| ICD 9 Surgical Codes Requiring Prior Authorization | |||
| Procedure Code | Type = of Service Description | Type of= Service Code | Prior Authorization Indicator-Proc |
| 0393 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0492 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0831 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0832 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0833 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0834 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0835 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0837 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0841 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0842 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0843 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0844 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0849 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0851 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0852 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0859 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 087 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0870 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0871 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0872 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0873 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0874 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0886 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0887 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 0889 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 116 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1161 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1162 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1163 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1390 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1578 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1579 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1581 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 185 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 186 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 187 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1871 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 1879 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 2184 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 2185 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 2186 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 2187 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 335 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 375 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 4389 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 443 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 4431 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 4439 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 446 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 4469 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 505 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 556 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 645 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 683 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 6831 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 684 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 685 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 6851 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 6859 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 686 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 687 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 689 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7643 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7646 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 765 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 766 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7661 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7662 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7663 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7664 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7665 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7666 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7667 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7668 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 7669 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 853 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8531 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8532 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 855 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8550 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8551 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8552 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8553 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8554 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 856 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8587 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8589 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 859 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8602 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8624 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8625 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8682 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8683 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8692 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |
| 8693 | ICD-9 SURGICAL PROCEDURE &nbs= p; | Y | Y |