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PW_B132379
Important Reminder to Facilities and Providers Concerning Services that Do Not Require Prior Authorization:
For services that do not require prior authorization, Empire may review the medical necessity or appropriateness of the health care service after the service has been performed to determine whether such services were medically necessary, cosmetic, or experimental or investigational.
Please note that the following codes referenced below are considered experimental and investigational in accordance with Empire’s medical policies and clinical guidelines.
For the most current version of medical policies and clinical guidelines, please visit empireblue.com. The policy documents available on empireblue.com include the codes and rationale.
| 15335
|
61640
|
91132
|
0064T
|
0140T
|
0187T
|
E1801
|
Q4109
|
S8035
|
| 15336
|
61641
|
91133
|
0068T
|
0141T
|
0190T
|
E1806
|
Q4110
|
S8040
|
| 15400
|
61642
|
92512
|
0069T
|
0142T
|
0191T
|
E1811
|
Q4111
|
S8042
|
| 15401
|
61870
|
92548
|
0070T
|
0143T
|
0192T
|
E1815
|
Q4112
|
S8080
|
| 15420
|
61875
|
93228
|
0071T
|
0144T
|
0193T
|
E1816
|
Q4113
|
S8092
|
| 15421
|
62263
|
93229
|
0072T
|
0155T
|
0198T
|
E1818
|
Q4114
|
S8190
|
| 15430
|
62264
|
93278
|
0077T
|
0156T
|
A4575
|
E1821
|
S0345
|
S8940
|
| 15431
|
62291
|
93701
|
0078T
|
0157T
|
A4638
|
E1830
|
S0346
|
S8948
|
| 19105
|
65756
|
93740
|
0079T
|
0158T
|
A4639
|
E1840
|
S0347
|
S9024
|
| 20985
|
65757
|
93760
|
0080T
|
0160T
|
A9284
|
E1841
|
S2095
|
S9055
|
| 22526
|
65770
|
93762
|
0081T
|
0161T
|
C1818
|
E2120
|
S2102
|
S9056
|
| 22527
|
72285
|
94014
|
0084T
|
0163T
|
C1821
|
G0130
|
S2103
|
S9090
|
| 22856
|
76977
|
94015
|
0085T
|
0164T
|
C9357
|
G0219
|
S2107
|
V5095
|
| 22857
|
77079
|
94016
|
0086T
|
0165T
|
C9358
|
G0252
|
S2117
|
|
| 22861
|
77082
|
95012
|
0087T
|
0166T
|
C9716
|
G0255
|
S2230
|
|
| 22862
|
77083
|
95027
|
0092T
|
0167T
|
C9724
|
G0282
|
S2300
|
|
| 22864
|
77084
|
95060
|
0095T
|
0168T
|
E0221
|
G0295
|
S2344
|
|
| 22865
|
77605
|
95065
|
0098T
|
0169T
|
E0481
|
G0341
|
S2348
|
|
| 27702
|
77620
|
95803
|
0101T
|
0170T
|
E0487
|
G0342
|
S2400
|
|
| 28446
|
78350
|
95965
|
0102T
|
0171T
|
E0617
|
G0343
|
S2404
|
|
| 28890
|
78647
|
95966
|
0104T
|
0172T
|
E0638
|
G0417
|
S3652
|
|
| 32998
|
78710
|
95967
|
0105T
|
0176T
|
E0641
|
G0418
|
S3711
|
|
| 33548
|
82107
|
96904
|
0106T
|
0177T
|
E0642
|
G0419
|
S3800
|
|
| 41019
|
83993
|
97533
|
0107T
|
0178T
|
E0740
|
M0075
|
S3852
|
|
| 41512
|
86001
|
99174
|
0108T
|
0179T
|
E0746
|
M0076
|
S3855
|
|
| 43257
|
86343
|
0017T
|
0109T
|
0180T
|
E0761
|
Q4102
|
S3860
|
|
| 46762
|
89346
|
0019T
|
0110T
|
0181T
|
E0762
|
Q4103
|
S3861
|
|
| 55706
|
89356
|
0042T
|
0123T
|
0182T
|
E0764
|
Q4105
|
S3862
|
|
| 61630
|
90911
|
0062T
|
0124T
|
0183T
|
E0769
|
Q4107
|
S3890
|
|
| 61635
|
91111
|
0063T
|
0126T
|
0186T
|
E0770
|
Q4108
|
S3905
|
|
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