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Geisinger Health Plan Prior Authorization List

Written by Nicole Saidai

Overview

Cohere Health, a patient journey optimization company, has been asked to deploy its Digital Prior Authorization solution to allow users to submit a variety of services directly through Cohere’s platform. Starting Oct 1, 2023, Cohere began managing Geisinger Health Plan submissions for most of the following services: DME, radiology, cardiology, musculoskeletal, and pain intervention.

For more information and to view the official and most up-to-date Geisinger Preauthorization List (PAL), please visit Geisinger's provider website. If you decide to fax a request for the codes listed below, please send it directly to Geisinger.

All practices are encouraged to submit preauthorization requests electronically by registering* for a Cohere account. Only Cohere users can benefit from instant authorization decisions, if eligible.

* If your practice already has access to Cohere, please ask any existing Cohere administrative user(s) at your practice to create an account for you.

The codes listed below require authorization for all lines of business unless otherwise noted.

Durable Medical Equipment (DME) & Outpatient Services

Durable Medical Equipment (DME) & Outpatient Services

Category

Procedure Code

Ablation

  • 0793T

Biofeedback for Non Behavioral Health indications

  • 90911

Cardiac devices

  • 33289, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T

Cardiac procedures/surgeries

  • 33875, 33877, 33880, 33881, 33883, 33886, 34701, 34702, 34703, 34704, 34705, 34706, 34830, 34831, 34832, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 35301, 37215, 37216, 37217, 37218

Chiropractic Services

  • 99202, 99203, 99204, 99205, 99206, 99207, 99208, 99209, 99210, 99211, 99212, 99213, 99214

Deleted Code

  • 0058T

Diagnostic/cardiac imaging

  • 36245, 36246, 36247

DME - Medical/Surgical Supplies - Other

  • E1399, E2342, E2351

DME - Orthotic Devices - Below Knee Orthotic

  • A5510, L1900, L1904, L1907, L1920, L1980, L1990, L2106, L2108, L3201, L3211, L3214, L3254, L3255, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5301, L5400, L5410, L5450, L5500, L5510, L5520, L5530, L5535, L5540, L5620, L5629, L5637, L5638, L5639, L5645, L5646, L5647, L5655, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5700, L5703, L5704, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5785, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5910, L5930, L5940, L5962, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5987, L5841, L1932, L1951

DME - Orthotic Devices - Knee Orthosis

  • L1834, L1840, L1844, L1846, L1860

DME - Orthotic Devices - Lumbar Sacral Orthosis (LSO brace)

  • L0629, L0632, L0634, L0636, L0638, L0640

DME - Orthotic Devices - Other

  • C1813, C2622, A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5512, A5513, A5514, K0672, K1015, L0112, L0220, L0452, L0480, L0482, L0484, L0486, L0622, L0624, L0700, L0710, L0810, L0820, L0830, L0859, L0861, L0999, L1000, L1005, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499, L1630, L1640, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2040, L2050, L2060, L2070, L2080, L2090, L2126, L2128, L2627, L2628, L2999, L3001, L3002, L3003, L3020, L3030, L3031, L3040, L3050, L3070, L3080, L3090, L3160, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3212, L3213, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649, L3671, L3674, L3702, L3720, L3730, L3740, L3763, L3764, L3765, L3766, L3806, L3808, L3891, L3900, L3901, L3904, L3905, L3906, L3913, L3919, L3921, L3933, L3935, L3956, L3961, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3995, L3999, L4000, L4002, L4205, L4210, L4631, K1022, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5312, L5321, L5331, L5341, L5420, L5430, L5460, L5505, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5622, L5624, L5626, L5628, L5630, L5631, L5632, L5634, L5636, L5640, L5642, L5643, L5644, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5656, L5658, L5661, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5701, L5702, L5705, L5706, L5707, L5781, L5782, L5790, L5795, L5850, L5855, L5920, L5925, L5950, L5960, L5961, L5964, L5966, L5982, L5984, L5985, L5986, L5988, L5990, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7360, L7362, L7364, L7366, L7367, L7368, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L7900, L7902, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, L8300, L8310, L8320, L8330, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8485, L8499, L8500, L8501, L8505, L8507, L8509, L8510, L8511, L8512, L8513, L8514, L8515, L8609, L8610, L8612, L8615, L8616, L8617, L8618, L8619, L8621, L8623, L8624, L8627, L8628, L8629, L8630, L8631, L8641, L8642, L8658, L8659, L8670, L8690, L8695, L8699, L9900, L1320, L5783, L0720

