Please note, in addition to the procedure codes found on Prior Authorization Lists (PAL), other request criteria may impact submission requirements. If you have questions, please reference this contact page for assistance. |
Below is a Prior Authorization List (PAL) for the following services. Please note, in addition to the procedure codes, other request criteria may impact submission requirements.
Beginning March 25, 2024, Medical Mutual contracted providers began submitting prior authorization requests for outpatient services, nursing, and investigational / experimental services through Cohere or through Rhyme’s EMR application. In addition, prior authorization requests for outpatient diagnostic radiology / imaging can be submitted through Rhyme’s EMR application.
Beginning December 16, 2024, prior authorizations for Radiology services must be submitted through the Cohere Health portal or the Rhyme EMR-based application.
Beginning of November 1, 2024, prior authorizations for Physical Therapy, Occupational Therapy, Speech Therapy, and Chiropractic services must be submitted through the Cohere Health Portal.
Beginning March 3, 2025, Cohere Health expanded its partnership with Medical Mutual Health Plans for Cardiology, Gastrointestinal (GI) and Sleep Services. Beginning March 3, 2025, prior authorizations for cardio, sleep and gastrointestinal services must be submitted through the Cohere Health portal or the Rhyme EMR-based application.
Please note, not all commercial plans require prior approval for gastroenterology, cardiology and sleep-related services. To verify benefits and authorization requirements, please use the For Providers number on the back of the Covered Person’s ID card.
Beginning January 28, 2026, prior authorizations for Pain Management and MSK Surgery should be submitted through the Cohere Health portal.
To view the official and most up-to-date Medical Mutual Prior Authorization List (PAL) for these services, please visit Medical Mutual's provider website. Please note, in addition to the procedure codes, other request criteria may impact submission requirements.
Outpatient Therapy (Physical, Occupational & Speech), Chiropractic and Radiology Services
Outpatient Therapy (Physical, Occupational & Speech), Chiropractic and Radiology Services
Category | Procedure Codes |
Outpatient Therapy (physical, occupational & speech) and Chiropractic | 98940, 98941, 98942, 98943, 97010, 97012, 97016, 97018, 97022, 97026, 97033, 97034, 97035, 97110, 97112, 97113, 97124, 97129, 97140, 97150, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97763, 92507, 92508, 92522, 92523, 92524, 92526, 96105, 92521, 92610, 92611, 97139, 97165, 97166, 97167, 97602, 97799, 97028, 97036, 97116, 97024 |
Radiology | 78429, 78430, 78431, 78432, 78433, 78459, 78491, 78492, 75571, 75572, 75573, 75574, 75580, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71271, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74263, 75635, 76380, 70544, 70545, 70546, 70547, 70548, 70549, 71555, 72159, 72198, 73225, 73725, 74185, C8900, C8901, C8902, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, 70336, 70540, 70542, 70543, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 74712, 75557, 75559, 75561, 75563, 77046, 77047, 77048, 77049, 77084, C8903, C8905, C8906, C8908, C9762, C9763, C9791, S8037, S8042, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0219, G0235, G0252, 76376, 76377, 74713, 76390, 76391, 77078, S8092 , 78494 |
Other | 64999 |
Cardiology Services
Cardiology Services
Category | Procedure Codes |
Ablation |
93650, 93653, 93654, 93656
|
Cardiac Devices | 0345T, 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0571T, 0572T, 0574T, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33217, 33221, 33224, 33230, 33231, 33240, 33249, 33270, 33271, 33273, 33285, 33289, 33340, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 93580, 93745, 93228, 93229, 93264, C1721, C1722, C1761, C1777, C1779, C1785, C1786, C1825, C1882, C1895, C1896, C1898, C1899, C1900, C2619, C2620, C2621, C2624, K0606, K0607, K0608, K0609, K1030 |
