Geisinger Health Plan Prior Authorization List

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.

• New users: register for an account: www.coherehealth.com/provider/register 
• Existing users: log in to Cohere: www.next.coherehealth.com 

* 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)
Category	Codes
Air Compressor	E0565
Apnea Monitor	E0618, E0619
Commodes	E0170
Electrical and Electromagnetic Stimulation to aid wound healing	E0761, G0281, G0329
High Frequency Chest Wall Oscillation Device	E0483, A7025
Hospital Bed	E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0462
Manual Wheelchair	K0002, K0003, K0004, K0005, K0006, K0007
Mechanical In-Exsufflation Device	E0482
Miscellaneous	A7025, A9900, A9901, A9999, E1399, K0669, K0672, K0730, K0733, K0738, K0739, K0740, K0743, K0745, K0746, E0147, E0170, E0193, E0194, E0217, E0236, E0239, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0371, E0372, E0373, E0424, E0431, E0433, E0439, E0462, E0465, E0466, E0467, E0470, E0471, E0472, E0480, E0482, E0483, E0550, E0565, E0574, E0575, E0600, E0601, E0615, E0617, E0618, E0619, E0617, E0618, E0619, E0630, E0635, E0636, E0639, E0640, E0650, E0651, E0652, E0656, E0657, E0668, E0670, E0671, E0675, E0677, E0691, E0692, E0693, E0694, E0740, E0744, E0745, E0762, E0766, E0781, E0782, E0783, E0784, E0785, E0786, E0791, E0849, E0855, E0911, E0912, E0920, E0930, E0941, E0946, E0947, E0948, E0958, E0983, E0984, E0986, E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1012, E1014, E1029, E1030, E1031, E1035, E1036, 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, E1230, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1270, E1280, E1295, E1296, E1310, E1390, E1391, E1392, E1399, E1405, E1406, E1700, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841, E2000, E2120, E2204, E2227, E2228, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2614, E2616, E2621, E2626, E2627, E2628, E2629, E2630, K0002, K0003, K0004, K0005, K0006, K0007, K0009, K0010, K0011, K0012, K0108, K0455, K0730, K0738, 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, K1002, K1006, K1009, K1016, K1018, K1020, K1024, K1025, K1031, K1032, K1033, B9998, B9999, L0999, L1499, L2999, L3999, L5999, L7499, L8499, L9900
Nebulizer	E0574, E0575
Neuromuscular Electrical Stimulator	E0740, E0744, E0745, E0770
Non-Wearable Automatic External Defibrillator	E0617
Orthotics & Orthopedic Shoes	Submit authorizations for Medicaid members through Cohere for the following codes: A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514, A8000, A8001, A8002, A8003, A8004, A9283, D7880, E0485, E0486, K0672, K0903, K1015, L0112, L0220, L0452, L0480, L0482, L0484, L0486, L0622, L0624, L0629, L0632, L0634, L0636, L0638, L0640, 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, L1834, L1840, L1844, L1846, L1860, L1900, L1904, L1907, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2040, L2050, L2060, L2070, L2080, L2090, L2106, L2108, L2126, L2128, L2627, L2628, L2999, L3001, L3002, L3003, L3020, L3030, L3031, L3040, L3050, L3070, L3080, L3090, L3160, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, 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, S1040
Oxygen	E0424, E0431, E0433, E0434, E0439, E1390, E1391, E1392, K0738
Patient Lift	E0630, E0635, E0636, E0639, E0640, E1035, E1036
Pneumatic Compression Device	E0650, E0651, E0652, E0675
Positive Airway Pressure Device	E0601
Pressure Reducing Support Surface Device	E0193, E0194, E0277, E0371, E0372, E0373
Progressive Stretch Device	E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1825, E1830, E1831, E1840, E1841
Prosthetics	Submit authorizations for Medicaid members through Cohere for the following codes: K1014, K1022, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5331, L5341, L5400, L5410, L5420, L5430, L5450, L5460, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, 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, L7259, L7360, L7362, L7364, L7366, L7367, L7368, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L7600, 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, L8622, L8623, L8624, L8625, L8627, L8628, L8629, L8630, L8631, L8641, L8642, L8658, L8659, L8670, L8690, L8691, L8692, L8693, L8695, L8699, L9900
Pulse Oximeter	E0445
Respiratory Assist Device	E0470, E0471, E0472
Speech Generating Devices	E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599
Suction Pump	E0600, E2000
Tumor Treatment Field Therapy	E0766
Ventilator	E0465, E0466, E0467