DME - Other DME - Other

  • E0761, S9127, S9128, S9208, S9211, S9213, S9214, Q5001, Q5002, Q5003, Q5007, Q5004, Q5005, Q5006, Q5008, Q5009, Q5010, E0617, S9432, S9434, S9435, A9283, E0485, E0486, K0903, S1040, K1014, L7259, L7600, L8622, L8625, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, A4555, E0766, E0466, E0467, S4030, S4031, S4040, T4522, T4539, T4540, T4534, T4541, T4542, T4543, T4538, T4532, T4537, T4535, T4536, T4533, T4523, T4524, T4521, T4525, T4530, T4531, T4528, T4529, T4526, T4545, T4527, T4544, E0565, E0618, E0619, E0170, E0483, A7025, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0462, K0002, K0003, K0004, K0005, K0006, K0007, E0482, E0574, E0575, E0740, E0744, E0745, E0770, E0424, E0431, E0433, E0434, E0439, E1390, E1391, E1392, K0738, E0630, E0635, E0636, E0639, E0640, E1035, E1036, E0650, E0651, E0652, E0675, E0601, E0193, E0194, E0277, E0371, E0372, E0373, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841, E0445, E0470, E0471, E0472, E0600, E2000, E0465, K0800, K0801, K0802, K0806, K0807, K0808, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, E0217, E0236, E0239, E0480, E0550, E0615, E0656, E0657, E0668, E0677, E0762, E0781, E0784, E0785, E0791, E0849, E0855, E0911, E0912, E0920, E0930, E0941, E0946, E0958, E0983, E0984, E0986, E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1012, E1014, E1029, E1030, E1031, E1037, E1050, E1060, E1070, E1083, E1084, E1087, E1088, E1092, E1093, E1100, E1110, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1221, E1222, E1223, E1224, E1225, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1270, E1280, E1295, E1405, E1406, E1700, E2120, E2227, E2228, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378, K0009, K0010, K0011, K0012, K0455, K0730, K1002, K1006, K1009, K1016, K1018, K1020, K1024, K1025, K1031, K1032, K1033, E0147, E0670, E0671, E0691, E0692, E0693, E0694, E0782, E0783, E0786, E0947, E0948, E1230, E1296, E1310, E2204, E2341, E2343, E2614, E2616, E2621, E2626, E2627, E2628, E2629, E2630, K0606, L5991, E0721, E0743

DME - Wheelchairs - Other

  • K0108

Dorsal Column Stimulation

  • 0417U

E & M - Behavioral health services - Other

  • 90901, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 97151, 97155, 97156, 97153, 97152, 97157, H0031, H2021

E & M - Behavioral health services - Psychotherapy - Group

  • 97158

E & M - Behavioral health services - Psychotherapy - Nongroup

  • 90832, 90833, 90834, 90836, 90837, 90838

E & M - E & M - Miscellaneous - Other

  • G0493, G0494, G0495, G0496, 95851, 95852, 99091

E & M - Home services - Home Health Skilled Services

  • G0162

E & M - Home services - Other

  • 99503, 99504, G0151, G0152, G0153, G0155, G0156, G0158, G0159, G0160, G0161, G0320, G0321, G0322, S9129, S9131, G0299, G0300, S9125, S9126, T1002, T1003, S5116

E & M - Hospice - Other

  • T2044, T2045

E & M - Ophthalmological services - Other

  • 92065

Emerging technology/new indications for existing technology

  • 93264

Endobronchial Valve

  • 31647, 31648, 31651, 61349

Epidural Steroid Injections (Outpatient Only)

  • 64480, 64484

Facet Injections

  • 64491, 64492, 64494, 64495, 64634, 64636, 0214T, 0215T, 0217T, 0218T

Gender Dysphoria and Gender Confirmation Treatment

  • 19369, 31540, 31541, 31570, 31571

Imaging - CT Scan - CT/CTA - Abdomen and Pelvis

  • 72191, 72192, 72193, 72194, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74263, 75635

Imaging - CT Scan - CT/CTA - Chest

  • 71250, 71260, 71270, 71271, 71275, G0297

Imaging - CT Scan - CT/CTA - Head and Neck

  • 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498

Imaging - CT Scan - CT/CTA - Spine

  • 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133

Imaging - CT Scan - Other

  • 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74262, 75571, 75572, 75573, 75574, 76380