Cath | 36245, 36246, 36247, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93593, 93594, 93595, 93596, 93597 |
EPS | 0577T, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93631, 93640, 93641, 93642, 93644 |
Interventions | 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, 37236, 37238, 37254, 37256, 37258, 37260, 37262, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298, 0234T, 0235T, 0236T, 0237T, 0238T, 0505T, C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775 |
PCI | 92920, 92924, 92928, 92933, 92937, 92943, 92972, C9600, C9602, C9604, C9607 |
Sleep Services
Sleep Services
Category | Procedure Codes |
Facility Based Sleep Studies | 95782, 95783, 95805, 95807, 95808, 95810, 95811 |
Home Sleep Study | 95800, 95801, 95806 |
Humidifier | E0561, E0562 |
Oral Appliance | E0470, E0485, E0486 |
PAP Therapy | E0471, E0601 |
Surgery/procedures for Obstructive Sleep Apnea | 21685, 33277, 33279, 33280, 33281, 33287, 33288, 41512, 41530, 42140, 42145, 42950, 64582, 64583, 64584, 93150, 93151, 93152, 93153, C9727, S2080, |
Gastrointestinal Services
Gastrointestinal Services
Category | Procedure Codes |
Capsule Endoscopy | 0651T, 91110, 91111, 91113 |
EGD | 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259 |
Gastric Pacing | 43647, 43648, 43881, 43882 |
Laparoscopic Hiatal Hernia Repair | 43280, 43281, 43282, 43284 |
Pain Management Services
Pain Management Services
Category | Procedure Codes |
ESI | 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 64999 |
Facet Injection | 0202T, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0219T, 0220T, 0221T, 0222T, 22899, 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636 |
Genicular Nerve Procedures | 64454, 64624 |
Pain Infusion Pump | 62324, 62325, 62326, 62327, 62350, 62351, 62355, 62360, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991, C1772, C1891, C2626, E0782, E0783, E0785, E0786 |
SI Injections | 27096, 64451, 64625, G0260 |
Spinal Allogeneic Tissue-Based Injections | 0627T, 0628T, 0629T, 0630T |
Spinal Cord Stimulators | 63650, 63655, 63663, 63664, 63685, 63688, 64555, 64575, C1816, C1820, C1822, L8679, L8680, L8682, L8685, L8686, L8687, L8688 |
Thermal Ablation of the Intraosseous Basivertebral Nerve (BVN) | 64628, 64629 |
Musculoskeletal Services
Musculoskeletal Services
Category | Procedure Codes |
Arthroplasty | 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27700, 27702, 27703 |
Arthroscopy | 0707T, 0737T, 23929, 27299, 27412, 27599, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29850, 29851, 29855, 29856, 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, 29999, C9781, G0289, S2112, S2300 |
Foot Surgery | 26535, 26536, 27870, 28110, 28240, 28285, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28306, 28308, 28310, 28740, 28750, L8641 |
Other Joint Procedures | 27036, 27071, 27170, 27405, 27407, 27409, 27418, 27420, 27422, 27424, 27427, 27455, 27457, 27488, 27570 |
Shoulder Surgery | 23120, 23125, 23130, 23334, 23335, 23410, 23412, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466 |
Spine Surgery | 0095T, 0098T, 0164T, 0165T, 0274T, 0275T, 0656T, 0657T, 0790T, 20999, 22100, 22101, 22102, 22103, 22116, 22206, 22207, 22210, 22212, 22214, 22220, 22222, 22224, 22510, 22511, 22512, 22513, 22514, 22515, 22526, 22527, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22836, 22837, 22838, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22853, 22854, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 27278, 27279, 27280, 62287, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, C1821, C2614, C9757, S2348, S2350, S2351 |
Issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to Medical Mutual’s Clinical Guidelines and additional resources at www.medmutual.com/For-Providers/Prior-Approval-and-Investigational-Services for the most up to date prior authorization requirements, coverage policies, and related plan policies.