Cigna prior authorization, page 5
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 |
|---|---|---|
| 0950T* | Ablation of benign prostate tissue, transrectal, with high intensity–focused ultrasound (HIFU), including ultrasound guidance | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0951T* | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0956T* | Partial craniectomy, channel creation, and tunneling of electrode for sub- scalp implantation of an electrode array, receiver, and telemetry unit for continuous bilateral electroencephalography monitoring system, including imaging guidance | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0957T* | Revision of sub-scalp implanted electrode array, receiver, and telemetry unit for electrode, when required, including imaging guidance | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0959T* | Removal or replacement of magnet from coil assembly that is connected to continuous bilateral electroencephalography monitoring system, including imaging guidance | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0960T* | Replacement of sub-scalp implanted electrode array, receiver, and telemetry unit with tunneling of electrode for continuous bilateral electroencephalography monitoring system, including imaging guidance | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0967T* | Transanal insertion of endoluminal temporary colorectal anastomosis protection device, including vacuum anchoring component and flexible sheath connected to external vacuum source and monitoring system | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0968T* | Insertion or replacement of epicranial neurostimulator system, including electrode array and pulse generator, with connection to electrode array | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0978T* | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0979T* | Submucosal cryolysis therapy; soft palate only | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0980T* | Submucosal cryolysis therapy; base of tongue and lingual tonsil only (Do not report Submucosal cryolysis therapy; base of tongue and lingual tonsil only | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0981T* | Transcatheter implantation of wireless inferior vena cava sensor for long- term hemodynamic monitoring, including deployment of the sensor, radiological supervision and interpretation, right heart catheterization, and inferior vena cava venography, when performed | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0990T* | Transcervical instillation of biodegradable hydrogel materials, intrauterine | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0991T* | Cystourethroscopy, with low-energy lithotripsy and acoustically actuated microspheres, including imaging | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0994T* | Endovascular delivery of aortic wall stabilization drug therapy through a sheath positioned within an abdominal aortic aneurysm, with aortic roadmapping, balloon occlusion, imaging guidance, and radiological supervision and interpretation; percutaneous | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0995T* | Endovascular delivery of aortic wall stabilization drug therapy through a sheath positioned within an abdominal aortic aneurysm, with aortic roadmapping, balloon occlusion, imaging guidance, and radiological supervision and interpretation; open | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0997T | Precuneus magnetic stimulation; treatment planning using magnetic resonance imaging-guided neuronavigation to determine optimal location, dose, and intensity for magnetic stimulation therapy, derived from evoked potentials from single pulses of electromagnetic energy recorded by 64-channel electroencephalogram, including automated data processing, transmission, analysis, generation of treatment parameters with review, interpretation, and report | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0998T | Precuneus magnetic stimulation; personalized treatment delivery of magnetic stimulation therapy to a prespecified target area derived from analysis of evoked potentials within the precuneus, utilizing magnetic resonance imaging-based neuronavigation, with management, per day | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 0999T* | Autologous muscle cell therapy, harvesting of muscle progenitor cells, including ultrasound guidance, when performed | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1000T* | Autologous muscle cell therapy, administration of muscle progenitor cells into the urethral sphincter, including cystoscopy and post-void residual ultrasound, when performed | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1001T* | Autologous muscle cell therapy, injection of muscle progenitor cells into the external anal sphincter, including ultrasound guidance, when performed | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1003T* | Arthroplasty, first carpometacarpal joint, with distal trapezial and proximal first metacarpal prosthetic replacement (eg, first carpometacarpal total joint) | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1008T* | Remote monitoring of sub-scalp implanted continuous bilateral electroencephalography monitoring system, device fitting, initial set-up, and patient education in wearing of system and use of equipment | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1009T* | Remote monitoring of a sub-scalp implanted continuous bilateral electroencephalography monitoring system, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and report, up to 30 days of recording without video | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1019T* | Lymphovenous bypass, including robotic assistance, when performed, per extremity | Master Precertification List For Health Care Providers, Pg 16 Original policy |
| 1025T* | Alternating electric fields dosimetry and delivery-simulation modeling, creation and selection of patient-specific array layouts, and placement verification | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1037T* | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1038T* | Autologous muscle cell therapy, injection(s) of muscle progenitor cells into the tongue, including esophagoscopy, when performed | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1039T* | Connectomic analysis of previously performed multi-modal brain magnetic resonance imaging (MRI) requiring physician or other qualified health care professional (QHP) analysis of software- and physician- generated structural and functional maps for integration of cortical grey matter correlation based on resting-state functional MRI and mapping of white matter connectivity based on diffusion-weighted MRI relative to brain regions, with physician or other QHP interpretation and report | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1050T* | Insertion, subcutaneous heart failure decompensation monitor, containing sensors that measure, at a minimum, heart rate, impedance, respiration rate, physical activity, heart sounds | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1056T | Cochlear infusion of pharmacologic agent (ie, gene therapy vector), including mastoidectomy, labyrinthotomy, and repair of fenestrations | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1057T* | Insertion or replacement of subcutaneous neurostimulator pulse generators, with tunneling of 4 electrode arrays, bilateral supraorbital and occipital nerves, including all interrogation, programming, and imaging guidance, when performed | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1080T* | Insertion, intracapsular magnifier, with attachment to previously placed intraocular lens | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1081T* | Microvascular anastomosis between a lymph node and a vein, including robot assistance, when performed; initial anastomosis | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1082T* | Microvascular anastomosis between a lymph node and a vein, including robot assistance, when performed; each additional anastomosis | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1083T | Stereotactic placement of infusion catheter(s), brain, for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1084T* | Implantation of scaffolding allograft to reinforce the suprachoroidal space | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1091T* | Placement of permanent common carotid artery filter, percutaneous, bilateral, including ultrasound guidance, when performed | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1092T* | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into chondral defect, open | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1093T* | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; into a chondral or osteochondral defect, arthroscopic | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1094T* | Implantation of acellular scaffold (eg, hyaluronan), knee, single implant; each additional acellular scaffold implantation | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1095T* | Harvesting and processing of autologous bone marrow aspirate concentrate (BMAC), with application onto scaffold or injection into anatomical recipient site (eg, subchondral bone, joint space, chondral lesion), including imaging guidance, when performed, for therapeutic musculoskeletal treatment, excluding spinal procedures | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 1099T* | Ablation of incompetent vein(s), extremity, transcutaneous, high intensity–focused ultrasound (HIFU), inclusive of all imaging guidance and monitoring | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 11950* | Subcutaneous injection of filling material (eg, collagen); 1 cc or less | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 11951* | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc | Master Precertification List For Health Care Providers, Pg 17 Original policy |
| 11952* | Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc | Master Precertification List For Health Care Providers, Pg 18 Original policy |
| 11954* | Subcutaneous injection of filling material (eg, collagen); over 10.0 cc | Master Precertification List For Health Care Providers, Pg 18 Original policy |
| 11980 | Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) | Master Precertification List For Health Care Providers, Pg 18 Original policy |
| 15011* | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | Master Precertification List For Health Care Providers, Pg 18 Original policy |
| 15012* | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof | Master Precertification List For Health Care Providers, Pg 18 Original policy |