precertification List For Health Care Providers, Pg 70 Original policy
A9699*	Radiopharmaceutical, therapeutic, not otherwise classified	Master Precertification List For Health Care Providers, Pg 70 Original policy
B4187	Omegaven, 10 grams lipids	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1062*	Intravertebral body fracture augmentation with implant (e.g., metal, polymer)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1607*	Neurostimulator, integrated (implantable), rechargeable with all implantable and external components including charging system	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1764*	Event recorder, cardiac (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1767*	Generator, neurostimulator (implantable), non-rechargeable	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1772*	Infusion pump, programmable (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1778*	Lead, neurostimulator (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1787*	Patient programmer, neurostimulator	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1816*	Receiver and/or transmitter, neurostimulator (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1820*	Generator, neurostimulator (implantable), with rechargeable battery and charging system	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1821*	Interspinous process distraction device (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1822*	Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1839*	Iris prosthesis	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1883*	Adapter/extension, pacing lead or neurostimulator lead (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1889*	Implantable/insertable device, not otherwise classified	Master Precertification List For Health Care Providers, Pg 70 Original policy
C1897*	Lead, neurostimulator test kit (implantable)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C2614*	Probe, percutaneous lumbar discectomy	Master Precertification List For Health Care Providers, Pg 70 Original policy
C2616*	Brachytherapy source, non-stranded, yttrium-90, per source	Master Precertification List For Health Care Providers, Pg 70 Original policy
C2624*	Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components	Master Precertification List For Health Care Providers, Pg 70 Original policy
C7557*	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 and intraprocedural coronary fractional flow reserve (ffr) with 3d functional mapping of color-coded ffr values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention	Master Precertification List For Health Care Providers, Pg 70 Original policy
C8002*	Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation)	Master Precertification List For Health Care Providers, Pg 70 Original policy
C8003*	Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (eg, fluoroscopy)	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8007*	Open implantation of hypoglossal nerve neurostimulator array and pulse generator, not requiring insertion of a separate distal respiratory sensor electrode or electrode array	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8011*	Open implantation of hypoglossal nerve(s) neurostimulator electrode array(s) and receiver, including external power source and all system components	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8900*	Magnetic resonance angiography with contrast, abdomen	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8901*	Magnetic resonance angiography without contrast, abdomen	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8902*	Magnetic resonance angiography without contrast followed by with contrast, abdomen	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8903*	Magnetic resonance imaging with contrast, breast; unilateral	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8905*	Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8906*	Magnetic resonance imaging with contrast, breast; bilateral	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8908*	Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8909*	Magnetic resonance angiography with contrast, chest (excluding myocardium)	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8910*	Magnetic resonance angiography without contrast, chest (excluding myocardium)	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8911*	Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium)	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8912*	Magnetic resonance angiography with contrast, lower extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8913*	Magnetic resonance angiography without contrast, lower extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8914*	Magnetic resonance angiography without contrast followed by with contrast, lower extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8918*	Magnetic resonance angiography with contrast, pelvis	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8919*	Magnetic resonance angiography without contrast, pelvis	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8920*	Magnetic resonance angiography without contrast followed by with contrast, pelvis	Master Precertification List For Health Care Providers, Pg 71 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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