Kepro/Hillsborough (HCHCP) Prior Authorization All CPT .

CPT 43458Dilation of esophagus with balloon (30 mm diameter or larger) forachalasiaCPT 45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with orwithout collection of specimen(s) by brushing or washing, with or withoutcolon decompression (separate procedure)CPT 45379Colonoscopy, flexible, proximal to splenic flexure; with removal of foreignbodyCPT 45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single ormultipleCPT 45381Colonoscopy, flexible, proximal to splenic flexure; with directed submucosalinjection(s), any substanceCPT 45382Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding(e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe,stapler, plasma coagulator)CPT 45383Colonoscopy, flexible, proximal to splenic flexure; with ablation oftumor(s), polyp(s), or other lesion(s) not amenable to removal by hotbiopsy forceps, bipolar cautery or snare techniqueCPT 45384Colonoscopy, flexible, proximal to splenic flexure; with removal oftumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolarcauteryCPT 45385Colonoscopy, flexible, proximal to splenic flexure; with removal oftumor(s), polyp(s), or other lesion(s) by snare techniqueCPT 50590Lithotripsy, extracorporeal shock waveCPT 51726Complex cystometrogram (i.e., calibrated electronic equipment);CPT 51727Complex cystometrogram (i.e., calibrated electronic equipment); withurethral pressure profile studies (i.e., urethral closure pressure profile), anytechniqueUpdated July 2021Page 8

CPT 51728Complex cystometrogram (i.e., calibrated electronic equipment); withvoiding pressure studies (i.e., bladder voiding pressure), any techniqueCPT 51729Complex cystometrogram (i.e., calibrated electronic equipment); withvoiding pressure studies (i.e., bladder voiding pressure) and urethralpressure profile studies (i.e., urethral closure pressure profile), anytechniqueCPT 51741Complex uroflowmetry (e.g., calibrated electronic equipment)CPT 51784Electromyography studies (EMG) of anal or urethral sphincter, other thanneedle, any techniqueCPT 51797Voiding pressure studies, intra-abdominal (i.e., rectal, gastric,intraperitoneal) (List separately in addition to code for primary procedure)CPT 52000Cystourethroscopy (separate procedure)CPT 52005Cystourethroscopy, with ureteral catheterization, with or without irrigation,instillation, or ureteropyelography, exclusive of radiologic service;CPT 52204Cystourethroscopy, with biopsy(s)CPT 52214Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethralglandsCPT 52224Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with orwithout biopsyCPT 52234Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)CPT 52240Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) and/or resection of; LARGE bladder tumor(s)CPT 52260Cystourethroscopy, with dilation of bladder for interstitial cystitis; generalor conduction (spinal) anesthesiaUpdated July 2021Page 9

CPT 52265Cystourethroscopy, with dilation of bladder for interstitial cystitis; localanesthesiaCPT 52276Cystourethroscopy with direct vision internal urethrotomyCPT 52281Cystourethroscopy, with calibration and/or dilation of urethral stricture orstenosis, with or without meatotomy, with or without injection procedurefor cystography, male or femaleCPT 52285Cystourethroscopy for treatment of the female urethral syndrome with anyor all of the following: urethral meatotomy, urethral dilation, internalurethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of thebladder neck, and fulgurationCPT 52310Cystourethroscopy, with removal of foreign body, calculus, or ureteral stentfrom urethra or bladder (separate procedure); simpleCPT 52315Cystourethroscopy, with removal of foreign body, calculus, or ureteral stentfrom urethra or bladder (separate procedure); complicatedCPT 52318Litholapaxy: crushing or fragmentation of calculus by any means in bladderand removal of fragments; complicated or large (over 2.5 cm)CPT 52320Cystourethroscopy (including ureteral catheterization); with removal ofureteral calculusCPT 52332Cystourethroscopy, with insertion of indwelling ureteral stent (e.g.,Gibbons or double-J type)CPT 53852Transurethral destruction of prostate tissue; by radiofrequencythermotherapyCPT 58150Total abdominal hysterectomy (corpus and cervix), with or without removalof tube(s), with or without removal of ovary(s);Elective InpatientCPT 58152Total abdominal hysterectomy (corpus and cervix), with or without removalof tube(s), with or without removal of ovary(s); with colpoElective Inpatient urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)Updated July 2021Page 10

