Cigna prior authorization, page 31

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
E0721*	Transcutaneous electrical nerve stimulator for nerves in the auricular region	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0738*	Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, include microprocessor, all components and accessories	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0739*	Rehabilitation system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0748*	Osteogenesis stimulator, electrical, non-invasive, spinal applications	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0760*	Osteogenesis stimulator, low intensity ultrasound, non-invasive	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0767*	Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0782*	Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)	Master Precertification List For Health Care Providers, Pg 73 Original policy
E0783*	Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)	Master Precertification List For Health Care Providers, Pg 74 Original policy
E0785*	Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement	Master Precertification List For Health Care Providers, Pg 74 Original policy
E0786*	Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)	Master Precertification List For Health Care Providers, Pg 74 Original policy
E1399*	Durable medical equipment, miscellaneous	Master Precertification List For Health Care Providers, Pg 74 Original policy
E1905	Virtual reality cognitive behavioral therapy device (cbt), including pre- programmed therapy software	Master Precertification List For Health Care Providers, Pg 74 Original policy
E2102	Adjunctive, non-implanted continuous glucose monitor or receiver	Master Precertification List For Health Care Providers, Pg 74 Original policy
E2103	Non-adjunctive, non-implanted continuous glucose monitor or receiver	Master Precertification List For Health Care Providers, Pg 74 Original policy
E2403*	External ocular negative pressure pump, electric	Master Precertification List For Health Care Providers, Pg 74 Original policy
E2508*	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device	Master Precertification List For Health Care Providers, Pg 74 Original policy
E2510*	Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0138	Intravenous infusion of cipaglucosidase alfa-atga, including provider/supplier acquisition and clinical supervision of oral administration of miglustat in preparation of receipt of cipaglucosidase alfa-atga	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0166*	External counterpulsation, per treatment session	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0219*	Pet imaging whole body; melanoma for non-covered indications	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0235*	Pet imaging, any site, not otherwise specified	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0252*	Pet imaging, full and partial-ring pet scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0260*	Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0277	Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0339*	Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0340*	Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0341	Percutaneous islet cell transplant, includes portal vein catheterization and infusion	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0342	Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0343	Laparotomy for islet cell transplant, includes portal vein catheterization and infusion	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0422*	Intensive cardiac rehabilitation; with or without continuous ecg monitoring with exercise, per session	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0423*	Intensive cardiac rehabilitation; with or without continuous ecg monitoring; without exercise, per session	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0458*	Low dose rate (ldr) prostate brachytherapy services, composite rate	Master Precertification List For Health Care Providers, Pg 74 Original policy
G0555*	Provision of replacement patient electronics system (e.g., system pillow, handheld reader) for home pulmonary artery pressure monitoring	Master Precertification List For Health Care Providers, Pg 74 Original policy
H0045	Respite care services, not in the home, per diem	Master Precertification List For Health Care Providers, Pg 74 Original policy
J0013	Esketamine, nasal spray, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0129	Injection, abatacept, 10 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0139	Injection, adalimumab, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0174	Lecanemab-irmb, for intravenous injection, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0175	Injection, donanemab-azbt, 2 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0177	Injection, aflibercept hd, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0178	Injection, aflibercept, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0179	Injection, brolucizumab-dbll, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0180	Injection, agalsidase beta, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0202	Injection, alemtuzumab, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0208*	Injection, sodium thiosulfate (pedmark), 100 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0217	Injection, velmanase alfa-tycv, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0218	Injection, olipudase alfa-rpcp, 1 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0219	Injection, avalglucosidase alfa-ngpt, 4 mg	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0220	Injection, alglucosidase alfa, 10 mg, not otherwise specified	Master Precertification List For Health Care Providers, Pg 75 Original policy
J0221	Injection, alglucosidase alfa, (lumizyme), 10 mg	Master Precertification List For Health Care Providers, Pg 75 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.