Imaging - MR - MRI/MRA - Abdomen and Pelvis

  • 72195, 72196, 72197, 72198, 74181, 74182, 74183

Imaging - MR - MRI/MRA - Head and Neck

  • 70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555

Imaging - MR - MRI/MRA - Lower Extremity

  • 73718, 73719, 73720, 73721, 73722, 73723, 73725

Imaging - MR - MRI/MRA - Other

  • 71550, 71551, 71552, 71555, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 74185, 74712, 75557, 75559, 75561, 75563, 77046, 77047, 77048, 77049, 77084, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, C9791

Imaging - MR - MRI/MRA - Spine

  • 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

Imaging - Nuclear - Myocardial Perfusion Scan

  • 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78491, 78492

Imaging - Nuclear - Other

  • 78429, 78430, 78431, 78432, 78433, 78472, 78473, 78481, 78483, 78494, 78609, G0219, G0235, G0252

Imaging - Nuclear - PET- Oncology

  • 92066, 89250, 89251, 89254, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89335, 89337, 89343, 89346, 89352, 89353, 78608, 78811, 78812, 78813, 78814, 78815, 78816

Interventional Cardiology-Electrophysiological Studies-(ESP) - Ablation

  • 92924, 92933, 0238T

Interventional Pain Management

  • 64454, 64624, 64625

Molecular Profiling of Malignant Tumors

  • 0391U, 0422U, 0428U, 0172U, 0326U, 0473U, 0511U, 0523U, 0211U

Musculoskeletal Procedures - Ankle

  • 27700, 27702, 27870

Oral Health

  • G0330

Orthopedic surgeries: hip, knee and shoulder arthroscopy

  • 29826, 29850, 29851, 0707T, 0737T, J7330, S2112, S2300

Orthotics

  • L1006, L2755

Other - Ambulance - Medical Transport - Air

  • A0140, A0430, A0431, A0435, A0436

Other - Ambulance - Medical Transport - Ground

  • A0100, A0110, A0120, A0130, A0426, A0428, A0432, A0434, A0998

Other - Ambulance - Medical Transport - Ground Emergency

  • A0225, A0424, A0427, A0429, A0433

Other - Ambulance - Medical Transport - Mileage

  • A0080, A0090, A0160, A0170, A0180, A0190, A0200, A0210, A0380, A0390, A0425

Other - Ambulance - Other

  • A0422

Other - Enteral & Parenteral - Enteral Feeding and Formula

  • B4034, B4035, B4036, B4087, B4088, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9998, S9342, S9343, S9433, B4148

Other - Enteral & Parenteral - Other

  • B4081, B4082, B4083, B4100

Other - Enteral & Parenteral - Parenteral Feeding and Formula

  • B9002

Other - Vision Hearing & Speech Services - Other

  • V2600, V2610, V2615, V2770

Peripheral revascularization (atherectomy, angioplasty)

  • 37254, 37256, 37258, 37260, 37262, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298, 0505T

Procedure - Breast - Mastectomy

  • 19318, 19301, 19303, 19325, 19350, 19357, 19300, 19304

Procedure - Cardiovascular - Comprehensive Electrophysiologic Evaluation

  • 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93631, 93650, 93653, 93654, 93656

Procedure - Cardiovascular - Insertion/Removal/Replacement ICD

  • 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33285, 33286

Procedure - Cardiovascular - Other

  • 33930, 33933, 33935, 33940, 33944, 33945, 0345T, 0571T, 0572T, 0573T, 0574T, 0577T, 0580T, 0614T, 33990, 33991, 33995, C9762, C9763

Procedure - Cardiovascular - Pacemaker Insertion or Repair

  • 33207, 33208, 33213, 33214, 33216, 33217, 33224, 33240, 33206, 33210, 33211, 33212, 33221, 33230, 33231, 33274

Procedure - Cardiovascular - Pacemaker Removal

  • 33233, 33234, 33241, 33227, 33228, 33229, 33235, 33275

Procedure - Cardiovascular - Percutaneous Coronary Artery Angioplasty and Stenting

  • 92920, 92928, 92937, 92943, 93593, 93594, 93595, 93596, 93597

Procedure - Cardiovascular - Percutaneous Transcatheterization

  • 33340, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580

Procedure - Digestive/gastrointestinal - Other

  • 43647, 43648, 43881, 43284, 43285, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 44135, 44136, 44715, 44720, 44721, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48160, 48550, 48551, 48552, 48554, 48556, S2053

