Cigna prior authorization, page 46
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
CPT code lookup
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| Q9997 | Injection, ustekinumab-ttwe (pyzchiva), intravenous, 1 mg | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| Q9999 | Injection, ustekinumab-aauz (otulfi), biosimilar, 1 mg | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S0122 | Injection, menotropins, 75 iu | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S0126 | Injection, follitropin alfa, 75 iu | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S0128 | Injection, follitropin beta, 75 iu | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S0132 | Injection, ganirelix acetate, 250 mcg | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S0145* | Injection, pegylated interferon alfa-2a, 180 mcg per ml | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S1040* | Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S2053 | Transplantation of small intestine and liver allografts | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S2054 | Transplantation of multivisceral organs | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S2060 | Lobar lung transplantation | Master Precertification List For Health Care Providers, Pg 100 Original policy |
| S2061 | Donor lobectomy (lung) for transplantation, living donor | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2065 | Simultaneous pancreas kidney transplantation | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2095* | Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2102 | Islet cell tissue transplant from pancreas; allogeneic | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2117* | Arthroereisis, subtalar | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2140 | Cord blood harvesting for transplantation, allogeneic | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2142 | Cord blood-derived stem-cell transplantation, allogeneic | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2150 | Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including: pheresis and cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with outpatient follow- up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre-and post-transplant care in the global definition | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S2152 | Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications; including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and post- transplant care in the global definition | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S5150 | Unskilled respite care, not hospice; per 15 minutes | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S5151 | Unskilled respite care, not hospice; per diem | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S8030* | Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S8037* | Magnetic resonance cholangiopancreatography (mrcp) | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S8092* | Electron beam computed tomography (also known as ultrafast ct, cine ct) | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S9122 | Home health aide or certified nurse assistant, providing care in the home; per hour | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S9123 | Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when cpt codes 99500-99602 can be used) | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| S9124 | Nursing care, in the home; by licensed practical nurse, per hour | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| T1000 | Private duty / independent nursing service(s) - licensed, up to 15 minutes | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| T1005 | Respite care services, up to 15 minutes | Master Precertification List For Health Care Providers, Pg 101 Original policy |
| T2044 | Hospice inpatient respite care; per diem | Master Precertification List For Health Care Providers, Pg 101 Original policy |