Cigna - Prior Authorization Procedure List: … Documents/CPT Codes Requiring...Cigna - Prior...

Last Updated: 03/23/2017

Product Category CPT® Code CPT® Code Description

Musculoskeletal Interventional Pain 27096Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Musculoskeletal Interventional Pain 62263Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhIPolysis sessions; 2 or more days

Musculoskeletal Interventional Pain 62264Percutaneous lysis of epidural adhesion using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhIPolysis sessions; 1 day

Musculoskeletal Interventional Pain 62280Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid

Musculoskeletal Interventional Pain 62281Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic

Musculoskeletal Interventional Pain 62282Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal)

Musculoskeletal Interventional Pain 62310

Effective 1/1/2017 code was retired by AMA. New codes are 62320 and 62321. Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic


Effective 1/1/2017 code was retired by AMA. New codes are 62322 and 62323. Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)


Effective 1/1/2017 code was retired by AMA. New codes are 62324 and 62325. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic


Effective 1/1/2017 code was retired by AMA. New codes are 62326 and 62327. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)


New code effective 1/1/2017 per American Medical Association. Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance

Cigna - Prior Authorization Procedure List: Interventioanl Pain Management




New code effective 1/1/2017 per American Medical Association. Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)


New code effective 1/1/2017 per American Medical Association. Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance


New code effective 1/1/2017 per American Medical Association. Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)


New code effective 1/1/2017 per American Medical Association. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance


New code effective 1/1/2017 per American Medical Association. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)


New code effective 1/1/2017 per American Medical Association. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance


New code effective 1/1/2017 per American Medical Association. Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Musculoskeletal Interventional Pain 62350Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy

Musculoskeletal Interventional Pain 62351Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy

Musculoskeletal Interventional Pain 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

Musculoskeletal Interventional Pain 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump

Musculoskeletal Interventional Pain 62362Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

Musculoskeletal Interventional Pain 63650 Percutaneous implantation of neurostimulator electrode array, epidural

Musculoskeletal Interventional Pain 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural

Musculoskeletal Interventional Pain 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling

Musculoskeletal Interventional Pain 64479Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level



Musculoskeletal Interventional Pain 64480Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level

Musculoskeletal Interventional Pain 64484Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64490Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Musculoskeletal Interventional Pain 64491Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64492Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Musculoskeletal Interventional Pain 64494Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64495Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic)

Musculoskeletal Interventional Pain 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)

Musculoskeletal Interventional Pain 64620This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Destruction by neurolytic agent, intercostal nerve

Musculoskeletal Interventional Pain 64633Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

Musculoskeletal Interventional Pain 64634Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64635Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

Musculoskeletal Interventional Pain 64636Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 64999This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, nervous system

Musculoskeletal Interventional Pain 0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level

Musculoskeletal Interventional Pain 0214TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)



Musculoskeletal Interventional Pain 0215TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic;third and any additional level(s) (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level

Musculoskeletal Interventional Pain 0217TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 0218TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level

Musculoskeletal Interventional Pain 0229TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level

Musculoskeletal Interventional Pain 0231TInjection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Musculoskeletal Interventional Pain C1767This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Generator, neurostimulator (implantable), non-rechargeable

Musculoskeletal Interventional Pain C1778This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Lead, neurostimulator (implantable)

Musculoskeletal Interventional Pain C1787This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Patient programmer, neurostimulator

Musculoskeletal Interventional Pain C1816This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Receiver and/or transmitter, neurostimulator (implantable)

Musculoskeletal Interventional Pain C1820This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Generator, neurostimulator (implantable), with rechargeable battery and charging system

Musculoskeletal Interventional Pain C1883This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Adaptor/extension, pacing lead or neurostimulator lead (implantable)

Musculoskeletal Interventional Pain C1897This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Lead, neurostimulator test kit (implantable)

Musculoskeletal Interventional Pain E0782

This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Infusion pump, implantable, non-programmable (includes all components, e.g., pump, catheter, connectors, etc.)