Procedure - Digestive/gastrointestinal - Upper GI Endoscopy

  • 43210

Procedure - Eye - Other

  • 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911

Procedure - Musculoskeletal - Arthrodesis - Spine

  • 22532, 22533, 22548, 22551, 22554, 22556, 22558, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22849, 22856, 22857, 22861, 22867, 22869, 22850, 22852, 22855, 22864, 22865

Procedure - Musculoskeletal - Arthroplasty - Hip

  • 27125, 27130, 27132, 27134, 27137, 27138, 27120, 27122

Procedure - Musculoskeletal - Arthroplasty - Knee

  • 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487

Procedure - Musculoskeletal - Arthroscopy - Lower Extremity

  • 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916, 29855, 29856

Procedure - Musculoskeletal - Arthroscopy - Upper Extremity

  • 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29827, 29828

Procedure - Musculoskeletal - Destruction by Neurolytic Agent - Back

  • 64633, 64635

Procedure - Musculoskeletal - Joint Injection

  • 27096, G0260

Procedure - Musculoskeletal - Laminotomy or Laminectomy - Lumbar

  • 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63040, 63042, 63045, 63046, 63047

Procedure - Musculoskeletal - Nerve Block Injection - Back

  • 64520, 62320, 62321, 62322, 62323, 64479, 64483, 64490, 64493, 64451

Procedure - Musculoskeletal - Neurostimulator - Back

  • 63650, 63655, 63685

Procedure - Musculoskeletal - Other

  • 20560, 20561, 21280, 21282, 21120, 21145, 21147, 62264, 64590, 64420, 64421, 64620, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21146, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 62263, 64418, 64505, 64510, 64530, 64568, 21899, 0202T, 0213T, 0216T, 0219T, 0220T, 0221T, 0274T, 0275T, 22818, 22819, 23472, 23473, 23474, 27279, 27280, 27412, 63050, 63051, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 23031, 23035, 23040, 23044, 23100, 23101, 23107, 23120, 23125, 23130, 23170, 23172, 23174, 23180, 23182, 23184, 23190, 23195, 23334, 23335, 23400, 23405, 23406, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23480, 23485, 23490, 23491, 23700, 23800, 23802, 26991, 26992, 27000, 27001, 27003, 27005, 27006, 27025, 27033, 27035, 27036, 27050, 27052, 27054, 27057, 27060, 27062, 27070, 27071, 27090, 27091, 27140, 27146, 27147, 27151, 27156, 27161, 27165, 27170, 27175, 27176, 27177, 27179, 27181, 27185, 27187, 27275, 27282, 27284, 27286, 27301, 27303, 27310, 27331, 27332, 27333, 27334, 27335, 27340, 27347, 27360, 27372, 27403, 27405, 27407, 27409, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27454, 27455, 27457, 27465, 27466, 27470, 27472, 27488, 27495, 27519, 27570, 27580

Procedure - Musculoskeletal - Percutaneous Vertebroplasty

  • 22510, 22511, 22513, 22514

Procedure - Other organ systems - Bronchoscopy

  • 31660, 31661, C9751, C8005

Procedure - Other organ systems - Other

  • 90912, 90913, 61850, 61860, 61863, 61864, 61867, 61868, 61885, 41874, 41899, 59072, 59074, 59076, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411, 31587, 31750, 53415, 53420, 53425, 53430, 54120, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54690, 55175, 55180, 55899, 55970, 55980, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 58150, 58260, 58275, 58285, 58291, 58543, 58550, 58553, 58570, 58572, 58661, 58720, 58940, 58152, 58180, 58200, 58210, 58240, 58262, 58263, 58267, 58270, 58280, 58290, 58292, 58294, 58541, 58542, 58544, 58548, 58552, 58554, 58571, 58573, 59525, D7230, D7240, 32491, 30468, 30400, 30410, 30420, 30430, 30435, 30450, 30469, 30520, 30620, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, S0199, 32850, 32851, 32852, 32853, 32854, 32855, 32856, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 50547, S2054, S2055, S2060, S2061, S2065, S2102, S2140, S2142, S2150, 61886, 58321, 58322, 58323, 58976, 54660, 19316, 19340, 19342, 19361, 19364, 19367, 19368, 19371, 19380, 53400, 53405, 53410, 53431, 54130, 54135, 55150, 56620, 57426, 57530, D7880, D9223, D9222, D7140, 64555, 64575

Procedure - Percutaneous Electrical Nerve Field Stimulation (PENFS)

