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.