Musculoskeletal Interventional Pain E0783

This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)

Musculoskeletal Interventional Pain E0785This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

Musculoskeletal Interventional Pain E0786This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)

Musculoskeletal Interventional Pain G0260Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

Musculoskeletal Interventional Pain L8680This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator electrode, each

Musculoskeletal Interventional Pain L8681This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only

Musculoskeletal Interventional Pain L8682This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator radiofrequency receiver

Musculoskeletal Interventional Pain L8683This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

Musculoskeletal Interventional Pain L8685This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

Musculoskeletal Interventional Pain L8686This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

Musculoskeletal Interventional Pain L8687This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

Musculoskeletal Interventional Pain L8688This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

Musculoskeletal Interventional Pain L8689This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.External recharging system for battery (internal) for use with implantable neurostimulator, replacement only

Musculoskeletal Interventional Pain L8695This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.External recharging system for battery (external) for use with implantable neurostimulator, replacement only



Musculoskeletal Joint Surgery 22899This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, spine

Musculoskeletal Joint Surgery 23000 Removal of subdeltoid calcareous deposits, open

Musculoskeletal Joint Surgery 23020 Capsular contracture release (eg, Sever type procedure)

Musculoskeletal Joint Surgery 23030 Incision and drainage, shoulder area; deep abscess or hematoma

Musculoskeletal Joint Surgery 23031 Incision and drainage, shoulder area; infected bursa

Musculoskeletal Joint Surgery 23035 Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area

Musculoskeletal Joint Surgery 23040 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body

Musculoskeletal Joint Surgery 23044 Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removalof foreign body

Musculoskeletal Joint Surgery 23065 Biopsy, soft tissue of shoulder area; superficial

Musculoskeletal Joint Surgery 23066 Biopsy, soft tissue of shoulder area; deep

Musculoskeletal Joint Surgery 23071 Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater

Musculoskeletal Joint Surgery 23073 Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater

Musculoskeletal Joint Surgery 23075 Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm

Musculoskeletal Joint Surgery 23076 Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm

Musculoskeletal Joint Surgery 23077 Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cm

Musculoskeletal Joint Surgery 23078 Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greater

Musculoskeletal Joint Surgery 23100 Arthrotomy, glenohumeral joint, including biopsy

Musculoskeletal Joint Surgery 23101 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage

Musculoskeletal Joint Surgery 23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy

Musculoskeletal Joint Surgery 23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy

Musculoskeletal Joint Surgery 23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body

Musculoskeletal Joint Surgery 23120 Claviculectomy; partial

Musculoskeletal Joint Surgery 23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release

Musculoskeletal Joint Surgery 23140 Excision or curettage of bone cyst or benign tumor of clavicle or scapula

Musculoskeletal Joint Surgery 23145Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft)

Musculoskeletal Joint Surgery 23146 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft

Musculoskeletal Joint Surgery 23150 Excision or curettage of bone cyst or benign tumor of proximal humerus

Musculoskeletal Joint Surgery 23155 Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)

Musculoskeletal Joint Surgery 23156 Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft

Musculoskeletal Joint Surgery 23170 Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle

Musculoskeletal Joint Surgery 23172 Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula

Musculoskeletal Joint Surgery 23174 Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck

Musculoskeletal Joint Surgery 23180 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle

Musculoskeletal Joint Surgery 23182 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula



Musculoskeletal Joint Surgery 23184 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus

Musculoskeletal Joint Surgery 23200 Radical resection for tumor; clavicle

Musculoskeletal Joint Surgery 23210 Radical resection for tumor; scapula

Musculoskeletal Joint Surgery 23220 Radical resection of bone tumor, proximal humerus

Musculoskeletal Joint Surgery 23330 Removal of foreign body, shoulder; subcutaneous

Musculoskeletal Joint Surgery 23333 Removal of foreign body, shoulder; deep (subfascial or intramuscular)

Musculoskeletal Joint Surgery 23334 Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component

Musculoskeletal Joint Surgery 23335Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)

Musculoskeletal Joint Surgery 23400 Scapulopexy (eg, Sprengels deformity or for paralysis)

Musculoskeletal Joint Surgery 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

Musculoskeletal Joint Surgery 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

Musculoskeletal Joint Surgery 23415 Coracoacromial ligament release, with or without acromioplasty

Musculoskeletal Joint Surgery 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

