Cigna prior authorization, page 30

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
C8931*	Magnetic resonance angiography with contrast, spinal canal and contents	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8932*	Magnetic resonance angiography without contrast, spinal canal and contents	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8933*	Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8934*	Magnetic resonance angiography with contrast, upper extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8935*	Magnetic resonance angiography without contrast, upper extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8936*	Magnetic resonance angiography without contrast followed by with contrast, upper extremity	Master Precertification List For Health Care Providers, Pg 71 Original policy
C8937*	Computer-aided detection, including computer algorithm analysis of breast mri image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation	Master Precertification List For Health Care Providers, Pg 71 Original policy
C9047	Injection, caplacizumab-yhdp, 1 mg	Master Precertification List For Health Care Providers, Pg 71 Original policy
C9311	Injection, eplontersen, 1 mg	Master Precertification List For Health Care Providers, Pg 71 Original policy
C9312*	Injection, trabectedin (apotex), not therapeutically equivalent to j9362, 0.01 mg	Master Precertification List For Health Care Providers, Pg 71 Original policy
C9313*	Injection, pivekimab sunirine-pvzy, 0.01 mg	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9352*	Microporous collagen implantable tube (neuragen nerve guide), per centimeter length	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9353*	Microporous collagen implantable slit tube (neurawrap nerve protector), per centimeter length	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9358*	Dermal substitute, native, non-denatured collagen, fetal bovine origin (surgimend collagen matrix), per 0.5 square centimeters	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9360*	Dermal substitute, native, non-denatured collagen, neonatal bovine origin (surgimend collagen matrix), per 0.5 square centimeters	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9364*	Porcine implant, permacol, per square centimeter	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9399*	Unclassified drugs or biologicals	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9726*	Placement and removal (if performed) of applicator into breast for intraoperative radiation therapy, add-on to primary breast procedure	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9727*	Insertion of implants into the soft palate; minimum of three implants	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9734*	Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with magnetic resonance (mr) guidance	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9762*	Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imaging	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9763*	Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imaging	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9764*	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9767*	Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9772*	Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9785*	Endoscopic outlet reduction, gastric pouch application, with endoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring components	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9791*	Magnetic resonance imaging with inhaled hyperpolarized xenon-129 contrast agent, chest, including preparation and administration of agent	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9793*	3d predictive model generation for pre-planning of a cardiac procedure, using data from cardiac computed tomographic angiography with report	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9807*	Nerve stimulator, percutaneous, peripheral (e.g., sprint peripheral nerve stimulation system), including electrode and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9808*	Nerve cryoablation probe (e.g., cryoice, cryosphere, cryosphere max, cryoice cryosphere, cryoice cryo2), including probe and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)	Master Precertification List For Health Care Providers, Pg 72 Original policy
C9809*	Cryoneurolysis needle (e.g., iovera system), including needle/tip and all disposable system components, non-opioid medical device (must be a qualifying medicare non-opioid medical device for post-surgical pain relief in accordance with section 4135 of the caa, 2023)	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0466*	Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0467*	Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0468*	Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0481*	Intrapulmonary percussive ventilation system and related accessories	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0483*	High frequency chest wall oscillation system, with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, each	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0492*	Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by phone application	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0530*	Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0627*	Seat lift mechanism, electric, any type	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0637*	Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0638*	Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0640*	Patient lift, fixed system, includes all components/accessories	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0641*	Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0642*	Standing frame/table system, mobile (dynamic stander), any size including pediatric	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0677*	Non-pneumatic sequential compression garment, trunk	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0678*	Non-pneumatic sequential compression garment, full leg	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0679*	Non-pneumatic sequential compression garment, half leg	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0680*	Non-pneumatic compression controller with sequential calibrated gradient pressure	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0682*	Non-pneumatic sequential compression garment, full arm	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0683*	Non-pneumatic, non-sequential, peristaltic wave compression pump	Master Precertification List For Health Care Providers, Pg 73 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.