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

Outpatient Services
Category	Codes
Abdominoplasty	Submit authorizations for Medicaid & Medicare members through Cohere for the following codes: 00802, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847 *This is an exclusion for Marketplace, Commercial, and CHIP plans, refer to member’s benefit documents. This exclusion may also apply to TPA lines of business. Please refer to the TPA benefit documents.
Ablation	93650, 93653, 93654, 93656, 0793T
Acupuncture	Submit authorizations for Medicaid, Medicare, and TPA members through Cohere for the following codes: 20560, 20561, 97810, 97811, 97813, 97814 *Service is excluded from coverage for Commercial and FEHBP
Ambulance Transport Service (Non-Emergent, Air/Water)	A0435, A0434, A0427, A0428, A0429, A0422, A0426, A0431, A0424, A0190, A0225, A0210, A0432, A0433
Ambulance Transport Service (Non-Emergent, Land)	A0160, A0090, A0080, A0100, A0110, A0120, A0130, A0425, A0436, A0434, A0427, A0428, A0429, A0170, A0998, A0422, A0426, A0190, A0380, A0390, A0180, A0200, A0225, A0210, A0432, A0433
Biofeedback for Non-Behavioral Health Indications	Submit authorizations for Medicare, Medicaid, FEHBP and certain TPA members through Cohere for the following codes: 90901, 90911, 90912, 90913
Blepharoplasty	15820, 15821, 15822, 15823, 21280, 21282, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911
Breast Reduction	19318
Bronchial Thermoplasty	31660, 31661, C9751
Cardiac Devices	33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33217, 33221, 33224, 33227, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33240, 33241, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33274, 33275, 33285, 33286, 33289, 33340, 93228, 93229, 0571T, 0572T, 0573T, 0574T, 0580T, 0614T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T
Cardiac Procedures/Surgeries	33361, 33362, 33363, 33364, 33365, 33366, 33418, 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, 92920, 92928, 92937, 92943, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93593, 93594, 93595, 93596, 93597, 0345T
Chiropractic Services	Submit authorizations for PEBTF & CHIP members through Cohere for the following codes: 97010, 97012, 97014, 97022, 97024, 97026, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97140, 97530, 97535, 98940, 98941, 98942, 98943, 99201, 99202, 99203, 99204, 99205, 99206, 99207, 99208, 99209, 99210, 99211, 99212, 99213, 99214, 99215, G0283, 97032
Colorectal Cancer Genetic Testing	81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, 81435, 81436, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0235U, 0238U, 0261U
Comparative Genomic Hybridization for Evaluation of Developmental Delay	81228, 81229, 82177, 0156U, 0209U, S3870
Deep Brain Stimulation	61850, 61860, 61863, 61864, 61867, 61868, 61885
Dental Services	21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21685, 41874, 41899
Diagnostic/Cardiac Imaging	36245, 36246, 36247, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93631, 93640, 93641, 93642, 93644, 0577T
Dorsal Column Stimulation	63650, 63655, 63684, 63685, 63688 *Changes to a generator for a previously placed permanent device do not require prior authorization.
Emerging technology/New Indications for Existing Technology	93264
Epidural Steroid Injections (Outpatient Only)	62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484
Epidural & Percutaneous Lysis of Adhesions	Submit authorizations for Medicare members through Cohere for the following codes: 62264, 62263 *This is not a covered service for other lines of business. Percutaneous lysis of epidural adhesions utilizing endoscopic approach is not covered for any line of business.
Facet Injections	64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Fetal Surgery	59072, 59074, 59076, S2400, S2401, S2402, S2403, S2404, S2405, S2409, S2411
Gastric Electrical Stimulation	43647, 43648, 43881, 64590
Gender Dysphoria and Gender Confirmation Treatment	11980, 15769, 15771, 15772, 15773, 15774, 17380, 19301, 19303, 19304, 19325, 19350, 19357, 31587, 31750, 53415, 53420, 53425, 53430, 54120, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55899, 55970, 55980, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58554, 58553, 58570, 58571, 58572, 58573, 58661, 58720, 58940, 90832, 90833, 90834, 90836, 90837, 90838, 96372, C1813, C2622, J1950, J9217, J9218, J9219
Genetic Susceptibility Cancer Panels	0101U, 0102U, 0103U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0160U, 0161U, 0162U, 0171U, 0211U, 81432, 81433, 81435, 81436, 81437, 81438, 0261U
Genetic Testing for Mitochondrial Disorders	81440, 81460, 81465
Home Health	G0151, G0152, G0153, G0155, G0156, G0299
Home Services for disabled children (Shift Care)	Submit authorizations for Medicaid members through Cohere for the following codes: T1002, T1003, T1019, S5116
Hospice (Outpatient)	Submit authorizations for PEBTF members through Cohere for the following codes: S9125, S9126, G0299, G0300, Q5001, Q5002, Q5003 *Please submit inpatient hospice requests directly to Geisinger.*
Hysterectomy	Submit authorizations for Medicaid members through Cohere for the following codes: 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 59525
Iatrogenic Infertility Treatment	Submit authorizations for FEHBP members through Cohere for the following codes: 58321, 58322, 58323, 58976, 89250, 89251, 89254, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89335, 89337, 89343, 89346, 89352, 89353, 0058T, S4030, S4031, S4040 *Excluded from coverage for all other lines of business unless specific contract benefits exist.