Musculoskeletal Joint Surgery 23430 Tenodesis of long tendon of biceps

Musculoskeletal Joint Surgery 23440 Resection or transplantation of long tendon of biceps

Musculoskeletal Joint Surgery 23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation

Musculoskeletal Joint Surgery 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)

Musculoskeletal Joint Surgery 23460 Capsulorrhaphy, anterior, any type; with bone block

Musculoskeletal Joint Surgery 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer

Musculoskeletal Joint Surgery 23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

Musculoskeletal Joint Surgery 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability

Musculoskeletal Joint Surgery 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

Musculoskeletal Joint Surgery 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))

Musculoskeletal Joint Surgery 23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Musculoskeletal Joint Surgery 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Musculoskeletal Joint Surgery 23490 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle

Musculoskeletal Joint Surgery 23491 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus

Musculoskeletal Joint Surgery 23700This procedue code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

Musculoskeletal Joint Surgery 23800 Arthrodesis, glenohumeral joint

Musculoskeletal Joint Surgery 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)

Musculoskeletal Joint Surgery 23929This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, shoulder

Musculoskeletal Joint Surgery 26990 Incision and drainage, pelvis or hip joint area; deep abscess or hematoma



Musculoskeletal Joint Surgery 26991 Incision and drainage, pelvis or hip joint area; infected bursa

Musculoskeletal Joint Surgery 26992 Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess)

Musculoskeletal Joint Surgery 27030 Arthrotomy, hip, with drainage (eg, infection)

Musculoskeletal Joint Surgery 27033 Arthrotomy, hip, including exploration or removal of loose or foreign body

Musculoskeletal Joint Surgery 27040 Biopsy, soft tissue of pelvis and hip area; superficial

Musculoskeletal Joint Surgery 27041 Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular

Musculoskeletal Joint Surgery 27043 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater

Musculoskeletal Joint Surgery 27045 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greater

Musculoskeletal Joint Surgery 27047 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm

Musculoskeletal Joint Surgery 27048 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm

Musculoskeletal Joint Surgery 27049 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm

Musculoskeletal Joint Surgery 27052 Arthrotomy, with biopsy; hip joint

Musculoskeletal Joint Surgery 27054 Arthrotomy with synovectomy, hip joint

Musculoskeletal Joint Surgery 27059 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater

Musculoskeletal Joint Surgery 27065Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed

Musculoskeletal Joint Surgery 27066Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed

Musculoskeletal Joint Surgery 27067Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incision

Musculoskeletal Joint Surgery 27070Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial

Musculoskeletal Joint Surgery 27071Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)

Musculoskeletal Joint Surgery 27075 Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis

Musculoskeletal Joint Surgery 27076 Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulum

Musculoskeletal Joint Surgery 27077 Radical resection of tumor; innominate bone, total

Musculoskeletal Joint Surgery 27078 Radical resection of tumor; ischial tuberosity and greater trochanter of femur

Musculoskeletal Joint Surgery 27086 Removal of foreign body, pelvis or hip; subcutaneous tissue

Musculoskeletal Joint Surgery 27087 Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular)

Musculoskeletal Joint Surgery 27090 Removal of hip prosthesis; (separate procedure)

Musculoskeletal Joint Surgery 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer

Musculoskeletal Joint Surgery 27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

Musculoskeletal Joint Surgery 27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

Musculoskeletal Joint Surgery 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

Musculoskeletal Joint Surgery 27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

Musculoskeletal Joint Surgery 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft



Musculoskeletal Joint Surgery 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft

Musculoskeletal Joint Surgery 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

Musculoskeletal Joint Surgery 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft

Musculoskeletal Joint Surgery 27140 Osteotomy and transfer of greater trochanter of femur (separate procedure)

Musculoskeletal Joint Surgery 27146 Osteotomy, iliac, acetabular or innominate bone;

Musculoskeletal Joint Surgery 27147 Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip

Musculoskeletal Joint Surgery 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy

Musculoskeletal Joint Surgery 27156 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip

Musculoskeletal Joint Surgery 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation)

Musculoskeletal Joint Surgery 27161 Osteotomy, femoral neck (separate procedure)

Musculoskeletal Joint Surgery 27165 Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast

