Medical Mutual (MMO) Prior Authorization List

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.

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.

Category	Codes
Outpatient Physical Therapy Occupational Therapy Speech Therapy 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

Category	Service	Codes
Cardiology	Ablation	93650, 93653, 93654, 93656
Cardiology	Cardiac Devices	0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, 0345T, 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0571T, 0572T, 0574T, 0797T, 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
Cardiology	Cath	36245, 36246, 36247, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93593, 93594, 93595, 93596, 93597
Cardiology	EPS	0577T, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93631, 93640, 93641, 93642, 93644
Cardiology	Interventions	0234T, 0235T, 0236T, 0237T, 0238T, 0505T, 33875, 33877, 33880, 33881, 33883, 33886, 34830, 34831, 34832, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 35301, 37215, 37216, 37217, 37218, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37236, 37238, 34701, 34702, 34703, 34704, 34705, 34706, C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775
Cardiology	PCI	92920, 92924, 92928, 92933, 92937, 92943, 92972, C9600, C9602, C9604, C9607
Sleep	Facility Based Sleep Studies	95782, 95783, 95805, 95807, 95808, 95810, 95811
Sleep	Home Sleep Study	95800, 95801, 95806
Sleep	Humidifier	E0561, E0562
Sleep	Oral Appliance	E0470, E0485, E0486
Sleep	PAP Therapy	E0470, E0471, E0601
Sleep	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	Capsule Endoscopy	0651T, 91110, 91111, 91113
Gastrointestinal	EGD	43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259
Gastrointestinal	Gastric Pacing	43647, 43648, 43881, 43882
Gastrointestinal	Laparoscopic Hiatal Hernia Repair	43280, 43281, 43282, 43284

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.