  • 0783T, 0720T

Procedure - Skin - Debridement

  • 97597, 97598, 97602

Procedure - Skin - Other

  • 15820, 15821, 15822, 15823, G0283, 15769, 15771, 15772, 15773, 15774, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 97610, G0281, G0329, 17380

Procedure - Vascular - Other

  • 0598T, 0599T, 0524T, 36465, 36466, 36470, 36471, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

Procedure - Vascular - Varicose Vein Ablation

  • 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483

Prosthetics

  • L8720, L8721, L5827, L6028, L5827, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6700, L7406

Radiation Oncology

  • G0562, G0563

Speech Generating Devices

  • E2513

Spinal cord stimulators

  • 63663, 63664, 63688

Spine Surgeries; Spinal fusion, decompression, kyphoplasty and vertebroplasty

  • 22100, 22101, 22102, 22103, 22116, 22512, 22515, 22526, 22527, 22534, 22552, 22585, 22586, 22614, 22632, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22853, 22854, 22858, 22859, 22862, 22868, 22870, 62287, 63035, 63043, 63044, 63048, 63052, 63053, 63057, 63066, 63076, 63078, 63082, 63086, 63088, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63308, 64628, 64629, 0095T, 0098T, 0164T, 0165T, 0222T, 0656T, 0657T, S2348, S2350, S2351

Surgical Procedures on the Respiratory System

  • 32141, 32655, 32672

Test - Cardiography - Electrocardiogram

  • 93228, 93229

Test - Cardiography - External Electrocardiographic Monitoring

  • 93640, 93641, 93642, 93644

Test - General Laboratory - Immunoassay

  • 86367, 86807, 86808, 86812, 86813, 86816, 86817, 86821

Test - General Laboratory - Other

  • 81417, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0156U

Test - Molecular testing - Other

  • 81228, 81229, 81277, S3870, 0101U, 0102U, 0103U, 0171U, 0211U, 81437, 81438, 0037U, 0048U, 0179U, 0239U, 0242U, 0244U, 81445, 81455, 81525, 81415, 81416, 0260U, 0264U, 0265U, 0266U, 0267U, 81349, 81440, 81460, 81465, 0334U, 0448U, 81443

Test - Test - Miscellaneous - Other

  • 0209U, 92520, 0615T, 0094U, 0362T

Treatment - Chemotherapy - Chemotherapeutic Agent

  • J9217, J9218, J9219

Treatment - Injections and infusions (nononcologic) - Other

  • J1950, 38242, 38243

Treatment - Physical occupational and speech therapy - Occupational Therapy

  • 97535, 97533, 97537, 97542, 97750, 97755, G0129

Treatment - Physical occupational and speech therapy - Other

  • 97129, 97130, T1015

Treatment - Physical occupational and speech therapy - PT Treatment

  • 97010, 97012, 97014, 97022, 97024, 97026, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97140, 97530, G0157, 97016, 97018, 97028, 97116, 97124, 97150

Treatment - Physical occupational and speech therapy - PT/OT Evaluation

  • 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168

Treatment - Physical occupational and speech therapy - Speech Therapy

  • 92507, 92508, 92524, 92526, 92606, 92609, 92610, 96105, S9152, V5362, V5363, V5364, 92522, 92523, 92597, 92605, 92607, 92608, 92618

Treatment - Radiation oncology - Conventional Radiation Treatment

  • 77520, 77522, 77523, 77525, S8030, A9513, A9543, A9590, A9606, A9607

Treatment - Radiation oncology - Radiation Treatment Planning

  • 77299

Treatment - Spinal manipulation - Chiropractic

  • 98940, 98941, 98942, 98943

Treatment - Treatment - Miscellaneous - Other

  • 97810, 97811, 97813, 97814, 90867, 90868, 90869, 90870, H0008, H0009, H0010, H0011, H0015, H0017, H0018, H0019, H0035, H2035, H2036, S9480, 0687T, 0688T, 0704T, 0705T, 0706T, H0032, 0373T, 97154, H2014, H2019, S0201

Under Proprietary Laboratory Analyses

  • 0318U

Vagal Nerve Stimulation

  • 0908T

Whole Exome Sequencing

  • 81425, 81426, 81427, 81449, 81456

Please note that issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to Geisinger’s Clinical Guidelines and additional resources at www.geisinger.org/health-plan for the most up to date prior authorization requirements, coverage policies, and related plan policies.

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