Musculoskeletal Joint Surgery 27175 Treatment of slipped femoral epiphysis; by traction, without reduction

Musculoskeletal Joint Surgery 27176 Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ

Musculoskeletal Joint Surgery 27177 Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft)

Musculoskeletal Joint Surgery 27178 Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning

Musculoskeletal Joint Surgery 27179 Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure)

Musculoskeletal Joint Surgery 27181 Open treatment of slipped femoral epiphysis; osteotomy and internal fixation

Musculoskeletal Joint Surgery 27187Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur

Musculoskeletal Joint Surgery 27299This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, pelvis or hip joint

Musculoskeletal Joint Surgery 27301 Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region

Musculoskeletal Joint Surgery 27303 Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess)

Musculoskeletal Joint Surgery 27310 Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection)

Musculoskeletal Joint Surgery 27323 Biopsy, soft tissue of thigh or knee area; superficial

Musculoskeletal Joint Surgery 27324 Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular)

Musculoskeletal Joint Surgery 27327 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm

Musculoskeletal Joint Surgery 27328 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm

Musculoskeletal Joint Surgery 27329 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 5 cm

Musculoskeletal Joint Surgery 27330 Arthrotomy, knee; with synovial biopsy only

Musculoskeletal Joint Surgery 27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies

Musculoskeletal Joint Surgery 27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral

Musculoskeletal Joint Surgery 27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral

Musculoskeletal Joint Surgery 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior

Musculoskeletal Joint Surgery 27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area

Musculoskeletal Joint Surgery 27337 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater



Musculoskeletal Joint Surgery 27339 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater

Musculoskeletal Joint Surgery 27340 Excision, prepatellar bursa

Musculoskeletal Joint Surgery 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee

Musculoskeletal Joint Surgery 27355 Excision or curettage of bone cyst or benign tumor of femur;

Musculoskeletal Joint Surgery 27356 Excision or curettage of bone cyst or benign tumor of femur; with allograft

Musculoskeletal Joint Surgery 27357 Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft)

Musculoskeletal Joint Surgery 27358Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure)

Musculoskeletal Joint Surgery 27360Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess)

Musculoskeletal Joint Surgery 27364 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greater

Musculoskeletal Joint Surgery 27365 Radical resection of tumor, femur or knee

Musculoskeletal Joint Surgery 27372 Removal of foreign body, deep, thigh region or knee area

Musculoskeletal Joint Surgery 27403 Arthrotomy with meniscus repair, knee

Musculoskeletal Joint Surgery 27405 Repair, primary, torn ligament and/or capsule, knee; collateral

Musculoskeletal Joint Surgery 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate

Musculoskeletal Joint Surgery 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

Musculoskeletal Joint Surgery 27412 Autologous chondrocyte implantation, knee

Musculoskeletal Joint Surgery 27415 Osteochondral allograft, knee, open

Musculoskeletal Joint Surgery 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

Musculoskeletal Joint Surgery 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure)

Musculoskeletal Joint Surgery 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure)

Musculoskeletal Joint Surgery 27422Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)

Musculoskeletal Joint Surgery 27424 Reconstruction of dislocating patella; with patellectomy

Musculoskeletal Joint Surgery 27425 Lateral retinacular release, open

Musculoskeletal Joint Surgery 27427 Ligamentous reconstruction (augmentation), knee; extra-articular

Musculoskeletal Joint Surgery 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open)

Musculoskeletal Joint Surgery 27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular

Musculoskeletal Joint Surgery 27438 Arthroplasty, patella; with prosthesis

Musculoskeletal Joint Surgery 27440 Arthroplasty, knee, tibial plateau

Musculoskeletal Joint Surgery 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

Musculoskeletal Joint Surgery 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee

Musculoskeletal Joint Surgery 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy

Musculoskeletal Joint Surgery 27445 Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)

Musculoskeletal Joint Surgery 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment



Musculoskeletal Joint Surgery 27447Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

Musculoskeletal Joint Surgery 27448 Osteotomy, femur, shaft or supracondylar; without fixation

Musculoskeletal Joint Surgery 27450 Osteotomy, femur, shaft or supracondylar;with fixation

Musculoskeletal Joint Surgery 27454 Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure)