CPT 58180Elective InpatientSupracervical abdominal hysterectomy (subtotal hysterectomy), with orwithout removal of tube(s), with or without removal of ovary(s)CPT 58200Total abdominal hysterectomy, including partial vaginectomy, with paraaortic and pelvic lymph node sampling, with or without removal of tube(s),Elective Inpatient with or without removal of ovary(s)CPT 58260Vaginal hysterectomy, for uterus 250 g or less;Elective InpatientCPT 58262Elective InpatientCPT 58263Elective InpatientVaginal hysterectomy, for uterus 250 g or less; with removal of tube(s),and/or ovary(s)Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s),and/or ovary(s), with repair of enteroceleCPT 58267Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with orElective Inpatient without endoscopic controlCPT 58270Vaginal hysterectomy, for uterus 250 g or less; with repair of enteroceleElective InpatientCPT 58275Vaginal hysterectomy, with total or partial vaginectomy;Elective InpatientCPT 58280Elective InpatientCPT 58285Vaginal hysterectomy, with total or partial vaginectomy; with repair ofenteroceleVaginal hysterectomy, radical (Schauta type operation)Elective InpatientCPT 58290Vaginal hysterectomy, for uterus greater than 250 g;Elective InpatientUpdated July 2021Page 11

CPT 58291Elective InpatientCPT 58292Elective InpatientVaginal hysterectomy, for uterus greater than 250 g; with removal oftube(s) and/or ovary(s)Vaginal hysterectomy, for uterus greater than 250 g; with removal oftube(s) and/or ovary(s), with repair of enteroceleCPT 58293Vaginal hysterectomy, for uterus greater than 250 g; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with orElective Inpatient without endoscopic controlCPT 58294Elective InpatientCPT 58550Vaginal hysterectomy, for uterus greater than 250 g; with repair ofenteroceleLaparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;Elective InpatientCPT 58552Elective InpatientCPT 58553Elective InpatientCPT 58554Elective InpatientLaparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;with removal of tube(s) and/or ovary(s)Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than250 g;Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than250 g; with removal of tube(s) and/or ovary(s)CPT 62287Decompression procedure, percutaneous, of nucleus pulposus ofintervertebral disc, any method utilizing needle based technique to removeElective Inpatient disc material under fluoroscopic imaging or other form of indirectvisualization, with the use of an endoscope, with discography and/orepidural injection(s) at the treated level(s), when performed, single ormultiple levels, lumbarCPT 62310Updated July 2021Injection(s), of diagnostic or therapeutic substance(s) (includinganesthetic, antispasmodic, opioid, steroid, other solution), not includingneurolytic substances, including needle or catheter placement, includesPage 12

contrast for localization when performed, epidural or subarachnoid; cervicalor thoracicCPT 62311Injection(s), of diagnostic or therapeutic substance(s) (includinganesthetic, antispasmodic, opioid, steroid, other solution), not includingneurolytic substances, including needle or catheter placement, includescontrast for localization when performed, epidural or subarachnoid; lumbaror sacral (caudal)CPT 62350Implantation, revision or repositioning of tunneled intrathecal or epiduralcatheter, for long-term medication administration via an external pump orimplantable reservoir/infusion pump; without laminectomyCPT 62355Removal of previously implanted intrathecal or epidural catheterCPT 63001Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), 1 or 2 vertebral segments; cervicalCPT 63005Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), 1 or 2 vertebral segments; lumbar, except forspondylolisthesisCPT 63012Laminectomy with removal of abnormal facets and/or pars inter-articulariswith decompression of cauda equina and nerve roots for spondylolisthesis,Elective Inpatient lumbar (Gill type procedure)CPT 63015Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), more than 2 vertebral segments; cervicalCPT 63017Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), more than 2 vertebral segments; lumbarCPT 63020Laminotomy (hemilaminectomy), with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedElective Inpatient intervertebral disc; 1 interspace, cervicalUpdated July 2021Page 13

CPT 63040Laminotomy (hemilaminectomy), with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedElective Inpatient intervertebral disc, reexploration, single interspace; cervicalCPT 63045Laminectomy, facetectomy and foraminotomy (unilateral or bilateral withdecompression of spinal cord, cauda equina and/or nerve root[s], [e.g.,Elective Inpatient spinal or lateral recess stenosis]), single vertebral segment; cervicalCPT 63047Laminectomy, facetectomy and foraminotomy (unilateral or bilateral withdecompression of spinal cord, cauda equina and/or nerve root[s], [e.g.,Elective Inpatient spinal or lateral recess stenosis]), single vertebral segment; lumbarCPT 63056Transpedicular approach with decompression of spinal cord, equina and/ornerve root(s) (e.g., herniated intervertebral disc), single segment; lumbarElective Inpatient (including transfacet, or lateral extraforaminal approach) (e.g., far lateralherniated intervertebral disc)CPT 63075Elective InpatientDiscectomy, anterior, with decompression of spinal cord and/or nerveroot(s), including osteophytectomy; cervical, single interspaceCPT 63076Discectomy, anterior, with decompression of spinal cord and/or nerveroot(s), including osteophytectomy; cervical, each additional interspaceElective Inpatient (List separately in addition to code for primary procedure)CPT 63081Vertebral corpectomy (vertebral body resection), partial or complete,anterior approach with decompression of spinal cord and/or nerve root(s);Elective Inpatient cervical, single segmentCPT 63082Vertebral corpectomy (vertebral body resection), partial or complete,anterior approach with decompression of spinal cord and/or nerve root(s);Elective Inpatient cervical, each additional segment (List separately in addition to code forprimary procedure)CPT 64418Injection, anesthetic agent; suprascapular nerveCPT 64420Injection, anesthetic agent; intercostal nerve, singleCPT 64421Injection, anesthetic agent; intercostal nerves, multiple, regional blockUpdated July 2021Page 14

CPT 64510Injection, anesthetic agent; stellate ganglion (cervical sympathetic)CPT 64530Injection, anesthetic agent; celiac plexus, with or without radiologicmonitoringCPT 66840Removal of lens material; aspiration technique, 1 or more stagesCPT 66850Removal of lens material; phacofragmentation technique (mechanical orultrasonic) (e.g., phacoemulsification), with aspirationCPT 66852Removal of lens material; pars plana approach, with or without vitrectomyCPT 66920Removal of lens material; intracapsularCPT 66930Removal of lens material; intracapsular, for dislocated lensCPT 66940Removal of lens material; extracapsular (other than 66840, 66850, 66852)CPT 66982Extracapsular cataract removal with insertion of intraocular lens prosthesis(1-stage procedure), manual or mechanical technique (e.g., irrigation andaspiration or phacoemulsification), complex, requiring devices ortechniques not generally used in routineCPT 66983Intracapsular cataract extraction with insertion of intraocular lensprosthesis (1 stage procedure)CPT 66984Extracapsular cataract removal with insertion of intraocular lens prosthesis(1 stage procedure), manual or mechanical technique (e.g., irrigation andaspiration or phacoemulsification)CPT 66985Insertion of intraocular lens prosthesis (secondary implant), not associatedwith concurrent cataract removalCPT 66986Exchange of intraocular lensCPT 70450Computed tomography, head or brain; without contrast materialCPT 70460Computed tomography, head or brain; with contrast material(s)Updated July 2021Page 15

