Cigna prior authorization, page 8
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 |
|---|---|---|
| 21123* | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) | Master Precertification List For Health Care Providers, Pg 21 Original policy |
| 21125* | Augmentation, mandibular body or angle; prosthetic material | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21127* | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21137* | Reduction forehead; contouring only | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21138* | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21139* | Reduction forehead; contouring and setback of anterior frontal sinus wall | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21141* | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21142* | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21143* | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21145* | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21146* | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21147* | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21150* | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher- Collins Syndrome) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21151* | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21154* | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21155* | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21159* | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21160* | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21172* | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21179* | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21180* | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21188* | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21193* | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21194* | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21195* | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21196* | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21198* | Osteotomy, mandible, segmental; | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21199* | Osteotomy, mandible, segmental; with genioglossus advancement | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21206* | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | Master Precertification List For Health Care Providers, Pg 22 Original policy |
| 21208* | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21209* | Osteoplasty, facial bones; reduction | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21210* | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21215* | Graft, bone; mandible (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21230* | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21235* | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21240* | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21243* | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21244* | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21245* | Reconstruction of mandible or maxilla, subperiosteal implant; partial | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21246* | Reconstruction of mandible or maxilla, subperiosteal implant; complete | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21248* | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21249* | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21270* | Malar augmentation, prosthetic material | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21299* | Unlisted craniofacial and maxillofacial procedure | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21497* | Interdental wiring, for condition other than fracture | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21499* | Unlisted musculoskeletal procedure, head | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21685* | Hyoid myotomy and suspension | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21740* | Reconstructive repair of pectus excavatum or carinatum; open | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21742* | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | Master Precertification List For Health Care Providers, Pg 23 Original policy |
| 21743* | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | Master Precertification List For Health Care Providers, Pg 23 Original policy |