Cigna prior authorization, page 41

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
J9362*	Injection, trabectedin, 0.01 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9370*	Vincristine sulfate, 1 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9376	Injection, pozelimab-bbfg, 1 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9380*	Injection, teclistamab-cqyv, 0.5 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9381	Injection, teplizumab-mzwv, 5 mcg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9382*	Injection, zenocutuzumab-zbco, 1 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9390*	Injection, vinorelbine tartrate, 10 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9393*	Injection, fulvestrant (teva), not therapeutically equivalent to J9395, 25 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9394*	Injection, fulvestrant (fresenius kabi) not therapeutically equivalent to J9395, 25 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9395*	Injection, fulvestrant, 25 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9400*	Injection, ziv-aflibercept, 1 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9601*	Injection, linvoseltamab-gcpt, 1 mg	Master Precertification List For Health Care Providers, Pg 90 Original policy
J9999*	Not otherwise classified, antineoplastic drugs	Master Precertification List For Health Care Providers, Pg 90 Original policy
K0899*	Power mobility device, not coded by dme pdac or does not meet criteria	Master Precertification List For Health Care Providers, Pg 90 Original policy
K1007*	Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors	Master Precertification List For Health Care Providers, Pg 90 Original policy
L1844*	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	Master Precertification List For Health Care Providers, Pg 90 Original policy
L1846*	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	Master Precertification List For Health Care Providers, Pg 90 Original policy
L2006*	Knee ankle foot device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated	Master Precertification List For Health Care Providers, Pg 91 Original policy
L2221*	Addition to lower extremity orthosis, ankle system, microprocessor- controlled feature plantarflexion and/or dorsiflexion, includes power source	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5781*	Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5827*	Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5828*	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5856*	Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5859*	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5973*	Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source	Master Precertification List For Health Care Providers, Pg 91 Original policy
L5999*	Lower extremity prosthesis, not otherwise specified	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6700*	Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition decoding intent movement	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6880*	Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6881*	Automatic grasp feature, addition to upper limb electric prosthetic terminal device	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6882*	Microprocessor control feature, addition to upper limb prosthetic terminal device	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6935*	Below elbow, external power, self-suspended inner socket, removable forearm shell, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	Master Precertification List For Health Care Providers, Pg 91 Original policy
L6955*	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	Master Precertification List For Health Care Providers, Pg 91 Original policy
L7007*	Electric hand, switch or myoelectric controlled, adult	Master Precertification List For Health Care Providers, Pg 91 Original policy
L7259*	Electronic wrist rotator, any type	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8499*	Unlisted procedure for miscellaneous prosthetic services	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8614*	Cochlear device, includes all internal and external components	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8641*	Metatarsal joint implant	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8642*	Hallux implant	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8679*	Implantable neurostimulator, pulse generator, any type	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8680*	Implantable neurostimulator electrode, each	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8681*	Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8682*	Implantable neurostimulator radiofrequency receiver	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8683*	Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver	Master Precertification List For Health Care Providers, Pg 91 Original policy
L8685*	Implantable neurostimulator pulse generator, single array, rechargeable, includes extension	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8686*	Implantable neurostimulator pulse generator, single array, non- rechargeable, includes extension	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8687*	Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8688*	Implantable neurostimulator pulse generator, dual array, non- rechargeable, includes extension	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8689*	External recharging system for battery (internal) for use with implantable neurostimulator, replacement only	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8695*	External recharging system for battery (external) for use with implantable neurostimulator, replacement only	Master Precertification List For Health Care Providers, Pg 92 Original policy
L8702*	Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated	Master Precertification List For Health Care Providers, Pg 92 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.