CPT 70470Computed tomography, head or brain; without contrast material, followedby contrast material(s) and further sectionsCPT 70480Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; without contrast materialCPT 70481Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; with contrast material(s)CPT 70482Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; without contrast material, followed by contrast material(s) andfurther sectionsCPT 70486Computed tomography, maxillofacial area; without contrast materialCPT 70487Computed tomography, maxillofacial area; with contrast material(s)CPT 70488Computed tomography, maxillofacial area; without contrast material,followed by contrast material(s) and further sectionsCPT 70490Computed tomography, soft tissue neck; without contrast materialCPT 70491Computed tomography, soft tissue neck; with contrast material(s)CPT 70492Computed tomography, soft tissue neck; without contrast material followedby contrast material(s) and further sectionsCPT 70496Computed tomographic angiography, head, with contrast material(s),including noncontrast images, if performed, and image postprocessingCPT 70498Computed tomographic angiography, neck, with contrast material(s),including noncontrast images, if performed, and image postprocessingCPT 70540Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck;without contrast material(s)CPT 70542Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; withcontrast material(s)Updated July 2021Page 16

CPT 70543Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck;without contrast material(s), followed by contrast material(s) and furthersequencesCPT 70544Magnetic resonance angiography, head; without contrast material(s)CPT 70545Magnetic resonance angiography, head; with contrast material(s)CPT 70546Magnetic resonance angiography, head; without contrast material(s),followed by contrast material(s) and further sequencesCPT 70547Magnetic resonance angiography, neck; without contrast material(s)CPT 70548Magnetic resonance angiography, neck; with contrast material(s)CPT 70549Magnetic resonance angiography, neck; without contrast material(s),followed by contrast material(s) and further sequencesCPT 70551Magnetic resonance (e.g., proton) imaging, brain (including brain stem);without contrast materialCPT 70552Magnetic resonance (e.g., proton) imaging, brain (including brain stem);with contrast material(s)CPT 70553Magnetic resonance (e.g., proton) imaging, brain (including brain stem);without contrast material, followed by contrast material(s) and furthersequencesCPT 70554Magnetic resonance imaging, brain, functional MRI; including test selectionand administration of repetitive body part movement and/or visualstimulation, not requiring physician or psychologist administrationCPT 70555Magnetic resonance imaging, brain, functional MRI; requiring physician orpsychologist administration of entire neurofunctional testingCPT 71250Computed tomography, thorax; without contrast materialCPT 71260Computed tomography, thorax; with contrast material(s)Updated July 2021Page 17

CPT 71270Computed tomography, thorax; without contrast material, followed bycontrast material(s) and further sectionsCPT 71275Computed tomographic angiography, chest (noncoronary), with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessingCPT 71550Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); without contrast material(s)CPT 71551Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); with contrast material(s)CPT 71552Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); without contrast material(s),followed by contrast material(s) and further sequencesCPT 72125Computed tomography, cervical spine; without contrast materialCPT 72126Computed tomography, cervical spine; with contrast materialCPT 72127Computed tomography, cervical spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72128Computed tomography, thoracic spine; without contrast materialCPT 72129Computed tomography, thoracic spine; with contrast materialCPT 72130Computed tomography, thoracic spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72131Computed tomography, lumbar spine; without contrast materialCPT 72132Computed tomography, lumbar spine; with contrast materialCPT 72133Computed tomography, lumbar spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72141Magnetic resonance (e.g., proton) imaging, spinal canal and contents,cervical; without contrast materialUpdated July 2021Page 18

CPT 72142Magnetic resonance (e.g., proton) imaging, spinal canal and contents,cervical; with contrast material(s)CPT 72146Magnetic resonance (e.g., proton) imaging, spinal canal and contents,thoracic; without contra

CPT 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid CPT 19318. Reduction mammaplasty CPT 19324 Mammaplasty, augmentation; without prosthetic implant CPT 19325. Mammaplasty, augmentation; with prosthetic implant CPT 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia") CPT 20551