UnitedHealthcare® Commercial Network Bulletin Appendix NOTIFICATION/PRIOR AUTHORIZATION REQUIREMENTS AND SITE OF SERVICE MEDICAL NECESSITY REVIEWS FOR CERTAIN SURGICAL PROCEDURES: CODE GROUP 1 APPLICABLE CODES Note that the information in this table only pertains to UnitedHealthcare commercial plans. State(s) Code Group 1 Effective Date Most States Nov. 1, 2019 California, Connecticut, New Jersey, New York Dec. 1, 2019 Colorado, Maryland, Rhode Island Jan. 1, 2020 Georgia, Iowa, Kansas, Maine, Nebraska, New Hampshire, North Carolina, Mar. 1, 2020 South Carolina, Vermont Alaska, Kentucky, Massachusetts, Texas, Utah and Wisconsin Excluded These CPT®/HCPCS codes are subject to notification/prior authorization requirements for dates of service starting on or after the dates listed in the table above. Use this link to return to the February 2020 Network Bulletin. Code Description Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance 0249T (CMS annual code deletion effective Jan. 1, 2020; replacing with CPT code 46948 on Mar. 1, 2020) 10121 Incision and removal of foreign body, subcutaneous tissues; complicated 10180 Incision and drainage, complex, postoperative wound infection 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface Debridement including removal of foreign material at the site of an open fracture and/or an open 11010 dislocation (e.g., excisional debridement); skin and subcutaneous tissues Debridement including removal of foreign material at the site of an open fracture and/or an open 11012 dislocation (e.g., excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11440 ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11441 ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11443 ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11444 ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11446 ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate 11450 repair 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate 11462 repair 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with 11470 simple or intermediate repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with 11471 complex repair UnitedHealthcare January 2020 Network Bulletin Appendix: Code Group 1 Page 1 of 26 Proprietary Information of UnitedHealthcare. 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Code Description 11601 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm 11602 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11620 0.5 cm or less Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11621 0.6 to 1.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11622 1.1 to 2.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11623 2.1 to 3.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11624 3.1 to 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 11626 over 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 11640 cm or less Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 11641 1.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 11642 2.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 11643 3.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 11644 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 11646 4.0 cm Excision of nail and nail matrix, partial or complete (e.g., ingrown or deformed nail), for permanent 11750 removal Biopsy of nail unit (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate 11755 procedure) 11760 Repair of nail bed 11770 Excision of pilonidal cyst or sinus; simple 11772 Excision of pilonidal cyst or sinus; complicated Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12031 feet); 2.5 cm or less Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12032 feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12034 feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12035 feet); 12.6 cm to 20.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12037 feet); over 30.0 cm 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 12042 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm 12051 or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm 12052 to 5.0 cm 13100 Repair, complex, trunk; 1.1 cm to 2.5 cm 13120 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm UnitedHealthcare January 2020 Network Bulletin Appendix: Code Group 1 Page 2 of 26 Proprietary Information of UnitedHealthcare. 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Code Description 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm 13131 to 2.5 cm 13151 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 13152 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants 15100 and children (except 15050) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 15120 and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm 15220 or less Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, 15240 neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 15260 sq cm or less 15576 Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral Graft; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor 15760 area 15770 Graft; derma-fat-fascia 15850 Removal of sutures under anesthesia (other than local), same surgeon Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 17000 premalignant lesions (e.g., actinic keratoses); first lesion Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 17004 premalignant lesions (e.g., actinic keratoses), 15 or more lesions Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 17110 of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), 17111 of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the 17311 surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage,