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Map Prior Authorization List Eff: 3/1/2021

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Map Prior Authorization List Eff: 3/1/2021 MAP PRIOR AUTHORIZATION LIST EFF: 3/1/2021 (Updated 02/18/2021) CPT, HCPCS or Revenue Description Comment Note Code INPATIENT All Inpatient admissions require authorization 0100 All inclusive room and board plus ancillary 0101 All inclusive room and board 0110 Room and Board Private (one bed) 0111 Room and Board Private (one bed) - Medical/Surgical/GYN 0113 Room and Board Private (one bed) - Pediatric 0117 Room and Board Private (one bed) - Oncology 0119 Room and Board Private (one bed) - Other 0121 Room and Board Semiprivate (two beds) - Medical/Surgical/GYN 0123 Room and Board Semiprivate (two beds) - Pediatric 0127 Room and Board Semiprivate (two beds) - Oncology 0130 Room & Board - Three and Four Beds General Classification 0131 Room & Board - Three and Four Beds Medical/Surgical/Gyn 0133 Room & Board - Three and Four Beds Pediatric 0137 Room & Board - Three and Four Beds Oncology 0139 Room & Board - Three and Four Beds Other 0140 Room & Board - Deluxe Private General Classification 0141 Room & Board - Deluxe Private Medical/Surgical/Gyn 0143 Room & Board - Deluxe Private Pediatric 0147 Room & Board - Deluxe Private Oncology 0149 Room & Board - Deluxe Private Other 0150 Room & Board - Ward General Classification 0151 Room & Board - Ward Medical/Surgical/Gyn 0153 Room & Board - Ward Pediatric 0157 Room & Board - Ward Oncology 0159 Room & Board - Ward Other 0160 Room & Board - Other General Classification 0164 Other Room & Board - Sterile Environment 0167 Room & Board - Other Self Care 0169 Room & Board - Other Other 00170 Anesthesia for intraoral treatments, including biopsy; not Direct to MAP dental otherwise specified clinics to coordinate payment for anesthesia/facility fees. 0190 General classification - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 0191 Subacute Care - Level I - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 0192 Subacute Care - Level II - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 0193 Subacute Care - Level III - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 0194 Subacute Care - Level IV - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 0199 Other Subacute Care - SNF Limited benefit - Pilot Program Effective 11/1/2018 Refer to MediView for PA MediView UM # 512-420-2777 MediView Fax # 512-420-2798 Toll Free Fax # 866-272-2542 00902 Exam Under Anesthesia 01999 Unlisted anesthesia procedure(s) Direct to MAP dental clinics to coordinate payment for anesthesia/facility fees related to dental. 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) 11010 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues 11011 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle 11012 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone 11040 Debridement; skin, partial thickness 11041 Debridement; skin, full thickness 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less 11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 11960 Insertion of tissue expanders for other than breast 11970 Replacement of tissue expander with permanent implant 11971 Removal of tissue expander(s) without insertion of implant 14000 Adjacent tissue transfer or rearrangement, truck; defect 10 sq cm or less 14001 Adjacent tissue transfer or rearrangement, trunk, defect 10.1 sq cm to 30.0 sq cm 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 14061 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm 14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof 15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 15005 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less 15050 Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter 15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 15101 Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15111 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15116 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 15121 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15131 Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15136 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15150 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less 15151 Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm 15152 Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof 15155 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less 15156 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm 15157 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or
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