Impacted Wisdom Teeth	Submit authorizations for Medicaid & CHIP members through Cohere for the following codes: D7230, D7240
Intercostal Nerve Block	64420, 64421, 64620
Intrathecal Infusion Pump	62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362 *Medication refill does not require prior authorization
Lung Volume Reduction Surgery	32491
Magnetic Esophageal Sphincter Augmentation (LINX)	43284, 43285 *This service is excluded from coverage for Medicare.
Mastectomy for Gynecomastia	Submit authorizations for Medicare, Medicaid, FEHBP & certain TPAs members through Cohere for the following codes: 19300 *This service is excluded from Commercial coverage.
Mental/Behavioral Health and Substance Abuse Treatment	For Medicare, Commercial, CHIP and most TPA's please call [phone]. 0632T, 90869, H0010, H0015, H0019, H0018, H2035, H2036, H0011, H0017, H0008, H0009, H0035, S9480, 96146, 96139, 96130, 96131, 96138, 96133, 96136, 96132, 96137, 90870, 90867, 90868, S0201 *For Medicaid only: refer to member's Behavioral Health HealthChoices Insurance card for contact information. (Not managed by Geisinger Health Plan) ***For PEBTF members, please use 800-924-0105.
Molecular Testing	0037U, 0048U, 0179U, 0239U, 0242U, 0244U, 81445, 81455
Multi-gene Expression Assay for Predicting Recurrence in Colon Cancer	81445, 81525
Non-Invasive Home Ventilator	E0466, E0467
Nutritional Supplements	B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9342, S9343, S9432, S9433, S9434, S9435
Obesity Surgery	43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
Orthopedic Surgeries: Hip, Knee and Shoulder Arthroplasty	0707T, 0737T, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27412, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29850, 29851, 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, J7330, S2112, S2300
Pain Infusion Pump	62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362
Peripheral Revascularization (Atherectomy, Angioplasty)	0505T, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231
Physical, Occupational, or Speech Therapy (Outpatient)	0598T, 0599T, 64550, 92507, 92508, 92520, 92524, 92526, 92606, 92609, 95831, 95832, 95833, 95834, 95851, 95852, 96001, 96002, 96004, 96105, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97597, 97598, 97602, 97610, 97750, 97755, 99091, S9152, G0281, G0283, G0329, T1015, V5362, V5363, V5364 The following evaluation codes only require authorization when they are out-of-network: 92522, 92523, 92597, 92605, 92607, 92608, 92610, 92611, 92618, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168
Percutaneous Lysis of Epidural Adhesions without endoscopic guidance/approach	Submit authorizations for Medicare members through Cohere for the following codes:  62263, 62264 *This is not a covered service for other lines of business; also note, percutaneous lysis of epidural adhesions utilizing endoscopic approach is not covered for any line of business.
Proton Beam Radiation	77520, 77522, 77523, 77525, S8030
Rhinoplasty/ Septoplasty	30468, 30400, 30410, 30420, 30430, 30435, 30450, 30469, 30520, 30620
Shift Care	Submit authorizations for Medicaid members through Cohere for the following codes: T1002, T1003, T1019, S5116
SI Joint Injections	27096
Spinal Cord Stimulators	63650, 63655, 63663, 63664, 63685, 63688
Spine Surgeries; Spinal Fusion, Decompression, Kyphoplasty and Vertebroplasty	0095T, 0098T, 0163T, 0164T, 0165T, 0202T, 0219T, 0220T, 0221T, 0222T, 0274T, 0275T, 0656T, 0657T, 20999, 22100, 22101, 22102, 22103, 22116, 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, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22856, 22857, 22858, 22859, 22861, 22862, 22867, 22868, 22869, 22870, 27279, 27280, 62287, 62380, 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, 64628, 64629, S2348, S2350, S2351
Suprascapular & Sympathetic Nerve Block	64418, 64505, 64510, 64520, 64530
Termination of Pregnancy	Submit authorizations for all lines of business through Cohere for the following codes, except when coverage is excluded: 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, S0199 *Termination of pregnancy is excluded from the benefits for Religious Exempt Entities.
Transoral Incisionless Fundoplication	43210
Transplant Evaluation Services	32850, 32851, 32852, 32853, 32854, 32855, 32856, 33930, 33933, 33935, 33940, 33944, 33945, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44135, 44136, 44715, 44720, 44721, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48160, 48550, 48551, 48552, 48554, 48556, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 50547, 86367, 86807, 56808, 86812, 86813, 86816, 86817, 86821, S2053, S2054, S2055, S2060, S2061, S2065, S2102, S2140, S2142, S2150
Tumor Treatment Fields	77299, A4555, E0766 *This is not a covered service for Medicaid.
Vagal Nerve Stimulation	61885, 61886, 64568
Varicose Vein Treatments	0524T, 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785
Ventricular assist devices (VADs)	33990, 33991, 33995
Vertical Expandable Titanium Rib	21899
Vision Services (Low Vision Aids, Eye Occluder)	Submit authorizations for Medicaid members through Cohere for the following codes: V2600, V2610, V2615, V2770,
Vision Therapy/Orthoptics	Submit authorizations for Medicaid members through Cohere for the following codes: 0615T, 0687T, 0688T, 0704T, 0705T, 0706T, 92065, 92066
Whole Exome Sequencing	0094U, 81415, 81416, 81417, 0260U, 0264U, 0265U, 0266U, 0267U, 81349

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.