Musculoskeletal Joint Surgery 27455Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee)); before epiphyseal closure

Musculoskeletal Joint Surgery 27457Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus (bowleg) or genu valgus (knock-knee));after epiphyseal closure

Musculoskeletal Joint Surgery 27465 Osteoplasty, femur; shortening (excluding 64876)

Musculoskeletal Joint Surgery 27466 Osteoplasty, femur;lengthening

Musculoskeletal Joint Surgery 27468 Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer

Musculoskeletal Joint Surgery 27470 Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique)

Musculoskeletal Joint Surgery 27472Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft)

Musculoskeletal Joint Surgery 27486 Revision of total knee arthroplasty, with or without allograft; one component

Musculoskeletal Joint Surgery 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

Musculoskeletal Joint Surgery 27488Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee

Musculoskeletal Joint Surgery 27495 Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur

Musculoskeletal Joint Surgery 27570This procedure code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage this procedure code.Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

Musculoskeletal Joint Surgery 27599This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, femur or knee

Musculoskeletal Joint Surgery 27899This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, leg or ankle

Musculoskeletal Joint Surgery 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)

Musculoskeletal Joint Surgery 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy

Musculoskeletal Joint Surgery 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion

Musculoskeletal Joint Surgery 29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body

Musculoskeletal Joint Surgery 29820 Arthroscopy, shoulder, surgical; synovectomy, partial

Musculoskeletal Joint Surgery 29821 Arthroscopy, shoulder, surgical; synovectomy, complete

Musculoskeletal Joint Surgery 29822 Arthroscopy, shoulder, surgical; debridement, limited

Musculoskeletal Joint Surgery 29823 Arthroscopy, shoulder, surgical; debridement, extensive

Musculoskeletal Joint Surgery 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)

Musculoskeletal Joint Surgery 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation



Musculoskeletal Joint Surgery 29826Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)

Musculoskeletal Joint Surgery 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair

Musculoskeletal Joint Surgery 29828 Arthroscopy, shoulder, surgical; biceps tenodesis

Musculoskeletal Joint Surgery 29850Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)

Musculoskeletal Joint Surgery 29851Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy)

Musculoskeletal Joint Surgery 29855Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy)

Musculoskeletal Joint Surgery 29856Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy)

Musculoskeletal Joint Surgery 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

Musculoskeletal Joint Surgery 29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body

Musculoskeletal Joint Surgery 29862Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum

Musculoskeletal Joint Surgery 29863 Arthroscopy, hip, surgical; with synovectomy

Musculoskeletal Joint Surgery 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

Musculoskeletal Joint Surgery 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Musculoskeletal Joint Surgery 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

Musculoskeletal Joint Surgery 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

Musculoskeletal Joint Surgery 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage

Musculoskeletal Joint Surgery 29873 Arthroscopy, knee, surgical; with lateral release

Musculoskeletal Joint Surgery 29874Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

Musculoskeletal Joint Surgery 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

Musculoskeletal Joint Surgery 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

Musculoskeletal Joint Surgery 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

Musculoskeletal Joint Surgery 29879Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

Musculoskeletal Joint Surgery 29880Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Musculoskeletal Joint Surgery 29881Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

Musculoskeletal Joint Surgery 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

Musculoskeletal Joint Surgery 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

Musculoskeletal Joint Surgery 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

Musculoskeletal Joint Surgery 29885Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)



Musculoskeletal Joint Surgery 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

Musculoskeletal Joint Surgery 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

Musculoskeletal Joint Surgery 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

Musculoskeletal Joint Surgery 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

Musculoskeletal Joint Surgery 29914 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

Musculoskeletal Joint Surgery 29915 Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

Musculoskeletal Joint Surgery 29916 Arthroscopy, hip, surgical; with labral repair

Musculoskeletal Joint Surgery 29999This unlisted code will be managed if submitted with a code that is in the delegated MSK program; otherwise, Cigna will manage the code.Unlisted procedure, arthroscopy

CPT® copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Cigna - Prior Authorization Procedure List: … Documents/CPT Codes Requiring...Cigna - Prior...

Documents

Transcript of Cigna - Prior Authorization Procedure List: … Documents/CPT Codes Requiring...Cigna - Prior...